The patient with pain is central not the therapist   May 9th, 2016

​One important aspect of dealing with patients with central pain syndromes is that no two patients are the same. Patients with persistent pain differ in their complaints and pain characteristics. Besides their pain related symptomatology, also their coping-style is different.

Coping is a broad concept including cognitive, behavioral, social (cultural) and psychological factors. These factors, in turn, are related to the perceived self-efficacy of the patient, his/her attitudes and environmental factors. This means that every patient needs a personal approach in which patient centeredness is key. What is patient centeredness and how is this really important?

Patient centeredness is about the process between the healthcare provider and the patient. In literature, several definitions and frameworks, with (largely) overlapping domains, have been presented. The framework of Mead and Bower, from a medical perspective, describes the patient-centered model with five interconnecting components: 1) bio-psycho-social perspective, 2) the ‘patient-as-person’, 3) sharing power and responsibility, 4) the therapeutic alliance, and 5) the ‘healthcare professional-as-person’. The bio-psycho-social perspective is probably the most challenging one since it may be assumed, in patients with central pain, that physicians/physical therapists are typically primed to diagnose and treat physical pathology leaving health-affecting psychosocial distress often unrecognized. In contrast, psychologists may have more difficulty interpreting the somatic symptoms.

The therapeutic alliance is related to treatment adherence and positive treatment outcome in several disciplines. Recently, Fuentes et al. (2014) showed the effects of therapeutic alliance on pain intensity and pain sensitivity using an experimental placebo-controlled study in patients with low back pain. One hundred and seventeen patients were assigned to one of four conditions. The groups received a single sham or active electrotherapy treatment with limited therapeutic alliance or a sham or active electrotherapy with enhanced therapeutic alliance. Effects were found in all four groups, but in the groups with therapeutic alliance the effect-sizes were significantly bigger and clinically relevant on both outcomes (pain intensity and pain sensitivity).

How can you implement patient centeredness in your clinical practice in patients with central pain? Start with the following; take your time for the assessment to understand someone’s pain, listen carefully to your patients, try to collaborate with other healthcare pain-professionals (with the same view on pain), be aware of your communication skills, try to explain pain to your patient from a bio-psycho-social model and most of all, be empathic.

Paul van Wilgen

2015  Pain in Motion

References and further reading:

-Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51(7):1087-110.

-van Wilgen CP, Koning M, Bouman TK. Initial responses of different health care professionals to various patients with headache; which are perceived as difficult? Int J Behav Med. 2012 Sep;20(3):468-75.

-Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014 Apr;94(4):477-89.