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Temporomandibular Joint Disorder https://www.instituteforchronicpain.org Mon, 30 Jan 2023 17:57:23 +0000 Joomla! - Open Source Content Management en-gb Is Degenerative Disc Disease Inevitably Degenerative? https://www.instituteforchronicpain.org/blog/item/136-39is-degenerative-disc-disease-inevitably-degenerative https://www.instituteforchronicpain.org/blog/item/136-39is-degenerative-disc-disease-inevitably-degenerative

It’s common to be upset when you’ve been told that you have degenerative disc disease. It’s an awful sounding diagnosis. It sounds like you have a disease that is deteriorating your spine. And on top of it all, it doesn’t sound like there’s much you can do about it. The spine, it seems, is inevitably degenerating.

Patients commonly express the belief that their chronic back or neck pain is a progressive condition that will unavoidably lead to greater and greater pain and disability. They’ve been told that they have degenerative disc disease and that it is the cause of their pain. It was found on their MRI scan of the spine. Since the cause of their pain is called ‘degenerative,’ they understandably believe that it’s inevitable that they are going to get worse. Their future, it seems, holds nothing but increasing pain and impairment.

Sometimes, healthcare providers believe that degenerative disc disease is inevitably degenerative too. Commonly, patients tell me that they’ve been told by their healthcare provider that they will end up in a wheelchair someday or that the provider is surprised the patient can walk upright given the extent of the findings of degenerative disc disease that’s evident on the MRI scan. Such comments by healthcare providers seem to indicate that they too believe that degenerative disc disease is inevitably degenerative, progressively leading to a worsening of pain and disability.

What is the natural course of degenerative disc disease?

How confident should we be in this belief that degenerative disc disease is inevitably degenerative? What does science tell us aboutDegenerative Disc Disease what happens to so-called degenerative changes of the spine over time? In healthcare, studies of what happens to health conditions over time when left untreated are called natural history studies. Such studies simply track a condition over time to see what its natural trajectory is– whether the condition tends to get better or worse. It would be helpful to look at natural history studies of the conditions that fall under the category of degenerative disc disease. We'd then know what the natural trajectory is for such conditions.

Degenerative disc disease is a catchall phrase for a number of conditions of the spine. These conditions are typically evident on CT and MRI scans. They are a loss of disc height, disc bulges and herniations, annular tears, endplate changes, osteophyte complexes, neuroforaminal stenosis, and central canal stenosis, among others.

Let’s look at what happens to these conditions over time. Many chronic back or neck pain patients have such degenerative changes in their spine as evidenced by MRI or CT scans and it will be helpful to know something about what typically happens to them if you have them. Contrary to popular belief, we will find that the changes to the spine that we call degenerative disc disease are not inevitably degenerative.

When patients review this research, they tend to be a little surprised. They have long thought of their condition as inevitably progressive and it can take a little bit of time to get used to the idea that their condition is not as degenerative as they had thought it to be. Moreover, they are frequently a little skeptical. One of the most common exceptions to the review of this research goes something like, ‘Well, Doc, I’ve been told that my degenerative disc disease is very severe… Severe or advanced degenerative disc disease is going to get worse. How could it not?’ That is to say, a common belief about degenerative disc disease is not only that it is inevitably degenerative, but that the more advanced it is the more progressive it will be. Another way to put it is the belief that the worst or most advanced stages of degenerative disc disease will always tend to lead to the most severe pain and disability. So, let’s review what science tells us about what happens to the most advanced or worst degenerative changes over time too.

Specifically, with our review of natural history studies of degenerative disc disease, we want to determine the answers to two questions:

  • Do degenerative changes to the spine inevitably worsen?
  • What happens to the most severe degenerative changes?

Natural history studies of degenerative disc disease

Symmons, et al., (1991) were some of the first investigators to look at these questions. They took X-rays of 742 women aged 45 or older and then repeated the X-rays 8 to 11 years later. They broke women into two groups, those with back pain and those without back pain. They found degenerative changes in both groups. They also found that degenerative disc disease progressed most often in those with back pain. Over the study period, they found that almost 60% of women with back pain had a progression of their degenerative disc disease; whereas, a little more than 30% of women without back pain had a progression of their degenerative disc disease. Notice, however, that progression of degenerative disc disease is not inevitable. The remaining 40% of those with back pain had degenerative disc disease that did not get worse. The remaining 70% of the women without back pain had degenerative disc disease that did not get worse.

This study relied on X-rays, rather than more accurate CT or MRI scans. Is there evidence of the same findings with CT or MRI scans?

Using MRI scans on a repeated basis, Matsubara, et al., (1995) followed 32 patients with herniated discs in their lumbar spine over the course of a year. They found that 62% of the disc herniations spontaneously reduced in size and the remaining 38% of herniations did not get worse. In this study, we see a significant degenerative disc problem – herniations – tending to get better the majority of the time. Even when disc herniations failed to get better, they did not tend to get worse. Here, we find that the disc herniations are not inevitably degenerative.

These researchers also found data that pertains to the severity of disc herniations. Contrary to the popular belief that the worst problems tend to become more problematic, they found that the larger the disc herniation, the more it reduced.

Another spinal condition that falls under the category of degenerative disc disease are endplate changes. Hutton, et al., (2011) reviewed two groups of patients with lumbar-related endplate changes who had had MRI’s repeated over time. The first group was 36 patients with a minimal level of endplate changes. The second group was 22 patients with a more advanced stage of such changes. Of the first group with less significant endplate changes, half remained the same; a little less than half got worse; and two patients reversed back to normal. Of the second group with the more advanced changes, most remained the same; some got better and none got worse.

Here again, we see two important facts about this specific type of degenerative change. First, in its least advanced stage, sometime it does get worse, but only less than half the time. Thus, we really can’t say it is inevitable that it gets worse. Second, contrary to the notion that the more severe spine problems always lead to more severe consequences, we see that the advanced stages of endplate changes generally stay the same. Sometimes it gets better, but they don’t tend to get worse.

Park, et al., (2013) found in a sample of 27 cervical spondylolisthesis patients that only three had a progressive worsening of their condition over a 2-7 year follow-up period. None of the three experienced any significant neurological injury or an increase in their symptoms as a result.

Humphreys, et al., (1998) looked at still other conditions of the spine, which are associated with degenerative disc disease. They found that foraminal stenosis did in fact narrow with age but found no progression of disc height, lordosis, or central canal stenosis. So, here again, we find that degenerative changes of the spine are far from inevitably degenerative.

Regarding the latter, Karadimas, et al., (2013) reviewed the literature on cervical spondyltic myelopathy, or a degenerative narrowing of the spinal cord in the area of the neck, and found that the condition naturally worsened in 20-60% of the cases. Again, we see a significant degenerative condition can get worse, but does not always get worse. Indeed, depending on the study, 40-80% of the time it does not get worse.

Some might counter with a subtle variation of the second question we have been attempting to review, namely that the most advanced degenerative disc disease tends to be more degenerative. They might acknowledge that degenerative disc disease itself may not inevitably become worse. They might even acknowledge that the most advanced stages of such changes don't tend to inevitably get worse. However, they might argue that the most severe degenerative changes to the spine do in fact lead to greater pain and/or a greater decline in functioning. In other words, those with the most severe degenerative disc disease will inevitably experience the greatest pain and disability.

A recent study by Berg, et al., (2013) inadvertently sheds light on this point. They were interested in looking at whether degenerative disc disease correlates with pain and disability in a sample of 170 low back pain patients who had been recommended for disc replacement surgery at either of the two lowest disc levels of the lumbar spine (i.e., L4-5 & L5-S1). Presumably, the degenerative disc disease evident at these two levels was severe enough to have the surgery recommended to them. Interestingly, they found no significant correlation at all between degenerative disc disease and either pain or disability. Even among a subgroup of people with the most severe degenerative changes (the severest of the severe), they still found no correlation. They subsequently added findings of facet arthropathy, another degenerative condition, and with the combination of degenerative disc and facet changes they still found no correlation between such changes and either pain or disability. In other words, neither more severe findings of degenerative disc disease nor a greater amount of such degenerative conditions lead to a worsening of pain or impairment. (This study highlights another interesting question to which we tend to all assume we know the answer – to what extent does degenerative disc disease explain chronic back or neck pain. This question will be taken up in our next blog post).

Concluding remarks

To summarize, we set out to determine the truth of certain common beliefs that patients have about degenerative disc disease. These beliefs are that degenerative disc disease is inevitably going to worsen, or at the very least the most severe degenerative changes are always going to get worse. By reviewing what the science tells us about degenerative disc disease, we see that neither of these beliefs are true. While degenerative changes do sometimes get worse, they often either remain the same or get better. Also, we see evidence that the worse the degenerative condition is, the more it tends to either stay the same or get better.

Has your healthcare provider ever told you or implied that degenerative disc disease was inevitably going to get worse? Why do you think that this belief continues to be common when the scientific literature doesn't support it?

References

Berg, L., Hellum, C., Gjertsen, O., Neckelmann, G., Johnsen, L. G., Storheim, K., Brox, J. I., Eide, G. E., & Espeland, A. (2013). Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis. Skeletal Radiology, 42(11), 1593-1602.

Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23, 2180-2184.

Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.

Karadimas, S. K., Erwin, W. M., Ely, C. G., Dettori, J. R., & Fehlings, M. G. (2013). Pathophysiology and natural history of cervical spondyltic myelopathy. Spine, 38(22S), S21-S36. doi: 10.1097/BRS.0b013e318a7f2c3

Matsubara, Y., Kato, F., Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.

Park, M. S., Moon, S. H. Lee. H. M., Kim, S. W., Kim, T. H., Suh, B. K., & Riew, K. D. (2013). The natural history of degenerative spondylolisthesis of the cervical spine with 2-7year follow-up. Spine, 38(4), E205-E210. doi: 10.1097/BRS.0b013e1827de4fd

Symmons, D. P., van Hemert, A. M., Vandenbroucke, J. P., & Valkenburg, H. A. (1991). A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings. Annals of the Rheumatic Diseases, 50, 162-166.

Date of last modification: 3-27-2021

Author: Murray J. McAllister, PsyD

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Degenerative Disc Disease Mon, 10 Mar 2014 07:11:19 +0000
What is your relationship to chronic pain? https://www.instituteforchronicpain.org/blog/item/135-38what-is-your-relationship-to-chronic-pain https://www.instituteforchronicpain.org/blog/item/135-38what-is-your-relationship-to-chronic-pain

What is your relationship to your chronic pain? At first thought, it seems like an odd question. But, if we stop to reflect on it, couldn’t we have a relationship to pain? Don’t you already have one?

