aCentre interdisciplinaire de recherche en réadaptation et en intégration sociale (CIRRIS), Laval University, Quebec city
bFaculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, Sherbrooke, Quebec, Canada
Correspondence to Guillaume Léonard, PT, PhD, Faculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, 3001 12th Avenue North, Sherbrooke (Quebec), Canada J1H 5N4 Tel: +1 819 820 6868, x12933; fax: +1 819 820 6864; e-mail: firstname.lastname@example.org
Received May 30, 2012
Accepted August 9, 2012
Psychological barriers to rehabilitation are generally viewed as pre-existing patient traits that clinicians are asked to evaluate and modify. In the present case report, we provide evidence that these barriers can also be involuntarily created or perpetuated by the clinician himself when too much attention is placed on physical abnormalities. Without discarding the need to treat the presumed biological source of pain, these observations remind rehabilitation professionals about the importance of showing a confident and reassuring attitude toward pain patients to reduce anxiety, promote physical activity, and reinforce self-management strategies.
There is substantial evidence on the risk factors for the development of persistent pain. Among the various factors identified, psychosocial factors have received considerable attention, and there are now significant indications that suggest that elements such as maladaptive coping behaviors and misbeliefs about pain are more important than physical findings to predict long-term outcomes in individuals suffering from low back pain (Gifford et al., 2006; Chou and Shekelle, 2010).
Traditionally, psychosocial risk factors are viewed as pre-existing patient traits that clinicians are asked to evaluate and modify (Deyo et al., 1992; Poitras et al., 2008). Rarely, however, does it come to the clinician’s mind that his own attitude and interventions can create or perpetuate pathological misbeliefs and maladaptive coping behaviors. In the present article, we describe the case of a 17-year-old female who complained of neck and back pain and whose condition improved markedly when a physiotherapist reassured her about the findings of the physical exam and brought her attention away from the abnormalities identified initially.
The patient, V.T., was a 17-year-old female who complained of neck and back pain following a motor vehicle accident. She was referred to a physiotherapy clinic, where she was treated for 7 weeks with manual therapy, range of motion (ROM) exercises, and electrotherapeutic modalities. V.T. then moved to a nearby city and was transferred to another clinic to pursue her rehabilitation.
During her initial visit at the second physiotherapy clinic, V.T. rated her neck and back pain at 75 on a 0–100 numerical pain scale (0=no pain; 100=worst pain imaginable). The pain was worse upon waking up, was increased by active movements of the cervical and thoracic spine, and relieved by rest and heat. Since the accident, V.T. believed that her condition was slightly worse. She was particularly concerned about the findings of the previous physiotherapist, who had identified four misaligned vertebrae in her back.
Postural evaluation indicated protracted cervical spine and shoulders, and increased lordosis of the lumbar spine. Active ROM of the cervical and thoracic spine was complete and nonpainful, except for right cervical rotation, which was reduced by 50% and reproduced her typical pain. Shoulder girdle movements were complete and nonpainful. Cervical and thoracic compression and traction did not induce nor relieve her symptoms. Posteroanterior pressure on the spinous and transverse processes of the cervical and thoracic spine showed normal mobility and did not elicit her typical pain. There was a slight left rotation of the vertebras T2–T4 that was considered nonclinically significant (Kouwenhoven et al., 2006). The neurological evaluation (reflexes, myotomes, and dermatomes) was normal. A score of 26 on the McGill Pain Questionnaire Pain Rating Index (MPQ-PRI) (Melzack, 1975) was obtained (Fig. 1). Perceived disability, measured with the Pain Disability Index (Tait et al., 1990), and catastrophic thinking, measured with the Pain Catastrophizing Scale (Sullivan et al., 1995), yielded total scores of 36 and 37, respectively, suggesting that the patient was at a high risk of developing chronic pain and disability (Neubauer et al., 2006; Adams et al., 2007).
