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Topical review

Reassurance: Help or hinder in the treatment of pain

Linton, Steven J.a,*; McCracken, Lance M.b; Vlaeyen, Johan W.S.c,d

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doi: 10.1016/j.pain.2007.10.002
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1. Introduction

Because patients normally worry about symptoms and may fear serious disease, reassurance is a logical intervention in a variety of pain conditions, and many practitioners consider it an essential part of a consultation [18]. Reassurance is specifically recommended for patients seeking care for back pain [2,13,22,32]; “We must address our patients’ fears and anxieties with firm, consistent and if necessary repeated reassurance. This is one of the major roles of the doctor…to provide reassurance that there is no serious disease.”[39, p. 185]. The purpose of this paper is to examine the effects of reassurance in the treatment of pain problems, and to consider its conceptualization.

“Reassurance” needs defining since it can refer to a process, method, or outcome, creating conceptual confusion. According to the Oxford dictionary, reassurance “…removes the fears or doubts of (pain/illness); to comfort”. Reassurance always takes place within the dynamics of the interaction between the caregiver who has the intention to reduce worry, and the patient who is concerned. Ultimately, reassurance is achieved if the patient changes his/her behavior, understanding or thoughts. The method of “reassurance”, on the other hand, is in the behavior of the healthcare provider (HCP). The HCP has an array of techniques that essentially include verbal processes of information, instruction, and persuasion [7].

2. Effects from the caregiver’s perspective

2.1. Information

Reassurance is typically provided in the form of accurate or potentially corrective verbal information, and a crucial question is whether patients respond with reduced fear or fewer health complaints. A study that sheds light on this question in primary care settings in the United Kingdom investigated how patients with various pain problems responded to doctors’ reassuring information [11]. First, they found that doctors “reassure” by providing information and diagnostic test results. Further, when doctors tried to dismiss a disease (“doesn’t sound serious”) or provided a physical explanation not related to the patient’s concerns, patients responded by further elaboration of their symptoms and requests for tests. Only when doctors provided reassurance that included a relevant (to the patient’s concerns) explanation that linked physical and psychological factors was the explanation accepted [11]. Thus, when patients experience the information as a lack of understanding of the legitimacy of the complaint, they responded by asserting the complaints more forcefully [35].

The effects of information have been reviewed for patients with low back pain. While “traditional” information based on a biomedical model is of limited value, specific information with a clear message in line with current guidelines could positively affect beliefs and outcomes even if the effect size is fairly small [6]. Among the positive studies are those from Australia illustrating that a media campaign can change beliefs [4]. However, a systematic review of RCTs using information showed that only 3 of 11 studies had positive results; the authors conclude that information is not sufficient to alter behaviors such as sick leave or health care utilization [16].

The effects of information as reassurance may vary depending on the patient’s level of health anxiety. An ingenious investigation evaluated patient ratings before and after reassurance in connection with gastroscopy [25]. Sixty patients completed several questionnaires one week before the examination (and reassurance), and at four follow-ups. Results showed that anxiety and illness beliefs decreased significantly immediately after the reassurance. However, patients with high health anxiety at the pretest demonstrated resurgence in their worry already after 24h and this was maintained a year later. This underscores that reassurance may be helpful for those with lower levels of worry, but not for those with high levels. Indeed, the psychological literature suggests that direct attempts to change thoughts or beliefs, such as by providing information, are not as effective as experience-based methods [9,15,20].

2.2. Diagnostic tests

The results of diagnostic tests often are included in the hope that they are more persuasive than the verbal explanation alone. For example, MRI examinations for chronic headaches [19], acute back pain [31], or even breast pain [12] may have little diagnostic or treatment value, but are often ordered to reassure the patient.

A large study in the Netherlands investigated the effects of imaging by comparing 1000 women with, and 1000 women without breast pain [12]. Imaging provided no clinical value, but was used to reassure the patient. Yet, the effects of negative test results for those screened for cancer suggest a transient positive effect [40]. Similarly, in a study of chronic headache sufferers who were randomized to either receive a brain scan or treatment as usual, negative results only reduced worry on the short term, but not at the 1-year follow-up [19].

There has also been some controversy concerning the benefits of imaging for acute low back pain, not least because reassurance is part of guideline management [23]. To this end, 246 patients with low back pain were randomized to either early MR imaging (within 48h) with information, or to blinded testing where neither the physician nor the patient received the MR results [31] and all received conservative care. Providing information about the MR did not show measurable value for care or outcome but did decrease patient reported well-being.

The use of diagnostic tests may also occur even before the condition becomes painful. For example, 40 patients referred for an echocardiography because of symptoms or a heart murmur were reassured by the consulting cardiologists that their heart was indeed normal [27]. The impact of this information depended on the patient’s situation. All 10 patients who already experienced symptoms remained anxious about their heart after the test, and of the 20 referred because of a murmur (but with no heart abnormality) who were anxious, 11 remained anxious despite the reassurance.