The Merriam-Webster Dictionary (n.d.) defines the word ‘relationship’ as “the way in which two or more people, groups, countries, etc., talk to, behave toward, and deal with each other.” We usually think about relationships as applying to people, such as our spouses, children, family, or enemies, but we also have relationships to non-human beings, such as God and pets, and even inanimate things, such as our work, our children's schools, our own alma maters, our country, or nature. We also have relationships to things that are somewhere in between, such as our bodies. Might we not have a relationship to chronic pain?

Let’s look at a number of different possible relationships to chronic pain. We’ll simply try to take an inventory of different relationships without judging whether they are good or bad or better or worse than any of the others. Our only goals for taking this inventory are to see how people relate to chronic pain and to see how different people relate to chronic pain differently.

Chronic pain as something that we must get rid of

In the acute medical model of healthcare, we often treat pain as something that we must get rid of. It’s a bad thing. It’s so bad, in fact, that we might unquestionably go to great lengths and almost all costs to get rid of it. As healthcare providers and as patients, we try one therapy after another, one procedure after another, and one medication after another.

All this healthcare hardly ever requires justification: our relationship to pain is such that it is something, which is assumedly bad -- so bad, in fact, that we must get rid of it.

Chronic pain as something that we fight againstImage by Raj courtesy of Unsplash

Indeed, pain is something that we declare war on. For after all, it is often thought of as fighting us. It’s stabbing, piercing, jolting, burning, and pounding. It’s like hand-to-hand combat, but it’s our hand, or arm, or leg, or neck or low back that’s fighting us. Our bodies have turned against us and the pain is insidious and relentless. It’s taken our life away. Our relationship to pain in such instances is one of fighting and war. Like any people under siege, we vow to maintain hope by never giving up the fight.

Chronic pain as something that imprisons us

Patients commonly tell me that they wish the painful part of their body could just be cut off. When you think about it, there’s something very primitive about this wish. It brings connotations of what an animal might do when caught in a steel jaw trap: it chews its limb off.

Pain can indeed capture our attention and ensnare us. We might find ourselves entertaining doing most anything in order to become pain-free. Our relationship to pain at such times is one of having been taken prisoner. Having lost our abilities to move about freely, we have to stay at home and rest day after day. Our sentence: house arrest.

Chronic pain as a mechanical problem that requires a fix

We can also think of pain as a mechanical problem for which there must be some type of fix. Both providers and patients can relate to pain in this way. Spine surgeons and interventional pain physicians commonly conceptualize back pain as ‘mechanical back pain.’ A common explanation for sciatica is that a disc in the low back has ‘slipped’ or ‘ruptured’ and is now ‘pinching’ the nerve that extends down the leg. It brings connotations of a car engine part slipping out of place or breaking altogether and is now pinching some important cable or hose. In a procedure called a ‘discectomy,’ a spine surgeon attempts to free the pinched nerve by scraping away the part of the disc that’s impinging the nerve. Interventional pain physicians attempt to temporarily reduce the inflammation around the ‘pinched’ nerve with epidural steroid injections. They might also attempt to temporarily deaden the nerve altogether with a rhizotomy (i.e., a radiofrequency neuroablation procedure, or what is called a ‘nerve burning’ procedure).

Chronic pain as something that is the result of a long-lasting injury

We can also relate to chronic pain as something that is the result of a long-lasting injury. In conditions that are acute, such as a bone fracture, pain occurs and we think of it as the result of the underlying acute injury. In such cases, we tend to react to the pain by staying home and resting. Commonly, people think of and react to chronic pain in similar ways. Even if it has been years since the onset of the initial injury that started the pain, we can think of the original condition as remaining unhealed (or even getting worse) and continuing to cause the chronic pain.

As such, we might remain concerned about making the underlying injury worse and engage in behaviors that we think will prevent harm. Similar to what we might do with acute injuries, we might stay home and rest. We also avoid activities that we think have a chance of making the underlying injury worse. In these ways, we tend to think of the pain that occurs with activities as a sign that we are in fact making the underlying problem worse.

Chronic pain as an illness

Sometimes, people with chronic pain think of themselves as ill. Their relationship to pain is one of illness even in cases of chronic pain that started with an injury or had no identifiable cause. They hear explanations for back pain, such as ‘degenerative disc disease,’ and understandably think of themselves as having a disease. People with headaches too can often refer to themselves as 'being ill with a headache.' Conceptualizations of chronic pain as an illness naturally lead to the above behaviors that we do when ill: we stay home and rest. Frequently, pain relievers subsequently get referred to as ‘medicines,’ a term that has connotations of something one takes to cure an illness.

Chronic pain as something that is alarming

In all the above ways of relating to pain, there is a common element: it’s that chronic pain is alarming. Whether it is war or imprisonment or a mechanical problem or an injury or illness, pain is an object of concern. It’s not only bad; it is bad enough to do something about it. In other words, it impels us to act like a fire alarm. Such alarms are emotionally distressing. We become concerned and aroused with some degree of fear. We can also cry when in pain. We don’t jump up and down for joy. Rather, we are emotionally distressed while in pain. As such, pain is alarming.

Differing relationships to chronic pain

As is clear, different people can have different relationships to chronic pain and an individual might have different relationships to his or her pain at different times in life. Moreover, this inventory of possible relationships is not exhaustive. There are more relationships that we could describe.

The point is important to remember because when you are in one of these relationships to pain they seem obviously accurate to the situation at hand. It’s hard, for instance, to recognize that it is just one perspective that you might take on pain when you are in one of these relationships. It can be hard to understand how someone might have a different relationship to his or her chronic pain. For instance, one might say, “Of course, you are going fight against the pain… Who wouldn’t?” The relationship to pain as alarming and something that must be gotten rid of seems so obviously true. What the inventory makes clear, though, is that each relationship is but one perspective and that it is possible to have different perspectives that you can take on your pain.

Are there other relationships to chronic pain? Ones that are very different than the above?

Sometimes people with chronic pain have none of the above relationships to pain and are, in fact, not very alarmed by their chronic pain. Rather than fighting against it, they have made peace with it. They are no longer alarmed by it and instead have learned to live with it.

Some people with chronic pain treat their pain like a noisy neighbor next door or in the apartment above. They once tried to get the neighbors to quiet down, but were unsuccessful and so have come to accept that they must learn to live with them. While the neighbors are still noisy, they no longer allow the neighbors to occupy too much of their time and attention. They still hear their neighbors but they then move on with the rest of their day.

Many people with chronic pain have a similar relationship to their pain. They are no longer alarmed by their pain. It’s there, but they realize that there’s not much they can do about it. So, ‘why fight it?’ they might ask. Instead, they move on with their day and get busy with other things. Of course, they would rather not have it, if they had a choice. But, they recognize that they don’t and so accept it. Part of acceptance is that they are just not that alarmed by pain anymore.

Their relationships to chronic pain involve understanding pain as something that is not alarming. They see chronic pain as part of life – the bad, along with the good, that we just have to put up with.

Now, what might that look like?

Chronic pain as a stable condition

Some people with chronic pain see their pain as a stable condition that doesn’t have any bearing on whether they are healthy or not. They might think of it or refer to it as ‘my old war injury’ or ‘my trick knee’ or ‘my old high school football injury’ or ‘my bad back’ or the like. The connotation in these ways of thinking about pain is that chronic pain is an old condition that isn’t going anywhere. That is to say, it’s stable and not going to get much better or much worse. In its familiarity, there’s not much cause for concern. While they may have seen a healthcare provider initially, a long time ago, there’s no need now to get it checked out. They know what it is and know that it is stable.

Notice too that people like who I’m describing tend not to view chronic pain as a health problem. They don’t see themselves as ill or unhealthy or in need of healthcare because of it. It’s a condition that they put up with. We all have things about our bodies that we don’t like or are bothersome, but we don’t feel any strong need to do anything about it because they are not indicators of an illness or poor health. Sometimes, it can be really big things, such as an old spinal cord injury that led to a paralysis. We don’t consider people in wheelchairs as ill. Paralysis is a stable condition that you live with. It is not an indicator of illness. Some people with chronic pain might see chronic pain in a similar way – it’s a stable condition that doesn’t lead to considering oneself as ill or unhealthy or in need of healthcare.

In these ways, they relate to chronic pain in ways that have taken the sense of alarm out of being in pain. As such, it makes it easier to put up with and they move on with their lives. The ‘bad back’ or the ‘trick knee’ or ‘the old war injury’ comes along for the ride, of course, but it is relegated to the background of their life. It is not a daily cause for much concern.

Chronic pain as part of growing old

Some people with chronic pain relate to their pain as something that just happens to most of us at some point in life. [They are not too far from the truth, in this regard. Anywhere between 20-30% of the general population has chronic pain and the percentages increase as we get older (Andersson, 1999; Manchikanti, et al., 2009; Toblin, et al., 2011.)] In this way, it’s not cause for much concern. It’s not unusual or startling. It’s an expected part of life and so it is not especially alarming. “Things are gonna hurt,” they might say with a certain amount of acceptance. Now, they might do things to manage pain, such as staying active, exercising, pacing themselves, and not doing any one thing for too long of a time. At the end of the day, though, they accept it and have made a place for it in their life.

Chronic pain as a broken check-engine light

A common cognitive behavioral intervention in chronic pain rehabilitation is to teach patients to relate to their chronic pain as a broken dashboard check-engine light. It goes something like the following. Acute pain is like a working check-engine light. When it comes on, it signals or warns us that something is wrong in the engine. As a result, we become mildly alarmed, pull over, and bring the car to the mechanic.

Acute pain has a similar function. It’s a danger signal that warns us that something is wrong in the body. As result, we become alarmed, stop what we are doing (i.e., pull over, as it were), and go see a healthcare provider.

Chronic pain is like a check-engine light that’s broken and remains stuck in the on-position. It doesn’t serve any useful function. The nerves are chronically reactive but they are not signaling any corresponding problem in the body (i.e., engine). Even if it is signaling some underlying problem, there isn’t much you can do about it. So, the check-engine light – the chronic pain – remains lit.

