Ev
ery clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Hi Dr. Swiontkowski
Thank you for your post which yet again provides insight into how psychosocial factors influence the pain experience.
When reading your post I find the way you explain pain as an underlying physical “thing” with psychosocial factors that can influence this physical “thing”. I sense the urge to divide the pain experience into categories but maybe I am misreading it?
Here are a few examples.
“We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history.”
Well we know all pain is biopsychosocial all the time, everytime. So I’m confused at what the intention of the above mentioned? With most pain psychosocial factors not biological factors seem to have the best prognostic predictors which is opposite of what most people and health care practitioners believe. Would you agree?
“I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.”
How can incompletely treated anxiety or depression NOT influence a patient’s pain response? Again pain is biopsychosocial and of course they will influence the pain response as everything else that is a part of that person will. Also if one wanted to misread this paragraph it could be interpreted as pain is a conscious decision made by the person (person’s response) and not a subconscious act by the brain.
“but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.”
They are always both and can not be only one or the other as the whole human experience consists of both psychosocial and physical input/state. You can not feel pain without consciousness though you can feel pain without a body part.
What are your thoughts on my perception or remarks?
Kind regards,
Simon Roost Kirkegaard
Dr. Kirkegaard:
Thank you for your letter on my commentary posted in OrthoBuzz regarding the manuscript entitled “Mental Health Medication Use Correlates with Poor Outcome After Femoroacetabular Impingement Surgery in a Military Population,” authored by Ernat et al.
I sense that the phenomenon of pain perception and response is an area of active research for you. I agree that in most cases biopsychosocial factors are the dominant prognostic predictor. In the case of high velocity trauma, the best prognostic factor may be injury characteristics rather than biopsychosocial factors.
My point was that we in orthopaedic surgery need to study the biopsychosocial impact on patient functional outcomes to a much greater degree than we have in the last two to three decades.
Thank you again for writing
Sincerely
Marc Swiontkowski, MD
Hi Marc
Thank you kindly for your response.
I very much agree with your conclusion that we need to study biopsychosocial impact on patient functional outcomes, but this was not the impression your article gave me. My current understanding is that with most pain and development of pain our best predictors are psychosocial factors and not biopsychosocial.
I would be interested in seeing studies that show high velocity trauma in which the best prognostic factors are the injury and not psychosocial factors. Would it be possible for you to reference these?
From my view we need to stop dividing the physical from the psychological and social. You cannot take the consciousness out of the person and only treat the tissues. We need to address everything and we need to explain treatment and pain from a whole-person perspective. Giving pathoanatomical explanations for pain has shown to induce nocebo or be of no help. Even the phenomenon nocebo is not well known in health care, which is very uncomforting for me but I would assume also for patients if they knew and understood the potential harmful effect.
Simon Roost Kirkegaard
Simon, if you search for the LEAP trial from a decade ago, you will find references to the issue of magnitude of injury trumping other factors in relation to functional and social outcomes.
Thank you for your interest in The Journal.
Marc Swiontkowski