Elsevier

Brazilian Journal of Physical Therapy

Volume 25, Issue 1, January–February 2021, Pages 17-29
Brazilian Journal of Physical Therapy

Masterclass
Beliefs about the body and pain: the critical role in musculoskeletal pain management

https://doi.org/10.1016/j.bjpt.2020.06.003Get rights and content

Highlights

  • Beliefs are an important target for the management of musculoskeletal pain.

  • Behavioural learning is key to elicit and disconfirm unhelpful beliefs.

  • We propose key principles to guide clinicians in promoting behavioural change.

  • A case illustrates the role beliefs have on musculoskeletal pain management.

Abstract

Background

Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by pain. Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability. Clinical guidelines recommend addressing unhelpful beliefs as the first line of treatment in all patients presenting with musculoskeletal pain. However, many clinicians hold unhelpful beliefs themselves; while others feel ill-equipped to explore and target the beliefs driving unhelpful responses to pain. As a result, clinicians may reinforce unhelpful beliefs, behaviours and resultant disability among the patients they treat.

Methods

To assist clinicians, in Part 1 of this paper we discuss what beliefs are; how they are formed; the impact they can have on a person's behaviour, emotional responses and outcomes of musculoskeletal pain. In Part 2, we discuss how we can address beliefs in clinical practice. A clinical case is used to illustrate the critical role that beliefs can have on a person's journey from pain and disability to recovery.

Conclusions

We encourage clinicians to exercise self-reflection to explore their own beliefs and better understand their biases, which may influence their management of patients with musculoskeletal pain. We suggest actions that may benefit their practice, and we propose key principles to guide a process of behavioural change.

Section snippets

Background

Musculoskeletal pain is a multi-factorial condition; it involves complex interactions between structural, physical, psychological, social, lifestyle, and comorbid health factors and is therefore best understood through a biopsychosocial framework.1, 2, 3, 4, 5 While in most cases, musculoskeletal pain is self-limiting, a significant proportion of society go on to experience long term pain and disability. Musculoskeletal pain is now a leading cause of disability world-wide6 and the prevalence of

What are beliefs and how are they formed?

Beliefs can be defined as “Something one accepts as true or real; a firmly held opinion” (Oxford dictionary). While modifiable, the core characteristics of beliefs can make them difficult to identify and target; (i) Beliefs are not always rational i.e. they can persist even after being presented with facts. For example, a patient might believe that structural changes seen on imaging are the source of their musculoskeletal pain, despite being told that the changes reflect ‘normal ageing’ and are

PART 2 – The process of changing beliefs and behaviour

“To understand the sufferer, one must understand the narrative, for it is through the story that the patient's suffering is accessed. This means both hearing the illness story and listening for the suffering narrative therein.”71

In this section, we will use the Common Sense Model (Fig. 1) as a framework to understand patient's beliefs, behavioural and emotional responses to their condition and the process by which change can be facilitated.

Person-centred communication underpins this process.

Person-centred interview

Completion of a body chart and a multidimensional screening questionnaire (e.g. short form Orebro) prior to the interview can provide helpful insight into the patient's perception of their pain.76 Relevant items from the questionnaire can be used to explore patient's beliefs in the interview and examination. For instance, clinicians can use scores in individual items to guide the interview, and to facilitate disclosure about specific factors (e.g. “You scored 8/10 on ‘avoiding painful

Summary

Beliefs about the body and musculoskeletal pain influence a person's behavioural and emotional response to pain. Beliefs are modifiable and should be considered an important target for the management of musculoskeletal pain. Clinicians have an important role to disseminate positive, evidence-based beliefs about musculoskeletal pain to both patients and society in general. However, many clinicians hold erroneous beliefs themselves, while others feel unskilled to explore and target patients’

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

JP Caneiro and Peter O'Sullivan deliver educational workshops on patient-centred care for the management of pain. Samantha Bunzli declares no conflict of interest.

Acknowledgements

The authors acknowledge the patient (Jamie E) for sharing his story.

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