What if you had a check-engine light that remained lit up, but your mechanic says that, while there is a problem in the engine, its basically not fixable. He adds that as long as you drive reasonably, such as not driving a hundred miles an hour, it’s safe to drive. He concludes that you should just ignore the check-engine light and learn to drive with it on. You don’t have to become alarmed by it, pull over or bring the car in every time it comes on or remains on. Now, you are no longer alarmed by it and you know that the car is safe to drive as long as you are reasonable about it. After awhile, you may not notice it as much. The check-engine light remains on, but it doesn't capture your attention as much any more.

Similarly, for most people with chronic pain, it’s safe to keep living life and engage in your normal activities as long as you are reasonable about what you do. With such reassurance from your healthcare provider, you can learn to ignore the pain, relegate it to the background, and not be concerned by it. You don’t have to pull over, as it were, and seek healthcare. You’ve had it checked out and your providers tell you that you should stay active.

The metaphor of the check-engine light takes the alarm out of pain. You still have it. The light is still on when you look at your dashboard, but it is not cause for alarm. So, you keep driving, or living life, engaged in your normal activities, as long as you are reasonable about it.

Some people with chronic pain relate to their pain as if it is a check-engine light that is broken. It provides no useful information. So, they keep living life despite it.

Chronic pain as something you get up and get out of the house for

As we described above, some people with chronic pain relate to pain as an injury or an illness and as such they react to pain as something for which they should stay home and rest. Other people with chronic pain, however, relate to their pain in almost the exact opposite way. When they have a bad pain day, they think to themselves, ‘I got to get up and get out of the house and go do something!’ They tend to think that, if they don’t get out of the house and get busy, all they’ll do is think about how much pain they’re in and how hard life is. In other words, they know they don’t cope very well when they don’t stay actively engaged in the activities of life. As such, they do the exact opposite of those who stay and rest: they get up and get out of the house!

This relationship to pain tends to involve continuing to work despite having chronic pain. For people who relate to pain in this manner, work is not something that one does after they get pain adequately managed; instead, work is a form of pain management. Work helps them to cope with pain. It allows them to get out of the house, structure their day, be involved with others, feel productive, feel good about themselves, and reduces financial stress. All these things buffer their pain by helping them to cope and all of it makes up for any added pain that they may have by being active. Contrariwise, they think that staying home and resting makes them not cope very well. It gets too depressing, for instance, if they don’t have anything else besides pain to hold their attention. They end up feeling unproductive and socially isolated.

Chronic pain as a barometer of what else is going on in life

Some people with chronic pain see their pain as a barometer for what’s happening in their life and how well they are managing it. While they might recognize that they will always have some baseline level of pain due to the medical aspects of their condition, they also understand that the overt fluctuations of pain – whether for the better or worse – are due to how well they are managing the stress in their lives. For instance, they notice that they are having more frequent headaches recently. Rather than understanding it as progression of an illness, they identify that the more frequent headaches are due to the stress of their recent insomnia. Maybe, they notice that their low back pain is worse in the last week. Rather than understanding the increase in pain as the result of ‘degenerating’ discs, they identify that they have been overly busy at work for the last few weeks and as a result they have fallen out of their usual mild aerobic exercise routine.

Understanding fluctuations of chronic pain as reflective of the stress in one’s life allows for people to then do something about it. They work on their insomnia or the workload at work. In other words, they take steps to manage their stress better.

Their relationship to pain is one that involves seeing fluctuations of pain as providing important information. It is not to be dreaded. They don’t feel vulnerable to pain as something that seems to come and go out of nowhere. Rather, they feel empowered by the important information that fluctuations of pain provide them. It allows them to know what they are doing works when their pain reduces or what they need to work on when their pain increases. They know that on most occasions there is a reason for the fluctuation of pain and it involves how well they are managing the stress of their lives. In other words, the relate to chronic pain as a barometer of what's going on in their lives.

Different relationships to chronic pain for different people

As our short inventory reveals, people relate to chronic pain in different ways. Each relationship to chronic pain can feel like the truth. They each seem obviously accurate to the situation at hand. It’s important, however, to recognize that it is possible to relate to chronic pain in very different ways. You don’t have to be stuck in any one particular relationship.

I’ll leave it to the reader to reflect on your personal relationship to chronic pain. You might see yourself in one of the relationships in the inventory above. Or maybe you have an altogether different one. Maybe you could comment on this post and describe it for us. I’ll also leave it to you to consider whether your particular relationship is the most accurate understanding of pain and the one that’s best for you. It may be. However, it might not be.

It is therefore important to reflect on your particular relationship to chronic pain and whether you might change it if it’s not working for you. If you feel stuck, it’s possible to change your relationship to pain. It likely will take some work on your part. It may even require the assistance of some chronic pain rehabilitation providers or a full-fledged chronic pain rehabilitation program. But, it is possible to do. You can change your relationship to chronic pain.

References

Andersson, G. B. (1999). Epidemiological features of chronic low-back pain. Lancet, 354, 581-585.

Manchikanti, L., Singh, V., Datta S., Cohen S. P., & Hirsch, J. A. (2009). Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician, 12, E35-70.

Relationship. (n.d.). In Merriam-Webster Dictionary. Retrieved from http://www.merriam-webster.com/dictionary/relationship

Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

Author: Murray J. McAllister, PsyD

Date of publication: 8-2-2014

ate of last modification: 11-14-2021

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Relationship to Pain Sat, 08 Feb 2014 09:28:28 +0000
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Author: Murray J. McAllister, PsyD

Date of last modification: 1-26-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Sun, 26 Jan 2014 08:42:56 +0000
Reducing Overtreatment & the Profit-Motive in Healthcare https://www.instituteforchronicpain.org/blog/item/133-36reducing-overtreatment-the-profit-motive-in-healthcare https://www.instituteforchronicpain.org/blog/item/133-36reducing-overtreatment-the-profit-motive-in-healthcare

It might be easy to conclude that anyone who wants to reduce the role of the profit-motive in healthcare must be either an extremist or a fool. Upon reflection, however, it becomes clear that we are experiencing an era of overtreatment in healthcare (see, for example, Dr. H. Gilbert Welch’s piece here) and one area where it is particularly apparent is in the management of chronic pain. While there are likely many causes of overtreatment, one of them surely is the profit-motive that occurs within a fee-for-service model of reimbursement.

In the last few posts (dated 12-22-13 & 12-29-13), we have been exploring the role that the profit-motive plays in the generation of recommendations for treatment. We have seen that in a fee-for-service model of reimbursement the treatment of chronic pain can constitute a perfect storm for overtreatment (i.e., providing an overabundance of care that has a low likelihood of effectiveness). Let’s review how it might play out.

How overtreatment occurs in chronic pain management

Patients with chronic pain are commonly distressed. This distress can lead to a willingness to try any number of medications and procedures, sometimes even repeating previously failed treatments over the years. Their healthcare providers lack any incentive to discourage such an overabundance of care, even if therapies have little chance for success. Rather, because of the fee-for-service system of reimbursement, they are in fact incentivized to make the recommendations. Indeed, the more care they recommend, the more they are likely to provide, and the more care they provide the more money they make.

It’s not that such providers are making recommendations solely on the basis of what’s in their financial best interests. As healthcare providers, they are charged to work in the best interests of the patient as well. They make recommendations and provide care in the ways they do because it is possible that such care might be helpful. If asked, they’d say that they see patients helped everyday by the medications or interventions or surgeries they provide. And it would be true.

Most any therapy can be helpful. Any clinician can point to patients for whom any numbers of the common available therapies have been helpful. For most patients and providers, this justification is good enough. If a particular therapy has been helpful in the past for Mr. Smith, why not try it for Ms. Jones? Besides, Ms. Jones has chronic pain, likely for years, and is in distress and seeking care, wanting to try something. Ms. Jones’ provider can thus recommend the therapy with a clean conscience. It’s what the patient wants and it’s possible that it will be effective.

Notice that the bar to justify a treatment recommendation gets set pretty low. A recommendation for a particular therapy seems reasonable if there’s a possibility of success. Both the patient and the provider seem satisfied to move forward with it, as long as it’s possible that it will be helpful. No one in this interaction seems to require a higher degree of justification, such as some degree of probability that a therapy will be effective. The possibility of effectiveness, rather than then probability of effectiveness, is good enough.

This all-too-common justification for treatment recommendations leads to overtreatment because it masks the profit-motive that underlies it. As we saw in our initial post, the justification only seems reasonable when it occurs within the context of a fee-for-service reimbursement system. In other words, providers would require a higher level of justification, if they themselves were the payer of the fee for the therapy, rather than the receiver of the fee. In a capitated system, for example, where providers stand to lose money rather than gain money when providing care, they might inquire more fully into how likely a given treatment will be effective before proceeding, rather than simply asking whether it might be effective. In contrast, in a fee-for-service system of reimbursement, there is no incentive to have a higher criterion for the care we deliver.

This state of affairs leads to scenarios like those of patients I see everyday. Working in chronic pain rehabilitation, we tend to evaluate patients after they have exhausted countless pharmacological, interventional, and surgical options – no matter how remotely likely they were to have been effective. The typical patient we see is in their forties or fifties and has had chronic pain for more than five years. They have been managed on opioids for most of these years. As a consequence, by the time they get referred to us, our patients have trialed a number of opioids and have become tolerant to even very high doses. They typically have been to two or more interventional pain clinics, where over the years they have had ten to twenty spinal injections and have had three or four repeated radiofrequency neuroablations. They commonly have had three or more spine surgeries.

I am not exaggerating.

They often tell me that I am the first person who has ever told them that they have chronic pain. I sometimes find it difficult to believe. I think what they must mean is that I was the first person to tell them in a way that they really understood – that “chronic” really means chronic, i.e., incurable. What they tell me, though, is that all other providers have tended to leave them with the impression that, while their pain has been long-lasting, it’s only a matter of finding the right procedure and they can be cured. When I ask, they tell me that no provider has ever sat them down and had a serious discussion of exactly how unlikely such a cure really is. Instead, what appears to happen is that they have undergone countless procedures and therapies over the years with very little chance of serious success. What it appears is that they have been overtreated.

Overtreatment in chronic pain management is exceptionally common. It is not just my impression. It’s been shown in systematic ways that the rates of use of opioids, interventional procedures, and spine surgeries have grown exponentially over the last few decades (Deyo, et al., 2009; Manchikanti, Pampati, et al., 2010).