3. Effects from the patient’s perspective

3.1. Social and emotional influences

Because reassurance deals with emotional, cognitive, and behavioral factors, an interesting aspect is how these interact to determine the overall impact. In a qualitative study of clinician–patient interactions, Donovan and Blake found that clinicians attempted to provide reassurance by underscoring the mildness or the early stage of the problem as well as the probability that the patient would recover [10]. However, the results showed that this increased worry for future pain and disability. On the other hand, the importance of the emotional valence of a message was seen in a study of the effects of normal cervical tests where the patient’s request for future tests was mediated by how reassured the patient felt by the message [29].

Expressing empathy may be a critical element in reassurance. Expressing empathy comprises the acknowledging and understanding of what the patient is experiencing and includes elements of respect and acceptance [14]. For example, patients with so-called medically unexplained pain have been found to desire more emotional support than other patients, even though they do not demand more explanations or information [37]. Another study of the clinician–patient interaction focused on the relationship between medical and psychosocial aspects [33]. This study revealed that while patients signaled psychosocial difficulties, GPs focused more on physical disease and that few GPs empathized with their patients. They concluded that the reason such patients are often given unnecessary physical interventions is associated with the GP’s responses rather than the patient’s demands. Similarly, another study of primary care patients found that GPs recommended physical treatments such as analgesic medications or tests regardless of the patient’s attribution to disease [36]. Some evidence also shows that changing expectations with positive information works best when combined with emotional support [1]. Thus, the clinician may need to demonstrate they “understand” the patient’s problem and that the problem is legitimate. Empathy may allow the patient to engage in treatment instead of needing to focus on having their symptoms understood or believed [21,30].

3.2. Can reassurance have adverse effects?

Some studies suggest that reassurance can increase fear. Importantly, a study of parental reassurance in children undergoing painful procedures demonstrated unexpected and counterintuitive results: reassurance was associated with increases in verbal expressions of fear, resistance, crying and restraint [28]. The authors put forward at least three possible reasons for this paradoxical association. First, by providing reassurance, the parent is conveying the message that indeed there must be some danger to worry about. Thus, children, who were not worried before, start worrying as a result of reassuring behavior of their parents. Second, children who are apprehensive will more easily trigger caregiver reassurance, which in turn may reinforce distressed behavior. Third, parental reassurance may facilitate the release of negative affect. Reassurance apparently can have unintended adverse effects.

4. Discussion

Based on the literature, the effects of reassurance on pain related problems are inconsistent, sometimes small, sometimes transient, and sometimes paradoxical. Thus, general recommendations for reassurance appear premature and a better understanding is needed.

We submit that current recommendations to employ reassurance rest on an implicit conceptualization that is not fully concordant with existing evidence. This implicit model for reassurance assumes that information effectively corrects mistaken beliefs which will, in turn, reduce fears or worries based on those mistaken beliefs, and that when thinking and emotions come in line, healthy behavioral functioning will follow. However, learning studies show that reducing pain-related fears may be difficult [16,24,25] and their return frequent because there is a basic difference between the acquisition (easier) and extinction (more difficult) of emotions [3,17]. While this implicit model has face validity, it clearly does not accommodate complexities in the experience of pain.

A better model of reassurance is likely to come from a more complete and precise theory of learning and behavior change. The review above suggests that characteristics of the patients and their history as well as characteristics of the communication, for example, empathy, will affect learning. Thoughts, beliefs, and moods vary in the ways they impact on behavior for different people in different situation [26]. For example, catastrophizing thoughts and worry about pain are common in the general public [5,38], but do not lead to problems for many people. Further, reassurance may increase a patient’s problems if it reinforces so-called safety-seeking behaviors like requests for tests or information [34]. Thus, complex situational factors may influence the results of providing reassurance and they may also explain inconsistencies in the literature.

Clinically, a new model would suggest that while didactic information may help to reduce fear and change behavior in some situations, it may be less effective than direct exposure or direct verification. Further, rather than attempting to suppress the fear and worry, an alternative approach might be to reduce their impact, such as by providing empathy and enhancing acceptance so that they do not result in avoidance or other forms of restrictive behavior patterns [8,26].

5. Conclusions

Although reassurance is one of the most frequently recommended procedures for pain, this procedure has a surprisingly thin evidence base. While the implicit model for reassurance is compelling, we conclude that reassurance is a complex process involving an interaction of patient experience, thoughts and beliefs, and emotions in a social context as well as an outcome measured in health behavior. There is a need for a sound theory of reassurance which distinguishes between the outcome process (patient) and reassurance methods (HCP perspective) so that reassurance might be utilized for best results.

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