The physiotherapy interventions (unidisciplinary treatments) were prescribed and provided by a certified physiotherapist. Treatments were articulated around an active approach with an emphasis on aerobic exercises (high-intensity walking on a treadmill, upper extremity cycling at a moderate pace on an ergocycle), postural exercises (gentle scapular and cervical retraction), and neck mobility exercises (active ROM in rotation). Education and reassurance was also used extensively to explain the condition in fear-reducing terms. For example, during the assessment of her vertebral mobility using manual therapy techniques, V.T. was told that the mobility of each vertebra assessed in her back and neck was normal, and that the alignment of her vertebras was within the normal limit and did not contribute to her symptoms.
At the next visit 2 days later, V.T. reported important improvements in her back and neck, and stated that she was reassured to know that the four vertebrae in her back were aligned properly. V.T. was seen three other times at the clinic (2, 5, and 10 days after the initial visit). At her last visit, she reported no neck or back pain, except during prolonged standing and sitting periods. The MPQ-PRI was now at 7. The next day, V.T. phoned the physiotherapy clinic to cancel her appointments. When contacted by her physiotherapist, she stated that her condition improved to the point where she judged that physiotherapy treatments were no longer required.
V.T. was seen one last time 8 months after the initial evaluation. During this last visit, V.T. stated that the pain in her neck and back had completely disappeared. She did not report any neck or back pain since her last visit and did not seek the services of any other health professionals. Physical examination showed that cervical and thoracic ROM were complete and pain free. Postural evaluation still indicated protracted cervical spine and shoulders, and increased lumbar lordosis. Both the MPQ-PRI and the Pain Disability Index yielded a score of 0.
Probably because of their strong biomedical background, considerable efforts are generally made by physiotherapists to identify and treat the presumed source of pain. Without excluding the influence of biological factors, physiotherapist and other healthcare professionals must keep in mind that pain perception is a subjective experience influenced both by biological and by psychological factors (Fillingim, 2000). Placing too much emphasis on physical abnormalities can induce a negative self-perception of health and lead to fear avoidance and pain-catastrophizing behaviors, a situation that may predispose individuals to chronic pain (Ash et al., 2008; Flynn et al., 2011).
Even though it might be tempting to suggest that the changes noted by V.T. are attributable to simple reassurance, we must keep in mind that other factors (e.g. use of an active rather than passive approach, change of neighborhood and working environment) probably also played a significant role. Still, we propose that the improvements noted by V.T. are largely attributable to the comforting attitude shown by the second physiotherapist who corrected V.T.’s misbeliefs about pain and reassured her concerns. This hypothesis is supported (a) by the patient herself, who stated that she was reassured to know that the vertebrae in her back were properly aligned, and (b) by the rapidity with which the changes occurred (i.e. reduction of pain from 75 to 0 in less than 2 weeks). These rapid changes contrast with the slight exacerbation noted during the first 7 weeks of treatment. It is also of particular interest to note that the improvements in pain noted by V.T. occurred despite the persistent postural abnormalities noted at follow-up, again arguing against the existence of a simple causal relationship between physical abnormalities and pain.
We argue that the emphasis placed by the former physiotherapist on the vertebral misalignment probably contributed to the maintenance of V.T.’s pain. Although the negative impact that clinicians can have on patients’ conditions has been discussed in a previous paper (Benedetti et al., 2007) and experimental data support such a negative influence (see for instance Goffaux et al., 2007), the present case report is, to our knowledge, the first article to show how these concepts can translate in clinical practice.
The authors thank Éric Bouchard and François Auray for their clinical support, as well as Joël Charlebois for his thoughtful comments on the manuscript.
Guillaume Léonard and Catherine Mercier are supported by CIHR (Canada). Catherine Mercier is also supported by NSERC (Canada) and FRSQ (Québec). Yannick Tousignant-Laflamme is a supported member of the Centre de recherche Clinique Etienne-Le Bel du CHUS.
Conflicts of interest
There are no conflicts of interest.
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