What can healthcare providers do?

The first thing any provider can do is to decide whether this state of affairs is a problem or not.

I suspect that some providers in chronic pain management won’t think it is problematic at all. Spine surgeons and interventional pain providers profit greatly from the current fee-for-service practice patterns (Medical Group Management Association, 2011). Recurrent studies over the years show that their routine care for pain disorders persistently fail to follow established guidelines for common conditions, such as back pain. Instead of obtaining care that professional organizations agree is the most effective, patients continue to obtain MRI or CT scans, interventional procedures, and spine surgeries at increasingly high rates (Deyo & Mirza, 2006; Deyo, et al., 2009; Hrudey, 1991; Ivanova, et al., 2011; Mafi, et al., 2013; Pham, et al., 2009). Such less than optimal tests and procedures constitute some of the most over-utilized assessments and treatments in our healthcare system.

Thought leaders in the field of interventional pain management advocate against policy changes that encourage the use of empirically supported treatments (Manchikanti, Falco, et al., 2010). Organizations of both spine surgeons and interventional pain providers have also advocated against the Affordable Care Act and its provisions to encourage the use of empirically effective treatments (see, for example, Branch & Rao, 2009; Manchikanti, et al., 2011).

Many of us, however, in chronic pain management consider overtreatment unacceptable and are committed to delivering healthcare based on what’s most effective. Indeed, it is a moral obligation. Whether done out of a business practice or ignorance or both, it is simply wrong to withhold the most effective therapy from patients or to recommend tests and procedures that lie outside of treatment guidelines, assuming that guideline based treatments have not already been tried.

If your patient had cancer, you wouldn’t want him or her to pursue less effective treatments before pursuing more effective treatments. But, this is exactly the scenario of care that most chronic pain patients get recommended today in our field.

These points bring us to the next thing that providers can do to reduce profit-motive and overtreatment in chronic pain management.

Learn about established treatment guidelines

The American Pain Society has developed and published a number of treatment guidelines. A brief list of them can be found here.

As a profession, we are called to first provide the most effective care to our patients. To do so, we first need to know what these therapies are. We are therefore obligated to know these therapies and to provide them or refer accordingly.

Take the time to teach patients about what therapies are most effective

It takes time to teach patients why orthopedic treatments for chronic pain, such as spine surgeries and interventional procedures, are commonly ineffective. The prevailing zeitgeist remains that chronic pain is an orthopedic condition. Initially, it often doesn’t make sense to patients why rehabilitation therapies are more effective.

A common complaint among providers is that it takes too much time to explain it to patients and so often ‘the path of least resistance’ is to refer them to orthopedic care that lies outside the treatment guidelines (see, for example, this problem as discussed by DeNoon in the Harvard Health Blog).

Another version of the profit-motive, however, underlies this complaint. It only takes too much time to explain to patients important aspects of their care if you are attempting to see as many patients as possible as a means to increase productivity reimbursement.

If, however, we take our calling as a profession as the primary value, and place business as a secondary value, then the practice of taking time to explain to patients the nature of their condition and the reasons why they should pursue guideline based care becomes our moral obligation. It's not inefficient. It is not a nuisance or an inconvenience. It’s our job.

We have the opportunity everyday – often multiple times daily – to do our job and explain to patients the following: chronic pain syndromes are a nervous system problem and not an orthopedic problem; and chronic pain syndromes are most effectively treated with chronic pain rehabilitation programs, not narcotics, spine surgeries, and interventional procedures.

To help in these discussions, refer patients and their families to the Institute for Chronic Pain and other resources. Indeed, keep a list of reputable websites and blogs to provide to patients so they can continue to educate themselves.

Support policies and organizations that encourage effective care over profitable care

Support organizations such as the following:

If you find important information, pass it on to all of those in your network. (Indeed, please pass this blog post on to all in your network.)

Also, if you are an American healthcare provider, support policies and laws, such as the Affordable Care Act (ACA), that encourage experimentation with getting away from the fee-for-service reimbursement system. For example, in some minimal ways, the ACA contains policies that experiment with moving away from paying provider organizations based solely on the quantity of patients they see and quantity of tests and procedures they perform; instead, it begins to experiment with paying provider organizations based on the quality of their performance in keeping people well. The jury remains out, of course, whether such projects will prove fruitful, but their intention is an admirable attempt to reduce the profit-motive in healthcare and subsequently reduce overtreatment.

Suggested reading: Unnecessary care: Are doctors in denial and is the profit motive to blame?

References

Branch, C. & Rao, R. (July 28, 2009). Letter to Honorable Speaker Pelosi. Retrieved from http://www.spine.org/Documents/NASSHealthCareReformLetterPelosi.pdf

DeNoon, D. (July 31, 2013). Back pain often overdiagnosed and overtreated. Harvard Health Blog. Retrieved from http://www.health.harvard.edu/instchronwp/back-pain-often-overdiagnosed-and-overtreated-201307316546

Deyo, R. A. & Mirza, S. K. (2006). Trends and variations in the use of spine surgery. Clinical Orthopedics 433, 139-146.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Hrudey, W. P. (1991). Overdiagnosis and overtreatment in low back pain. Journal of Occupational Rehabilitation, 1(4), 303-312.

Ivanova, J. I., Birnbaum, H. G., Schiller, M., Kantor, E., Johnstone, B. M., & Swindle, R. (2011). Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine Journal, 11(7), 622-632.

Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581. doi: 10/1001/jamainternmed.2013.8992

Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the healthcare reform for the new decade. Pain Physician, 14, E35-E67.

Manchikanti, L., Falco, F., Parr, A. T., Boswell, B., & Hirsch, J. A. (2010). Facts, fallacies, and politics of comparative effectiveness research: Part I: Basic considerations. Pain Physician, 10, E23-E54.

Manchikanti, L., Pampati, V., Singh, V., Boswell, B., Smith, H. S., & Hirsch, J. A. (2010). Explosive growth of facet joint injections in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. BMC Health Services Research, 10, 84. doi: 10.1186/1472-6963-10-84

Medical Group Management Association. (2011). Physician Compensation and Production Survey 2011 Report Based on 2010 Data. Washington DC: Medical Group Management Association.

Pham, H. H., Landon, B. E., Reschovsky, J. D., Wu, B., Schrag, D. (2009). Rapidity and modality of imaging in acute low back pain in elderly patients. Archives of Internal Medicine, 169(10), 972-981. doi: 10.1001/jamainternmed.2009.78

Date of publication: 1-5-2014

Date of last modification: 7-17-2017

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) For-Profit Healthcare Sun, 05 Jan 2014 19:06:08 +0000
How to Reduce the Influence of Money on your Healthcare https://www.instituteforchronicpain.org/blog/item/127-30how-to-reduce-the-influence-of-money-on-your-healthcare https://www.instituteforchronicpain.org/blog/item/127-30how-to-reduce-the-influence-of-money-on-your-healthcare

In the last post, we looked at the influence of money on your healthcare providers’ recommendations. We saw that in a fee-for-service model of healthcare, which is the predominant model in the U.S., individual providers, clinics and hospitals get paid based on the number of patients they see and the number of procedures and tests they perform. In other words, the more patients a provider, clinic, or hospital sees or the more procedures or tests they perform, the more they get paid. As such, a fee-for-service model of healthcare incentivizes productivity – providing more care leads to making more money.

In turn, the financial incentives of the fee-for-service model can lead to overtreatment. Overtreatment is care that is provided despite a high likelihood that it will be ineffective or unnecessary.

Chronic pain patients are especially prone to overtreatment. Chronic pain can be a highly distressing experience. It can be difficult to accept. As such, patients and their providers can go against all odds to get rid of it. It’s not uncommon to see patients who have had numerous interventions and surgeries, often with the same procedures repeated even when they weren’t initially helpful.

The fee-for-service model of reimbursement reinforces the pattern of pursuing care that has little chance of success. Providers financially benefit from providing care whether or not there is much chance that it will significantly reduce pain or improve function.

This combination of factors – difficulties in accepting the chronicity of pain and the fee-for-service model of reimbursement – is a perfect storm for overtreatment in chronic pain. It leads to providers making recommendations based on the possibility of effectiveness rather than the probability of effectiveness. It’s a certain willingness on the part of patients and their providers to try something to reduce pain, even if it is not very likely to be helpful.

Over the past twenty years, the field of chronic pain management has witnessed exponential growth of the use of spine surgeries, interventional procedures (i.e., epidural steroid injections, nerve blocks, neuroablations, and the like), and opioid medications. The growth rates of this care have occurred despite evidence that they are not particularly effective. During this period of time, there have been record numbers of disability applications for chronic pain (Deyo, Mirza, Turner, & Martin, 2009) and numerous publications of clinical trials, reviews, and meta-analyses that show that these treatments are unlikely to be helpful for most patients (see, for example, Gibson & Waddell, 2007; Martell, et al., 2007; van Tulder, et al., 2006; van Wijk, et al., 2005).

Why, then, do healthcare providers continue to recommend them at such high rates? Patients, of course, might be excused for not knowing that these common therapies are ineffective for most people, but healthcare providers should know about their low level of effectiveness. While they might know of the research, it may be that it doesn’t enter into their decision-making process when making recommendations on a day-to-day basis. Here’s how it might play out.

All these therapies can help some minority of people. That is to say, it’s possible that they are helpful for any given patient. However, it’s not likely that they will be helpful. This distinction can get overlooked in a fee-for-service reimbursement system. Money comes to influence healthcare recommendations because providers, clinics, and hospitals get paid based on quantity of patients seen and procedures provided, not on how healthy patients become or how effective procedures are.

In a fee-for-service reimbursement system, the criteria for whether to pursue a treatment gets lowered to whether it is possible that the procedure could be helpful, and not whether it is likely that it will be helpful. The consequence is overtreatment.

So, what can you, the patient, do about it?

Importance of the therapeutic relationship

As a patient, you can do a number of things to reduce the role that money might play in your care. They all relate to being able to establish and maintain a healthy therapeutic relationship with your chronic pain management provider(s) that allows you to make effective and informed decisions about your care.

