Patients in pain rely heavily on coping mechanisms to get them through their day but are these mechanisms helpful or hurtful? Coping with pain can be described as an initial appraisal of pain and evaluation of personal resources available to deal with it, followed by cognitive, behavioral, and emotional responses based on those appraisals (Tan et al. 2011). Pain coping responses are generally placed in two categories: adaptive and maladaptive.
Adaptive behaviors tend to be more active (e.g. exercise, problem solving, regulation of emotion) while maladaptive behaviors are more passive (e.g. rest, avoidance, escape). Adaptive coping behaviors are associated with less pain, less depression, less functional impairment, and higher general self-efficacy, whereas maladaptive coping behaviors are associated with greater depression, greater pain and flare-up activity, greater functional impairment, and lower general self-efficacy (Bussing et al. 2010). If maladaptive coping negatively affects adjustment strategies for people in pain then it’s necessary to identify these people in order to employ appropriate treatment strategies, but how?
Maladaptive behaviors are those that are either non-beneficial or even negatively affect a patient’s ability to successfully adjust to pain. These behaviors usually arise from cognitions regarding their situation, which is part of the appraisal portion of the above mentioned definition of coping. Three important cognitions for determining whether or not someone will use passive coping strategies are fear, catastrophizing, and their current beliefs.
Fear is defined as a distressing negative sensation induced by a perceived threat. Fear is useful because it is an alarm system for the body along with pain, but many times it can be unfounded. Fear within the general population is associated with the belief that increased activity, movement, or exercise will not only increase pain, but create further damage (Louw and Puentedora, 2013). As clinician’s, we know that’s not the case but patients are dealing with the unknown, so it is understandable that pain creates fear. They don’t know what is happening to them, if they will get better or not, how they will get better, or how long it will take, etc… Fear stops individuals in their tracks from doing their normal activities and this fear avoidance has been linked to increased risk of disability and work loss (Louw and Puentedora, 2013).
Catastrophizing is the inability to foresee anything but the worst outcome in a given situation and/or interpreting a situation as unbearable or uncomfortable. This leads to apathy, further disuse, and fear avoidance. For example when someone hurts their back and a clinician tells them that they have a herniation, large or small doesn’t matter, and the patient says things like “oh my god my life is over”; “I’ll never be able to go back to work like this”; or even “I will be in a wheelchair soon, how can this happen to me?”. These are all very dramatic thoughts, that based on what we know about back pain, arthritis, etc…. Is all very unlikely to be the end game.
The last little bit that hinders someone’s ability to cope is their current beliefs and understanding of pain, dysfunction, and movement. Many believe that because they don’t fully comprehend what is going on with their body they seek people like us to help and find safety. This is great, it’s why we are here but this becomes troubling when they believe that we’re the only ones that can help. Maybe they believe only medications or surgery are the answer? This is passive care and we know that passive care is not the answer for people in pain especially chronic pain. By feeding into this we actually increase disuse by transposing all responsibility onto the clinician and off of the patient.
Here are some maladaptive behaviors created by these cognitions that will help you identify people who may be struggling to adapt to their situation.
- Increased rest or belief that rest is the only thing that will help
- Withdrawal from normal daily activities or social life
- Poor compliance with MD suggestions or therapy
- Reports extremely high or over exaggerated pain
- Excessive use of aids or appliances
- Overuse of medical professionals or a large number of medical professionals involved in treatment
- Overuse of prescription pain medication or over the counter medication
- Decreased desire for movement, fear of movement, or stopping exercise regimen
You may also use some very beneficial outcome measures. The Fear Avoidance Beliefs Questionnaire (FABQ) is a great tool that has been proven to show acceptable levels of reliability and validity. Another good outcome measure to use is the Pain Catastrophizing Scale (PCS) and a third is the Coping Strategies Questionnaire. Hope this helps you on the endless journey of patient care. Thanks for reading….