How many times has each of us been told to “think positive”? Presumably never by our English teachers or copyeditors (who might prefer to say “think positively”), but no doubt countless times by friends, mentors, and coaches. And most of us probably also have noticed that doing so has generated some benefits along the way.
Yet strangely, most research that connects thoughts—positive or otherwise—with the degree to which our patients achieve pain reduction or functional restoration after the operations we do has focused on those who have trouble “thinking positive” (or even “positively”). Many studies have associated endpoints like persistent disability and more severe pain after musculoskeletal injury or surgery, poorer patient-reported outcomes scores, and revision procedures with depression [9, 13, 17], anxiety [6, 13], catastrophic thinking , or poor coping skills . By contrast, much less is known about whether patients and providers can bend the curve up by cultivating positive attitudes or habits, such as mindfulness or gratitude [1, 12, 16]. In short, while thinking negatively seems to hurt, how much does it help our patients—if at all—if they “think positive”?
In this month’s Clinical Orthopaedics and Related Research®, a group from the Massachusetts General Hospital lead by Ana-Maria Vranceanu PhD, found that an assortment of what they characterized as “positive-psychology variables”— humor, resilience, optimism, and mindfulness—account for an astonishingly high 23% of the variation in pain intensity among patients with upper-extremity conditions after controlling for relevant confounding variables (such as pain duration and prior treatments), and 15% of the variation in those patients’ physical limitations .
Although this study was performed in an urban, tertiary-care, hand-surgery practice, there is every reason to think that the findings here will generalize to other settings and patient populations. After all, if what they’ve studied here doesn’t count as “human nature,” I don’t know what would. And as one might expect in a paper on this topic, Dr. Vranceanu and her team leave us with a happy message that ought to generalize well to other settings: Positive-psychology factors may be more readily modified through skills-based interventions than are pain or physical limitations, and those kinds of interventions generally can be implemented with little cost and essentially no risk. Since they found mindfulness and satisfaction with life to have the largest explanatory power, they suggested those variables—which, again, are amenable to relatively simple interventions—especially deserve our attention in future trials.
Because their findings are so likely to be generalizable, and because the interventions they point to are so likely to be successful, this study is worth the attention of every clinician in our specialty, and not just those who practice hand surgery.
But these findings also will raise many important questions in the minds of readers; I know it got me thinking. Discover the answers by joining me in the Take 5 interview that follows with Dr. Vranceanu, senior author of “What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper-extremity Conditions?”
Take Five Interview with Ana-Maria Vranceanu, PhD, senior author of “What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper-extremity Conditions?”
Seth S. Leopold MD:Congratulations on this lovely study. I’ll admit that when I first read it, my own notes said, “if negative psychology is associated with worse pain and functional scores, why wouldn’t positive psychology be associated with higher scores?” In other words, the key finding seemed to me to be at first glance—forgive the pun—a no-brainer. But as is so often the case, a deeper dive here proved well worth it, as your findings open up whole new avenues of inquiry about treatments that seem quite likely to be helpful. How would you persuade the skeptical reader that this isn’t just the flip side of “negative thinking is bad, positive thinking must be ____”?
Ana-Maria Vranceanu PhD: We are thrilled that the field of orthopaedics is opening the door more and more to psychosocial research. CORR® has been a leader in this, and we appreciate the ability to bring novel concepts and out-of-the-box ideas that can perhaps provide a paradigm shift in how we think about our patients and their orthopaedic illness.
It is common and intuitive to think that positive psychology constructs are opposites of the more traditional, “negative” psychology constructs. This is not necessarily incorrect, since the two categories of constructs are negatively interrelated. Indeed, a person who catastrophizes pain or has negative thoughts when experiencing pain will likely score low on positive psychology constructs such as gratitude, satisfaction with life, and mindfulness.
However, the positive-psychology framework is inherently different from the more traditional approach. Traditional approaches focus on understanding deficits (like negative thoughts, or negative emotional states), framing them as unhelpful and undesired, and turning these into positives or adaptive. The positive-psychology field, on the other hand, is focused on providing individual tools that help him or her to harness strength. The goal here is for an individual to be present with emotions and discomfort without judgement, tolerate and contain these intense feelings, and not allow them to interfere with daily life. Negative thoughts or emotions are not considered good or bad, or even important, they just are. Within the field of positive psychology, we are focusing on embracing emotions and cultivating inner strength and coping skills that can help individuals successfully navigate challenges.
Dr. Leopold:You appropriately caution against inferring causation here; since your study is observational and cross-sectional, you’ve studied correlation but not proven that the positive-psychology factors actually produce the benefits they’re associated with. And yet, you use words like “positive-psychology factors did contribute…” and “positive-psychology variables together explained…”. You’re an experienced investigator, so you know better than most the difference between association and causation; why did you feel so comfortable using language like that in a study of this design?