What does such a healthy therapeutic relationship look like? It’s a safe, non-judgmental relationship in which you can have mature, adult-to-adult discussions about your concerns and your care. It’s a relationship in which you can take an active role in the decision-making processes of your care. I sometimes tell patients to think of it like a high school or college level seminar in which the things that you are discussing are open to interpretation and respectful debate. There is no absolute, right-or-wrong way of going about managing chronic pain. There is no clearly defined conventional agreement about what treatments to pursue and what not to pursue, even for common conditions, such as chronic low back pain. As such, recommendations for treatment are open to some respectful debate. If you have a safe, non-judgmental relationship with your healthcare provider, you can have an adult-to-adult, respectful debate about what to do.

Appreciate the conflict of interest that your healthcare provider has

In this relationship, you can keep in the back of your mind an appreciation for the inherent tension that occurs in your healthcare provider when practicing in a for-profit healthcare system. On the one hand, as a professional and based on a high level of expertise, your healthcare provider is charged to act in your best interest, making recommendations that are going to work best for you. On the other hand, understand that your healthcare provider is also operating a practice that is essentially a business, one in which your healthcare provider’s recommendations also serve his or her own self-interest. When you appreciate this inherent tension in the relationship that you have with your healthcare provider, you are in a better position to make more informed decisions.

The point, here, is not to accuse providers within a for-profit healthcare system of wrong-doing. They are simply engaging in the practice of healthcare delivery in the manner that is encouraged by their system. Rather, the point, here, is simply to know the lay of the land, as it were. The ground on which you stand when obtaining care from a chronic pain management provider involves an inherent tension between conflicting motivations. The provider, clinic, or hospital that you seek care from is attempting to work in your best interest and their own self-interest at the same time. It’s important that you understand this tension that is inherent in the recommendations that you receive from your chronic pain management providers and take it into account as you decide on which recommendations to pursue and which not to pursue.

Stay grounded when making decisions about your care

It also helps if you can stay grounded when making decisions about your healthcare. While it is understandable that you may become overwhelmed or desperate or angry at times, you likely may not make your best decisions when feeling these ways. It fosters the likelihood that you’ll be willing to ‘take a long shot’ – a treatment that might work, but is unlikely to work. In turn, being willing to try anything, fosters unnecessary care, which may be recommended to you in part because of profit motive. Instead, you will be more successful in managing pain when you make decisions about treatment based on probability of effectiveness, not the possibility of effectiveness. While all things are possibly helpful, only a few things are likely to be helpful. So, when you are ungrounded and apt to want to ‘throw a Hail Mary pass,’ maybe the first thing to do is to get grounded and then have a respectful, adult-to-adult discussion with your healthcare provider about what treatment is most likely to be helpful.

Know which treatments are effective and which are not effective

Related to this point, and in order to have such a grounded discussion that minimizes the role of money in your healthcare, you need to know what is effective and what is not effective in the management of chronic pain. The Institute for Chronic Pain and other organizations (such as Body in Mind) attempt to translate published, clinical research into language that is approachable to patients, their families, primary care providers, and third-party payers. To minimize the role that money plays in your care, it pays to educate yourself about the empirical evidence for the effectiveness of common treatments for chronic pain. By having a command of such knowledge, you will be able to have a more sophisticated discussion with your healthcare providers about the recommendations that you receive.

Seek out second opinions

Another important strategy is to seek out second opinions from providers whose training and practice are different from the provider who made the initial recommendation. By doing so, you allow yourself a greater amount of options from which you can make a more informed decision about your care. As such, it minimizes the risk of acting on recommendations that may in part have been provided based on profit motive.

For example, if you receive a recommendation from a spine surgeon for your chronic low back pain, don’t just seek out a second opinion from another surgeon, who may very likely come up with the same recommendation; rather, seek out a second opinion, say, from a chronic pain rehabilitation provider who will likely conceptualize and treat your chronic low back pain differently.

Understand that there is no conventional agreement as to how to manage common chronic pain disorders. Surgeons, interventional pain providers, and chronic pain rehabilitation providers all treat the same condition differently. Among all the different types of chronic pain management providers, there is considerable debate as to how to conceptualize and treat chronic pain. Some commonly performed procedures have very little empirical support for their effectiveness and still others have been shown to be ineffective. In the on-going debate, it is common to highlight the potential role of the profit motive when discussing why these procedures continue to be performed (see, for instance, Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

When you obtain a second opinion that is outside the field of the initial recommendation, you are more apt to obtain an opinion that reflects another side of the debate that goes on among chronic pain management providers. In doing so, you learn about options that you might not otherwise obtain. Subsequently, you can learn about the relative effectiveness of each option you receive, discuss them with your healthcare providers, and foster an informed decision. Consequently, you minimize the degree to which profit motive influences the recommendations you receive and pursue.

Seek out care from salaried providers or non-profit organizations

Lastly, if you have the option, seek out healthcare providers who work in organizations that pay them on a salary, rather than through a fee-for-service model. When the livelihood of your healthcare providers are not dependent on whether you give consent to the recommendations they provide, you minimize the role that money plays in generating those recommendations. It’s interesting to note that some of the most prestigious healthcare institutions in the U. S. pay their healthcare providers on a salary. Some examples are the Mayo Clinic, the Cleveland Clinic, the VA Medical Centers, Kaiser Permanente, and GroupHealth.

Of course, many patients do not have the option to seek care in one of these organizations. In such circumstances, you might try to obtain care in a non-profit healthcare organization. Non-profit organizations might still pay their providers through a fee-for-service system, but they may also have a mission that tempers the profit motive of their individual providers.

References

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved December 27, 2013, from The Cochrane Library, Wiley Interscience.

Martell, B. A., O’Conner, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

Perret, D. & Rosen, C. (2011). A physician-driven solution – The Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-29-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) For-Profit Healthcare Sun, 29 Dec 2013 15:22:09 +0000
How Money Influences Healthcare Recommendations https://www.instituteforchronicpain.org/blog/item/126-29how-money-influences-healthcare-recommendations https://www.instituteforchronicpain.org/blog/item/126-29how-money-influences-healthcare-recommendations

One of the more common sentiments that patients express to me is that they have come to the conclusion that money influences healthcare recommendations. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried multiple times, they have concluded that the business side of healthcare played too much of a role in their own care. They are now disappointed, angry, and jaded about how much they trust healthcare providers.

Sometimes, the sentiment comes when they first accept that their chronic pain is really chronic. They wonder why no one ever sat them down and talked with them about how their pain is actually chronic. What they got instead, they say, were healthcare providers who kept recommending procedure after procedure that were all vain attempts to cure something that they should have acknowledged was a chronic condition. It must have been for the money, they conclude.

Sometimes, the sentiment comes after patients learn how ineffective common surgical and interventional procedures are. They subsequently wonder why, if it’s not for the money, healthcare providers recommend treatments that well-designed studies have shown to be ineffective.

Sometimes, too, they come to wonder about the role of money once they have participated in a chronic pain rehabilitation program. After being on opioid medications for many years, they go through a program and come to learn how to self-manage pain without the medications. Once they get over their initial shock that they really can manage pain without opioids, they begin to wonder, “Why didn’t anyone ever refer me to a program like this before?” Then, they start wondering about the role that money might have played in continuing them on opioids for many years without ever referring them to a program that could have shown them how to live well without the medications.

However the sentiment arises, patients with chronic pain express it fairly often: money influences healthcare recommendations.

So, is it true that money can play a role in the recommendations that healthcare providers make? I think that most healthcare providers would quietly acknowledge that it is true. A number of commentators in the field also acknowledge it (see, e.g., Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

Like most things in life, though, it’s complicated. The question doesn’t lend itself very well to a simple ‘yes or no’ response. Let’s look at some of these complications so that we can appreciate how complicated the issue really is. It’s important to have an accurate understanding and appreciation for the issue, because, after all, it’s not true that all healthcare is bad even if things like the profit-motive sneak into it and influences it. We need healthcare. It’s too simple and likely not good for any of us to get so mad at its imperfections that we become jaded and forego it. We shouldn’t throw the baby out with the bath water, as the old saying goes. Rather, we can acknowledge its imperfections and take them into account in order to make clear-headed decisions about the recommendations that our healthcare providers make. By having a sophisticated understanding and appreciation for how healthcare works, we can make better and more informed decisions about the recommendations that we receive – whether to pursue them or not.

The following is the first of a three-part series on the role of the profit-motive in healthcare, particularly as it relates to the management of chronic pain. This first blog post focuses on how money influences healthcare recommendations. The two following posts will be about 1) what you, as a patient, can do about it, and 2) what healthcare providers can do about it.

Fee-for-service reimbursement influences healthcare recommendations

In countries where healthcare delivery is a for-profit industry, financial incentives can influence recommendations. To see how, we need to provide a quick review of how financial reimbursement works in a for-profit health care industry.

In the U. S., for example, most hospitals, clinics, and individual providers get paid a set amount of money every time they see a patient or perform a procedure or order a test. This system of reimbursement is called ‘fee-for-service.’ Individual providers are commonly akin to independent contractors with their practice being their business and their livelihood dependent on how many patients they see and how many procedures and tests they provide. In addition, administrators of hospitals and clinics track and evaluate providers’ performance based on ‘productivity’ (i.e., how many patients that are seen and how many procedures and tests that are provided).

Notice the subtle value system at work. Healthcare providers make more money when they see more patients and perform more procedures and tests. Their administrators will subsequently see those providers with the highest productivity as most favorable. Administrators promote or lay off healthcare providers in part based on productivity or lack of it. In all these ways, fee-for-service reimbursement creates incentives to provide more rather than less care.

Now, we all know that incentives influence behavior. It’s true in all walks of life and it is similarly true in for-profit healthcare. Fee-for-service incentives influence the type and amount of recommendations that patients receive from their providers, clinics and hospitals. It stands to reason that such influence occurs. Sales people are rarely salaried employees. Rather, they are paid on commission because it influences them to be more productive in the amount of sales they produce – the more they sell, the more they are paid and the more their positions remain safe from being laid off. It’s the same with most healthcare providers – the more patients they see and the more procedures and tests they recommend and convince patients to have, the more they get paid and the more their administrators value their position.

There are actual studies that demonstrate the influence of incentives on productivity in healthcare. For example, Hickson, Altmeier, and Perrin (1987) compared salaried physicians to fee-for-service physicians. Both groups involved the same type of physician and saw the same types of patients. The fee-for-service physicians saw more patients than the salaried physicians.

