Where Are We Now?
Uncertainty is a normal part of the human existence, yet for some, it can be aversive and threatening. Intolerance of uncertainty refers to challenges managing the experience of “not knowing”, and is associated with a range of cognitive, emotional, and behavioral responses aimed at resolving the aversive experience . Older theories considered intolerance of uncertainty to be a symptom, but recently researchers have proposed that intolerance of uncertainty is a core construct associated with the development and maintenance of many psychological difficulties [6, 8]. This contention is based on mounting evidence [2, 4, 14] showing that intolerance of uncertainty is a common factor across a variety of psychological conditions including anxiety disorders (generalized, social, obsessive compulsive, health anxiety), depression, eating disorders, and psychosis.
Intolerance of uncertainty can also be relevant to patients when adjusting to medical illness. Although the body of research is small, several studies have shown that intolerance of uncertainty is associated with distress among cancer survivors  and individuals with neurological illness . Uncertainty is also relevant to the experience of musculoskeletal pain.
In the current study, Donthula and colleagues  found that among the patients we treat, intolerance of uncertainty is associated with more pain and lower physical function. As humans, we are biologically predisposed to notice and make sense of pain sensations. For patients with a high level of intolerance of uncertainty, pain sensations can trigger negative thoughts, (“there is something seriously wrong”, “my doctor is missing something”), negative behaviors (hypervigilance, avoidance, multiple doctors’ visits and medical procedures, excessive reassurance seeking), and negative emotional responses (anxiety, depression) that reinforce each other over time and increase pain and limitations. Taken together, these findings suggest that surgeons should be aware of intolerance of uncertainty in their patients in order to improve outcomes and provide the best patient care.
Where Do We Need To Go?
Despite mounting evidence [10, 15] showing that psychological factors explain a substantial amount of variance in reports of pain and physical function among our patients, current practices continue to overemphasize treating the disease rather than the person. Although progress has been made during the last decade, several key barriers (including established cultural patterns, mental health stigma, lack of trained providers, misconceptions about pain, disability, and the role of surgery, and challenges with current healthcare reimbursements that make it easy to get surgery and hard to access psychosocial care ) have slowed the transition toward biopsychosocial models of care in orthopaedics. Of these barriers, stigma is both pervasive and, arguably, the most-challenging to address, as it affects both patients and surgeons. In my experience, patients don’t expect surgeons to ask questions about their psychosocial functioning, and surgeons themselves don’t feel comfortable discussing psychosocial factors, and are worried about offending their patients . Intolerance of uncertainty, as a core construct, may bypass this barrier because it does not have the ingrained negative connotations associated with other cognitive, behavioral, and emotional aspects of pain.
Assessing and addressing high intolerance of uncertainty among our patient population may be an effective and efficient way to improve physical function and pain outcomes. Ignoring it means that we will not only miss out on helping our patients experience less pain and improved function, but we may inadvertently reinforce their transition to persistent pain through well-intentioned surgical or medical procedures.
How Do We Get There?
Surgeons can generally recognize patients who have high levels intolerance of uncertainty—those who are not put at ease by reassurance on their course of illness, who seem upset when they hear that a particular test is negative, or who seek absolute certainty (“are you absolutely sure?”). Patients who endorse symptoms of depression or anxiety, or those who catastrophize or avoid, are also likely high in intolerance of uncertainty. One of the easiest ways to address uncertainty in the orthopaedic practice is to normalize it, validate its challenges, provide educational information on its role in the maintenance of pain and limitations, and encourage patients to focus on understanding the function of their behaviors around uncertainty in the short-term (escape distress). The surgeon and the patient for example, can both acknowledge the uncertainty, and make a plan for meeting at set time intervals (rather than when patient’s distress is high) for exams and reassurance. The goal is to help patients learn to become comfortable with this uncertainty rather than threatened by it. Further, it is important for orthopedic surgeons to refrain from performing medical tests and procedures that are triggered by the patient's intolerance of uncertainty.
In order to provide patients with comprehensive, high-quality care, it will be important to develop or adapt current evidence-based psychosocial interventions for the needs of patients presenting to orthopaedic practices. Current evidence-based protocols to treat intolerance of uncertainty exist , but are not easily transferable to our patients. We need to adapt such intervention to be feasible and accepted through direct feedback from patients and providers to ensure buy in and participation. If delivered early on, after the first orthopaedic visit, such programs can be highly effective and require little time commitment from patients. “Toolkit for Optimal Recovery”, a novel program developed specifically for the needs of patients with orthopaedic trauma, has shown feasibility and efficacy in reducing pain and improving function [11, 12]. The program has only four sessions, which are delivered virtually at a time that is convenient to patients. Although this particular program is delivered by a psychologist, it could be implemented and delivered in a cost-effective manner by trained nurses or medical assistants. A similar model can be used to develop an intervention targeting intolerance of uncertainty as the core construct. Such an intervention delivered via live video, if reinforced by messages from orthopaedic surgeons, may be particularly effective. Collaboration from orthopaedic surgeons is of utmost importance to ensure that patients receive a unified message. Once efficacy is established, there is an opportunity to develop mobile applications that can deliver skills without the need of a provider. Through shared decision-making with the patient , including the use of decision aids at the orthopaedic visit, a treatment plan addressing intolerance of uncertainty can be implemented. Such a plan should include virtual or application-based skills training depending on individual patient presentation and circumstances.
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