From patient to person?

For the last decade, we have seen an increase in quality research into pain neuroscience and the effective treatment of chronic pain conditions. Within the currently accepted biopsychosocial model of treatment, active participation is often emphasized as important and integral to successful rehabilitation. But so often, we convey the message that action on the patient’s part, is a means to an end. There is also evidence that supports the use of exercise as part of the biopsychosocial treatment of chronic pain. Though we can prove that exercise contributes towards achieving a more functional life with less pain and disability, we often get stuck on the type and intensity of the exercise, and then get disappointed when we can’t seem to pinpoint an exact recipe for everyone to follow. In recent years, we have learned that it is in fact more the cognitive processes that take place due to the physical activity and the underlying mechanisms involved that benefit the patient, than the actual act of exercise and the resulting physiological changes that occur as result thereof in the human body. The act of physical activity and movement, most efficiently used when applying graded exercise or graded exposure, changes attitudes and beliefs of the chronic pain patient and therefore reduces disability.

In a recent article by Mark Sullivan and Kevin Vowles (Sullivan & Vowles, 2017), the authors beautifully explained that action or active participation should be ameans and an end in itself in the pursuit of reduced chronic pain and disability. Relating their argument back to neuroscience, they explained that the “salience network” are those cortical regions involved in the multisensory interpretation of events that threaten the bodies integrity regardless of the sensory modality. This salience network can be activated by nociceptive and innocuous stimuli but what is of more relevance to pain, is the context within which the salience experiences the stimuli. This implies, that the affective, cognitive and emotional state the patient finds themselves in, is of more relevance where chronicity is concerned. If we accept this as the current model of treatment, then we are moving back to the work of Fordyce which places a large emphasis on behavioural change and not just on the physical (Wilbert E Fordyce, 1988).

Knowing that our focus should be more behaviour orientated (Wilbert Evans Fordyce, 1976), why is it that so many healthcare professionals still get stuck in the same rabbit hole of wanting a “recipe” for exercise in patients with chronic pain? What struck me about this article, is that it is not a new concept that the authors have stumbled upon, but rather that these authors have found a succinct way of communicating the correct approach to chronic pain rehabilitation and management. Namely, action or active participation by the patient, is not just an approach to a recipe, but it’s the actual core message of every chronic pain management program out there. Or rather, it should be. Once we can bring that message home to healthcare professionals, it will be like the pieces of a puzzle that just falls into place. The different components of the biopsychosocial model and the tools we use to work on these aspects of the rehabilitation process should be used like the links in a chain. Every link is important to the ultimate goal, but no individual link is more important than the next. Yet when every link does its part, the results speak for itself. And in the centre of all the links in the biopsychosocial chain, is action. As Sullivan and Vowles so eloquently stated in their article, we need to help our patients become persons again by using action as the means and the end to the goal. Because if we use that approach, the recipe of exercise doesn’t matter, but what matters is that this patient in front of you, becomes a person again in their own right.

Fordyce, Wilbert E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43(4), 276.
Fordyce, Wilbert Evans. (1976). Behavioral methods for chronic pain and illness: CV Mosby.
Sullivan, Mark D, & Vowles, Kevin E. (2017). Patient action: as means and end for chronic pain care. Pain, 158(8), 1405-1407.