Likewise, Strope, et al. (2009) studied a recent trend for providers to build their own ambulatory surgery centers and subsequently change the site where they perform procedures, from the hospital or clinic, to the ambulatory surgery center that they own. The advantage of performing procedures at an ambulatory care center that the provider owns is that the provider will make more money. Specifically, they get to bill at a higher rate than in the clinic, even if it is for the same procedure, and they get to keep the money that ordinarily would have gone to the hospital for the use of the hospital facilities. So, what did Strope, et al., find in their study of this recent trend? Once providers could bill at higher rates of reimbursement and subsequently collect more money, the rate of procedures significantly increased, including the most profitable procedures. It’s hard to argue, in such circumstances, that need for such procedures dramatically changed once providers came to own the surgery centers.

Similarly, providers who own their own imaging devices (e.g., X-ray, CT or MRI scans) are upwards of eight times more likely to order scans than those who don’t own their own imaging devices, even when the latter providers are from the same specialty and are seeing the same type of patients with the same types of health problems (Kouri, Parsons, and Alpert, 2002). Again, it’s hard to argue that those providers who own their own imaging devices have somehow tapped into an unmet need of patients (see, for example, Fisher & Welch, 1999).

Rather, it stands to reason that such incentives lead to healthcare providers seeing more patients and providing more recommendations to undergo procedures and tests. As such, incentives to make more money can influence what and what doesn’t get recommended.

The concern is that money influences healthcare recommendations in such a way that it leads to unnecessary and/or ineffective care. As seen above, healthcare providers who own their own facilities or equipment have dramatically higher rates of procedures and tests than the same type of healthcare providers who don’t own their own facilities or equipment. Are the dramatically higher numbers of procedures and tests necessary? If they are unnecessary, they likely do not add value to the diagnosis or treatment of the condition of the particular patient. In other words, under these circumstances, they are ineffective for the particular need of the patient.

The pressure of a fee-for-service system of healthcare can similarly lead to unnecessary and therefore ineffective treatments and tests in the management of chronic pain. It’s common to see patients who have a history of obtaining multiple series of the same surgical or interventional procedures at different clinics, even though the first series turned out to be ineffective for their particular pain condition. Why did the subsequent providers think that repeating the same series of interventional procedures or re-doing the spine surgery was a good idea when previously the procedures were ineffective?

How money influences clinical decision-making

To be fair, there are likely many factors at work that go into a decision to make a recommendation for a particular treatment and not just the fact that the provider will personally profit from delivering the treatment.

Imagine, for example, that you are the provider in the following scenario. You have a patient who has chronic pain and is in some degree of distress about it. You’ve learned that the patient has already had a series of interventional procedures, say, and they were not helpful in reducing pain. However, you are an interventional pain provider and interventional procedures are what you do. The patient is there, at your clinic, and wants you to do something. Might you not reason to yourself, ‘well, there’s a chance that it might work, even if it’s unlikely to work, and the patient wants me to try something; rather than sending the patient away without doing anything and making him or her dissatisfied, let’s give it a try.’ We could call this type of clinical decision-making the ‘we might as well give it a try’ decision

At first blush, it doesn’t seem like the fact that you will personally profit from the procedure has anything to do with the decision. Indeed, the decision seems to be able to stand on its own, as it were. The patient is in pain and is upset about it. The patient wants you to do something. It just so happens that what you do is something that has already been tried and failed in the past. However, there’s still a chance that it might now work. If it works, the patient will be happy. If it doesn’t work, you can say that at least you tried. If you don’t do anything and send the patient away, they’ll likely be more upset than they are now. So, you ‘might as well give it a try.’ The argument seems to stand on its own without needing to reference the fact that you will personally profit from the procedure. This last statement might be true at least until we change the scenario a little by changing the reimbursement system.

Suppose, for instance, that, rather than a fee-for-service system where you profit directly from delivering the care, you work within a capitated system of reimbursement where the profit lies in providing the least and most effective care possible. In a capitated system, providers are not given a fee each time they see a patient or perform a procedure. Instead, they are given a set amount of money for the entire care of a patient for a certain time frame, such as a year. The set amount of money will cover all the care that the patient needs for the given time frame. The incentive in a capitated system is to keep people healthy and out of the doctor’s office so that they don’t use up the set amount of money with frequent visits, procedures, and tests. It also incentivizes providing the care that’s most likely to be effective, and minimizing any ineffective or unnecessary care – again, for the same reason, so that the patients don’t use up the set amount of money that was previously given for their care over the year. Capitated systems of reimbursement are not very common these days, though they were the heart of the HMO system back in the 1970-80’s in America.

Nonetheless, suppose that, as the interventional provider in our scenario, you are now working under such a system of reimbursement. Under this system, would you be as inclined to come to the same decision to repeat a series of interventions that had previously failed– the ‘we might as well give it a try’ decision. Providing the interventional procedures are going to hurt, rather than help, your bottom line. You are still charged to care for the patient who is in pain and distress, but would you use up the set amount of money that you were given by performing procedures that have already been done and were ineffective? Might it not be the case that you would reason against it now? In this scenario, the fact that the series of interventions has already been tried and failed seems to take on greater importance. You would weigh the previously failed treatment more heavily in your decision-making process. In your clinical decision-making process, you might reason, ‘well, why repeat a failed treatment?’

At first blush, it seems like a perfectly reasonable decision. If your car wouldn’t start and you had already paid one mechanic to fix it and the repair didn’t work, you wouldn’t take it to another mechanic and pay for the exact same repair. Rather, you’d want to pursue a different approach. Similarly, as the interventional provider, your decision to refrain from pursuing the same procedure that previously had not worked seems sound.

But, let’s step back for a second, and take stock of our two different, albeit reasonable, decisions.

It’s the same patient with the same condition, but you’ve come to two contradictory treatment recommendations. The only difference that accounts for the different treatment recommendations is how you will get reimbursed. Notice how subtly money influences your decision-making.

It’s an uncomfortable fact that the system of reimbursement in healthcare can influence clinical decision-making.

In the posts to follow, we’ll review what you, the patient, can do to minimize the role that money has in the recommendations that you receive and decide to pursue. Then, we’ll review what us healthcare providers can do to reduce the role that money has on our recommendations.

References

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Fisher, E. S. & Welch, H. G. (1999). Avoiding the unintended consequences of growth in medical care: How might more be worse? Journal of the American Medical Association, 281(5), 446-453.

Hickson, G. B., Altmeier, W. A., & Perrin, J. M. (1987) Physicians reimbursement by salary or fee-for-service: Effect on physician practice behavior in a randomized prospective study. Pediatrics, 80(3), 344-350.

Kouri, B. E., Parsons, R. G, & Alpert, H. R. (2002). Physician self-referral for diagnostic imaging: Review of the empiric literature. American Journal of Roentgenology, 179(4), 843-850.

Perret, D. & Rosen, C. (2011). A physician driven solution – The association for medical ethics, the physician payment sunshine act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

Strope, S. A., Daignault, S., Hollingsworth, J. M., Ze. Z., Wei, J. T., & Hollenbeck, B. T. (2009) Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the state of Florida. Medical Care, 47(4), 403-410.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 12-22-2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) For-Profit Healthcare Sun, 22 Dec 2013 18:00:26 +0000
Is Spinal Surgery for Neck Pain Effective? https://www.instituteforchronicpain.org/blog/item/125-28is-spinal-surgery-for-neck-pain-effective https://www.instituteforchronicpain.org/blog/item/125-28is-spinal-surgery-for-neck-pain-effective

The third of three reviews of research on spinal surgery for neck pain was recently published by a group of well-known pain experts (van Middelkoop, et al., 2012; van Middelkoop, et al., 2013; Verhagen, et al., 2013). The investigators undertook the reviews of the research on different aspects of neck surgery because the most recent previous studies, done as Cochrane reviews (Fouyas, et al., 2002; Nikolaidis, et al., 2008), were now outdated. So, they systematically reviewed the latest published research on different types of spinal surgery for neck pain to determine whether and how such surgeries are effective. What they found was that spinal surgery for neck pain is not any more effective than other, less invasive, therapies.

Moreover, they found that the published clinical trials on surgeries for neck pain commonly suffered from poor quality research methods and/or a high risk of bias that might skew the results towards surgery. These latest reviews echo the earlier Cochrane reviews of the research. The Cochrane reviews also found that spinal surgery for neck pain is no more effective than other therapies.

Taken altogether, we now have about two decades of scientific research showing that spinal surgery for neck pain adds no value over less invasive therapies.

Specifically, here’s what they found:

  • Regardless of type of surgery or technique, spinal surgery for neck pain is no more effective than less invasive, non-surgical therapies for neck pain (Middelkoop, et al., 2012).
  • Fusion surgery is not more effective than other spinal surgeries that do not involve fusion (Middelkoop, et al., 2013).
  • Fusion with artificial discs provides no clinically significant benefit over other types of fusion surgery (Verhagen, et al., 2013).
  • There is no one type of spinal surgery for neck pain that is especially better than any other type (Verhagen, et al., 2013).

These findings are important because spinal surgery for neck pain is by no means a benign treatment. Such surgeries are apt to have higher and more significant rates of complications, relative to less invasive treatments of at least equal therapeutic value. They are also significantly more expensive. As such, these findings might give providers and patients pause before pursuing spinal surgeries for neck pain.

Interestingly, however, the accumulation of this research over the years has not provided any pause to the exponential increases in the rates of spinal surgeries for neck pain (Davis, 1994; Marawar, et al., 2010).

References

Davis, H. (1994). Increasing rates of cervical and lumbar spine surgery in the United States, 1979-1990. Spine, 19(10), 1117-1123.

Fouyas, I. P., Statham, P. F., & Sandercock, P. A. (2002). Cochrane review on the role of surgery in cervical spondylotic radiculomyopathy. Spine, 27(7), 736-747.

Marawar, S., Girardi, F. P., Sama, A. A., Ma, Y. Gaber-Baylis, L. K., Basculides, S. C., & Memtsoudis, S. G. (2010). National trends in anterior cervical fusion procedures. Spine, 35(15), 1454-1459. doi: 10.1097/BRS.0b01381bef3cb

van Middelkoop, M., Rubinstein, S. M., Ostelo, R., van Tulder, M. W., Peul, W., Koes, B. W., & Verhagen, A. P. (2012). Surgery versus conservative care for neck pain: A systematic review. European Spine Journal, 22(1), 87-95. doi: 10.1007/s00586-012-2553-z

van Middelkoop, M., Rubinstein, S. M., Ostelo, R., van Tulder, M. W., Peul, W., Koes, B. W., & Verhagen, A. P. (2013). No additional value of fusion techniques on anterior discectomy for neck pain: A systematic review. Pain, 153, 2167-2173.