Dr. Vranceanu: This is an important point and I am glad you are bringing this up. I appreciate CORR’s rigorous approach to interpreting results, which ensures that conclusions do not go beyond what the data can support.
We designed the current study to inform interventions and practices that can improve patient care and facilitate recovery. While it is likely that positive-psychology constructs, pain, and disability all are interrelated, we had imposed directionality on the analysis a priori (that is, the direction from positive psychology constructs to the endpoints of pain and disability) because we wanted to find whether and which of these positive psychology constructs are relevant for orthopaedic patients. With that information in hand, we thought we might then have the ability to target interventions based on these findings, in the hopes of improving patients’ recovery trajectories, and mitigating pain. Randomized controlled trials in a variety of medical populations have shown when we teach individuals positive-psychology skills, they report improved health and function [2, 3, 5, 7, 8, 14].
From a theoretical standpoint, positive psychology constructs are what we call “higher-order traits”, meaning they more-directly influence (rather than are influenced themselves) by life events like an orthopaedic illness. To simplify, it makes more sense that an individual who is generally grateful, satisfied with life, and mindful (that is, accepting emotions and thoughts as they are, and engage in activities regardless) will report less pain and higher function, than to think that the onset of an orthopaedic illness will decrease a patient’s gratitude, mindfulness, and satisfaction with life. Mindfulness, gratitude, and satisfaction with life allow an individual experiencing a challenge (stressor or orthopaedic illness) to not “get stuck” or fused with this event, and be able to put it in perspective. They are what we call resiliency factors, that shape coping with adversity, in this case, orthopaedic illness.
Dr. Leopold:How can surgeons introduce these ideas to patients in practice? How can surgeons model the values, habits, and strategies you studied here for their patients? Do we all need to meditate every day? Or is it sufficient just to talk about these strategies with those whom we treat?
Dr. Vranceanu: We can all benefit from meditating every day, practicing gratitude and appreciation, and focusing on increasing satisfaction with life! Practicing these skills ourselves can be particularly helpful—we can all get better at understanding our own emotions, approaching them with curiosity, and learning to contain them or let them go rather than automatically reacting to them, whether these are frustrations that a patient is not getting better, or that a patient is experiencing symptoms that are over and above what a radiograph shows, or general life stress. When physicians practice these skills, whether mindfulness, empathy, or self-compassion, it becomes less challenging to use them with (and teach them to) our patients. If we become aware of what we are feeling and make room for these emotions, we can become better at connecting with our patients. Positive psychology connects us with our humanity, and it is an equalizer with our patients. When we experience the benefit of practicing these skills, we become more authentic when we recommend these skills and strategies to our patients. And, importantly, we also can build our reserve for whatever challenges come our way, whether life stress or our own illnesses.
Dr. Leopold:Some surgeons may believe that factors like gratitude, coping through humor, and certainly satisfaction with life are traits that are fundamental to an individual’s personality, rather than elements that can be modified; in this paper, you say the opposite is true, and that these factors indeed are highly modifiable. Why do you think so, and how easy or hard are they for most of us (or most of our patients) to modify?
Dr. Vranceanu: We are all born with a biological predisposition, and some of us are lucky enough to also have life experiences or context that allow them to be naturally high on positive-psychology constructs, or to nurture these tendencies in ourselves. If you are naturally high on positive psychology constructs, you will have an easier time adjusting to orthopaedic illness or life stress. However, most of us need to do the work. Intervention-based research shows that positive-psychology constructs are modifiable [2, 19]. An orthopaedic illness can be a “teachable moment” that can increase motivation to engage in this line of work.
Dr. Leopold:Presumably, if your findings hold not just for hand surgery but for the rest of orthopaedic surgery as well, your findings might also apply to other medical and surgical interventions. If that is the case, it sounds like we may need more mental-health providers than we now have in order to teach positive psychology in every practice setting, unless you have some suggestions that practicing surgeons (and internists, and neurologists, and …) can use in the flow of their daily routines. What can you offer busy physicians in this regard?
Dr. Vranceanu: We already know that positive-psychology factors are helpful not only for patients with disorders of the hand, but also for other medical populations. Our team has shown that mindfulness is associated with lower risk for chronic emotional distress among patients with acute brain injury admitted to neuro-intensive care units, as well as their caregivers. We’ve done similar work for patients with chronic pain and neurofibromatosis [4, 10, 11, 18]. I think integrated medical practices (akin to integrated primary care practices) would be ideal, but we need buy-in from surgeons and insurance companies who would have to cover the cost. The ability to deliver interventions feasibly via live video is particularly useful for those who need to travel long distances for weekly clinic visits. I think surgeons have a unique opportunity to introduce these concepts to their patients as part of their visit. We have come a long way since 2007 when I first started working in this field. It’s an exciting time and I am thrilled that journals like CORR, as well as orthopaedic surgeons and the NIH are opening the door for clinical research that moves away from just the knife and the needle to address comprehensively the whole experience of an orthopaedic illness.
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