Nikolaidis I., Fouyas, I. P., Sandercock, P. A., & Statham, P. F. (Updated December 14, 2008). Surgery for cervical radiculopathy or myelopathy. [Cochrane Review]. In Cochrane Database of Systematic Reviews, 2010 (1).

Verhagen, A. P., van Middelkoop, M, Rubinstein, S. M., Ostelo, R., Jacobs, W., Peul, W., Koes, B. W. van Tulder, M. W. (2013). Effect of various kinds of cervical spinal surgery on clinical outcomes: A systematic review and meta-analysis. Pain, 154, 2388-2396.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 12-8-2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Cervical Surgery Sun, 08 Dec 2013 18:58:01 +0000
Catastrophizing and Chronic Pain https://www.instituteforchronicpain.org/blog/item/124-27catastrophizing-and-chronic-pain https://www.instituteforchronicpain.org/blog/item/124-27catastrophizing-and-chronic-pain

It’s not uncommon to exclaim, at the beginning of a pain flare, “I’m not going to be able to stand it!” Another might express, “Now, I’m not going to be able to do anything today!” Yet, another takes it as a given that the increased pain is an indicator that the underlying health problem is getting worse. From this assumption, it’s easy to start thinking about how the future holds nothing but increasing disability, wheelchairs, and suffering.

These sentiments are examples of catastrophizing.

What is catastrophizing?

Catastrophizing is what we do when we see something through the lens of it being the worst-case scenario. We believe and feel that something is worse than it actually is.

We all do it. Everyone catastrophizes at least occasionally. Some of us do it a lot. Most of us are somewhere in between. The point, though, is
that we all do it.

The most common example of catastrophizing is simple worrying. When we worry, we don’t ponder good things happening to us. We don’t even Image by hello i m nik Courtesy of Unsplash tend to think about minimally bad things happening to us, such as inconveniences or hassles. We don’t tend to waste a lot of time worrying about those things. Rather, it’s the really bad stuff that we tend to worry about. It’s the worst-case scenarios that hold our attention and get us worked up.

Now, the thing about catastrophizing is that we tend to overestimate the likelihood that the worst-case scenarios will occur. Of course, worst-case scenarios are possible. Sometimes, they do in fact occur. If, however, we step back and take a real objective look at them, we might compare how often they occur with the countless number of times when they don’t occur. The comparison is stark. Worst-case scenarios are possible, but they are not likely. They tend to be once or twice in a lifetime events. When catastrophizing, though, we see the worst-case scenario as all-but-inevitable or, worse yet, already happening. There’s an assumption of certainty about it. That is to say, this sense of certainty comes about by overestimating the likelihood of the worst-case scenario.

Like anyone else, people with chronic pain can catastrophize. Take the common sentiments expressed in the above examples. When experiencing a pain flare, common automatic reactions are that you aren’t going to be able to stand it or that now you’ll never get anything done or that you think the increased pain is indicative of an inevitable worsening of the underlying health condition that initially started the pain. There is a sense of certainty that goes along with these automatic reactions. You just “know” that you won’t ever be able to stand it, or that you’ll never be able to get anything done, or that increasing disability is inevitable. However, if you can step out of the moment, and hold on your judgment of such certainty, you might begin to reflect on how true, really, these sentiments are.

What makes you so sure that you’ll ‘never be able to stand it’? How do you ‘know’ that this pain flare is going to be the whopper of all whoppers? Maybe it would be best to hold judgment, and see if it will be as bad as you anticipate. It might just turn out to be a run-of-the-mill flare. In fact, it is much more likely that it will be an average pain flare than the one that you'll 'never be able to stand.'

How warranted is your certainty that you’ll ‘never be able get anything done’? How likely is that scenario to occur? With a little creativity, there is almost always going to be something that you can do, even while experiencing a pain flare. Maybe you could sit and pay bills. Maybe you could call someone who you have been meaning to call but haven’t gotten around to it. Maybe you are at work and you decide to use the afternoon to catch up on reports and emails. You sit for a while at the computer and then you stand for a while at the computer, putting a few books under the keyboard, so you can still work at the computer. You also might take breaks to walk the hallway or stretch or both. Now, it won’t be the most productive day you’ll ever have, but, with pacing and a little adaptability, it’s much more likely that you’ll be able to do something productive.

What about the certainty that your pain flare is a sign of your inevitable decline? How true is that worst-case scenario? Of course, it is possible, but it’s not very likely. The nature of chronic pain is that pain waxes and wanes – pain flares come and pain flares go. What’s the likelihood that this pain flare is the one that won't ever go away and from which you'll start the decline into becoming wheelchair-bound? Isn’t it much more likely that this pain flare, like the others that come before it, will come and go?

While always possible, worst-case scenarios are low probability events. When we catastrophize, though, we overestimate the likelihood that the worst-case scenario will occur and become certain that it will happen or is already happening. We lose perspective on the problem and become certain that it is worse than it actually is.

Catastrophizing influences our perceptions

The sense of certainty that goes along with catastrophizing colors our perceptions, making what we experience worse than it actually is. This fact is what leads psychologists to categorize catastrophizing as a form of cognitive distortion. Catastrophizing distorts what it is we perceive.

It’s not very mysterious. Rather, it’s super common. We can think of any number of examples. Suppose your boss makes a critical remark about you and later looks at you strange after you say something in a meeting. You associate these events with some problems you have been having at work and before you know it you are taking the boss’ remark and the look as confirmation that any day now you are going to be let go. If you don’t step out of the moment, and gain some perspective on how you are perceiving these events, your experience is that you simply and unquestionably are in the process of getting fired and it can’t get much worse. To take another example, suppose you are arguing with your spouse and he or she walks out of the room hurt and angry. Your first thought is that your last hurtful remark put your spouse over the edge and that he or she is now leaving you. Your immediate reaction is one of ‘Don’t leave me!’ For the moment, your thoughts are going a million miles an hour and you have all the accompanying feelings of fear, anger, and abandonment. If you don’t step out of the moment, get grounded, and reflect on what’s going on, your experience is that your marriage is unquestionably ending and it can’t get much worse. In both these cases, we see that catastrophizing distorts our experience of what is really happening.

Catastrophizing tends to happen when we are ungrounded, vulnerable, anxious, or upset already and then something bad happens. In such cases, it’s hard to see the problem clearly. We are too ungrounded or anxious or upset. As such, the overall experience of the problem is that it is worse than it actually is. Conversely, when a problem occurs during a time that we are grounded, focused, supported, and confident, we deal much better with it because, in part, we see the problem more accurately.

The two parts that make up experience

This last notion leads to an exceptionally important, yet often overlooked, fact about human experience. We tend to think that whatever it is that we experience is solely due to what is happening to us. That is to say, we often simply assume that the quality and intensity of our experiences are only due to the qualities and severity of the external things that occur to us. It’s as if we forget that there’s a perceiving subject, who has these experiences.

Now, of course, what we experience is determined in part by external events – what they are, whether they are bad or good, and how bad or good they are. But, our experience is also determined in part by where we are at when these events occur.

When we are grounded and present, we might notice the beautiful sunset and fully appreciate it. The sunset subsequently might have a big impact on us. If, however, we are lost in our thoughts, or fretting because we are stuck in rush hour traffic, we might hardly even notice the beautiful sunset, let alone appreciate it, and subsequently it has little to no impact on us. It's the same external event, but two very different experiences and the experience is determined by how we are at the time of the external event.

Human experience is made up from two parts: 1) the things that happen to us and 2) how we are when things happen to us. When we are grounded, supported, confident and well-rested, we tend to experience the same event differently than when we are anxious, upset, vulnerable, lonely, abandoned, or overly tired and fatigued.

Catastrophizing is one of the ways that we color our perceptions of events when we come to the event feeling anxious, upset, vulnerable, left alone, or fatigued.

Catastrophizing is all-too-human

Sometimes, people are reluctant to acknowledge that they catastrophize. You can sometimes feel judged when people tell you that you’re making a mountain out of a molehill. You might automatically want to respond with assertions that the problem really is that bad -- it really is catastrophic -- and then feel invalidated when they don't believe you.

It’s important to remember, though, that we all do it. It’s part of our all-too-human condition. Human beings are not perfect. We are not omnipotently objective observers of the things that happen to us. We have all sorts of beliefs, attitudes, and feelings that bias and distort our perceptions. And, yes, we also catastrophize. All of us sometimes perceive things as worse than they really are. Some people do it rarely while other people do it a lot. Most of us are somewhere in between, catastrophizing more than rarely and less than all the time.

A good healthcare provider tends to remind us of things that we already know, but tend to forget in our day-to-day routines. One of these reminders is that it is a mark of health to be able to admit our imperfections. The first step towards getting better with regard to a problem is always to admit that you have the problem. In the case of catastrophizing, it’s a mark of health when we can acknowledge that we catastrophize, especially at the time when we are actually doing it. Indeed, an important health skill is the ability to step out of any given moment, reflect on what’s going on, and come to see the problem more clearly. By gaining perspective on the problem, we reduce the distress that’s associated with the problem and the problem comes to no longer have such a big impact on our lives. The problem comes to be less problematic as we initially experienced it to be.

This process is one of the many ways that people come to cope better with problems in life, including chronic pain. That is to say, we come to cope better with a problem when we get better at catching ourselves catastrophizing it, acknowledge that we are doing it, and reality-checking it. We thereby come to see the problem more clearly and subsequently we cope with it better– the problem becomes less distressing and less impairing.

Author: Murray J. McAllister, PsyD

Date of oublication: 11-24-2013

Date of last modification: 9-16-2022

About the author: Dr. McAllister is a pain psychologist, and the founder & publisher of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Catastrophizing Sun, 24 Nov 2013 13:44:09 +0000
Stress and Chronic Pain https://www.instituteforchronicpain.org/blog/item/123-26stress-and-chronic-pain https://www.instituteforchronicpain.org/blog/item/123-26stress-and-chronic-pain

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another.

It goes something like the following: ‘I’m hear to talk about my pain and what we can do about it, but you ask me about all these things that are unrelated to pain, like whether I worry, whether the worry keeps me up at night, what’s going on at home, whether my spouse believes me that I hurt as much as I do. In effect, I’m here to talk about my pain but you want to know how stressed I am. Why?’

It’s true. Providers who specialize in chronic pain rehabilitation always evaluate the patient’s pain, of course, but they also always assess the stressful problems that the patient experiences. To the list above, we might add such stressors as depression, anxiety, past trauma, sleep problems, persistent problems with concentration and short-term memory, financial problems, loss of the role in your occupation or family, the loss of sexual and emotional intimacy in your relationship, and the list could go on. All these problems cause stress, which is why we call them stressors. Why is it important to deal with stressors when having chronic pain?

There are a number of reasons why it is important, but let’s review two today:

  • If you can’t fix the pain, you might as well work on reducing the problems that occur because of the pain.
  • To successfully self-manage chronic pain, you have to manage your stress.

Let’s look at these reasons one at a time.

Stress caused by pain

Understandably, patients with chronic pain want to focus on how to reduce pain. To some extent, this focus is helpful. There are indeed a number of lifestyle changes, such as mild aerobic exercise and regular relaxation exercises, which, when done over time, can reduce pain. There are some medications, such as tricyclic antidepressants and antiepileptics, which have been shown to reduce pain too. However, these treatments are only so effective. We really don’t have any treatments that are super effective for chronic pain. (Procedures, such as injection therapies and spine surgeries, are known to be largely ineffective, despite how often they are pursued.) At the end of the day, chronic pain is chronic. It’s not ultimately fixable. While some of things that can be done to reduce chronic pain are helpful, they are only mildly so.

Given this fact, if you can’t fix the pain, then you might as well work on the problems that occur as a result of the pain. It’s possible to have chronic pain and not have it disrupt your life. It’s possible to have chronic pain and not be depressed about it. It’s possible to have chronic pain and sleep well at night. It’s possible to have chronic pain and work full-time. It’s possible to have chronic pain and have a fulfilling and intimate relationship.

Now, many people have to learn how. But, if they are open to learning, they can learn to self-manage pain well enough to be able to overcome these secondary problems. Such learning can take time and practice. It also takes a certain amount of devotion to maintain lifestyle changes, once you learn how to do them. Nonetheless, it is possible.

What patients learn could be called stress management and it involves cognitive behavioral therapies.

Good self-management of chronic pain involves stress management. When you overcome depression, even if chronic pain remains, it’s still a win for you. When you come to sleep well at night, after a period of chronic insomnia, life gets better, even if you continue to have chronic pain. When the strain in your relationships subside, your marriage and family life deepen, making life more meaningful and fulfilling, despite having chronic pain.

Overcoming the stressors in life, even when they occur as a result of chronic pain, is a way to get better when there is no cure for the pain itself. Patients with chronic pain might initially wonder why chronic pain rehabilitation providers want to focus on the stressors in their life, but from here we can see why. It’s a way to get better when there is no cure. If you can’t fix the pain, focus on overcoming the stressful consequences of living with pain. By doing so, you make life easier and better.

You also make the chronic pain more tolerable by coping better with it. By overcoming your depression or anxiety, everything in life gets easier to deal with – pain included. It becomes more tolerable. When you sleep reasonably well, on most nights, you deal with everything better – pain included. It becomes more tolerable. The same is true with any of the stressful problems that go along with living with chronic pain. When you overcome them, you cope better with the pain itself. By focusing on reducing stress, you come to cope better and pain can go from what was once intolerable to what is now tolerable.

Chronic pain rehabilitation is the form of chronic pain management that most focuses on helping patients to overcome the stress of living with chronic pain and thereby cope better with pain. The other forms of chronic pain management – spine surgery clinics, interventional pain management clinics, medication management clinics—focus mostly on reducing pain, and not on the stressors that occur as a result of pain. Chronic pain rehabilitation programs focus on both. They provide empirically proven methods to reduce pain, while also providing therapies to overcome depression, anxiety, insomnia, cognitive deficits, relationship problems, and disability.

Stress management and chronic pain management

We just saw how overcoming stressors related to pain makes life easier and better, even though you continue to have chronic pain. We also saw how overcoming stressors can lead to better coping, which, in turn, makes chronic pain more tolerable. Doing so, however, is important for another reason: managing stress well also reduces pain itself.

We all know that stress makes chronic pain worse (Alexander, et al., 2009; Flor, Turk, & Birbaumer, 1985). No matter what the original cause of your pain, stress exacerbates the pain. You have probably noticed this fact.

Whether it’s from depression, insomnia, relationship or financial problems, stress affects us by its effect on the nervous system. Stress makes us tense and nervous – literally. Our muscles becomes tight, particularly in certain areas of the body – the low back, mid and upper back, shoulders, neck, head, forehead, and jaw are the most common areas (we also feel it in our gut, by the way, with upset stomachs, reflux, diarrhea, among other things). Over time, the chronically tense muscles can ache and spasm. In other words, the persistent stress that results from chronic pain can cause chronic muscle tension, which, is painful.

Chronic pain causes more pain! It does so through the stress that it causes, which subsequently activates the nervous system and the persistently stressed nervous system leads to chronic muscle tension, which becomes painful in and of itself.

When understanding the role of stress from this perspective, most every chronic pain patient readily understands it because they live it. They see how stress affects their pain levels from their own experience.

Stress and its effect on the nervous system can exacerbate pain through more direct routes too. It's not just the effect that stress has on muscle tension. It’s harder to see from your own personal experience, however, and so you'll have to rely on a more textbook-like explanation. Stress, particularly the persistent stress of problems that occur as a result of chronic pain, causes changes to the nervous system itself. These changes occur in the spinal cord and brain and they result in changes in how sensory information is processed. An example of sensory information is pain signals that travel from nerves in the body, through the spinal cord, and up to the brain; the brain subsequently processes this information and the experience of pain results. As a result of persistent stress to this system, the brain comes to process such information with greater and greater sensitivity and as a result less and less stimuli (i.e., sensory information) is required to experience pain (Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Imbe, Iwai-Liao, & Senba, 2006; Kuehl, et al., 2010; Rivat, et al., 2010).

It’s generally accepted that by overcoming the persistently stressful problems that occur as a result of living with chronic pain – such as insomnia, depression, anxiety, you can make some headway in reversing these changes. You might not be able to change them entirely, but enough to reduce the pain itself. Indeed, most providers would concur that to adequately manage chronic pain these kinds of stressors must be addressed (Asmundson & Katz, 2009; Kroenke, et al., 2011; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009).

Concluding remarks

In all, good stress management is essential when it comes to successfully self-managing chronic pain. There is only so much that can be done to reduce pain when you have chronic pain. The most effective therapies we have for chronic pain are at best only mildly or modestly helpful at reducing pain. There is, however, no end to how well you can get at managing the stressors that result from chronic pain. It’s possible to overcome depression or anxiety or insomnia or relationship problems or any other stressor, even if you continue to have chronic pain. Now, these problems are not easily overcome. They take work and motivation and perseverance. Nonetheless, it is possible. By doing so, you get better. Pain becomes more tolerable too. In fact, by reducing the amount of stress in your life, you also reduce pain itself.

It’s for all these reasons that your healthcare providers keep wanting to focus on the stress in your life, in addition to the chronic pain in your life.

References

Alexander, J. K., DeVries, A. C., Kigerl, K. A., Dahlman, J. M., & Popovich, P. G. (2009). Stress exacerbates neuropathic pain via glucorticoid and NMDA receptor activation. Brain, Behavior, and Immunity, 23(6), 851-860. doi: 10.1016/j.bbi.2009.04.001.

Asmundson G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26(10), 888-901.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Castillo, R. C., Wegener, S. T. , Heins, S. E., Haythornwaite, J. C., MacKenzie, E. J., & Bosse, M. J. (2013). Longitudinal relationships between anxiety, depression, and pain: Results from a two-year cohort of lower extremity trauma patients. Pain, 30. doi: 10.1016/j.pain.2013.08.025.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S.  (2006).  Central hypersensitivity in chronic pain:  Mechanisms and clinical implications.  Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Turk, D. C., & Birbaumer, N. (1985). Assessment of stress-related psychophysiological reactions in chronic back pain patients. Journal of Clinical and Consulting Psychology, 53(3), 354-364. doi: 10.1037.0022-006X.53.3.354.

Imbe, H., Iwai-Liao, Y., & Senba, E.  (2006).  Stress-induced hyperalgesia:  Animal models and putative mechanisms.  Frontiers in Bioscience, 11, 2179-2192.

Kroenke, K., Wu, J., Bair, M. J., Krebs, E. E., Damush, T. M., & Tu, W. (2011). Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain, 12(9), 964-973. doi: 10.1016/j.jpain.2011.03.003.

Kuehl, L.  K., Michaux, G.  P., Richter, S., Schachinger, H., & Anton F.  (2010).  Increased basal mechanical sensitivity but decreased perceptual wind-up in a human model of relative hypocortisolism.  Pain, 194, 539-546.

Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J.  (2010).  Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long-lasting anxiety-induced hyperalgesia.  Pain, 150, 358-368.

Vachon-Presseau, E., Roy, M., Martel, M., Caron, E., Marin, M., Chen, J., Albouy, G., Plante, I., Sullivan, M. J., Lupien, S. J., & Rainville, P. (2013). The stress model of chronic pain: Evidence from basal cortisol and hippocampal structure and function in humans. Brain, 136, 815-837. doi: 10.1093/brain/aws371.

Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 5(4), 355.

Author: Murray J. McAllister, PsyD

Date of last publication: 11-4-2013

Date of last modification: 2-18-2018

About the author: Dr. McAllister is a pain psychologist, and founder and publisher of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister consults to pain clinics and health systems on redesigning pain care deliver in order to make it more empirically supported and cost effective. He is also a frequenter presenter on pain, addiction, and redesigning healthcare.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stress Mon, 04 Nov 2013 20:06:49 +0000
Overcome Social Stigma of Chronic Pain https://www.instituteforchronicpain.org/blog/item/122-25overcome-social-stigma-of-chronic-pain https://www.instituteforchronicpain.org/blog/item/122-25overcome-social-stigma-of-chronic-pain

The Institute for Chronic Pain website has a new article on the social stigma of chronic pain. It explains the nature of social stigma and challenges both providers and patients to  take the difficult steps to overcome it.

If it challenges and inspires you, please share it with your network.

Click here to read it.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-26-2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stigma Sat, 26 Oct 2013 11:01:17 +0000