Understanding Patient Assessments of Pain

By focusing on coping strategies and appraisal, physicians can enhance their capacity to "understand disease related pain and disability."

The lecture, titled “Physical and Psychological Functioning Important to Patient Coping and Appraisal of Disease-Related Pain,” focused on examining how patients understand and react to their pain.

Keefe is a professor of psychiatry and behavioral sciences and associate director for research in the Duke Pain and Palliative Care Initiative at Duke University Medical Center.

According to a growing body of evidence, a patient’s method of coping with and appraising their pain is not only based on their experience, but also their physical and psychological functioning, Keefe said.

Keefe presented data on studies involving osteoarthritis pain patients and GI cancer pain patients that focused on how these patients defined pain. What the research found was that “patients think pain represents, more or less, disease activity,” he said. Often times, patients felt that if they can control their disease, then the pain will go away, he said, but diseases don’t always equal pain.

In addition, multiple studies have found that patients exhibited varied outcomes when given the same interventions. Keefe used the Stress and Coping Model, proposed by Lazarus & Folkman, to explain why this may be so, but emphasized the importance of examining pain-catastrophizing in trying to understand the variation.

Those patients who seemed to demonstrate pain-catastrophizing had a more difficult time managing their pain. These patients tended to “report more pain,” even when “pain was being controlled,” he said. Additionally, they tend to be more physically disabled, more depressed, and they take more medicines. Yet, they do report that they have more social support, a fact that can sometime feed the cycle of helplessness.

Imaging studies revealed pain castatrophizing was related to regions in the brain associated with affect and attention.

This is why it is important that physicians focus on enhancing coping skills to positively influence a patient’s appraisals of pain, Keefe said. Coping skills should be designed to help patients reconceptualize pain and pain control. The programs should make sure to include relaxation, activity pacing, cognitive restructuring, distraction and imagery, behavioral rehearsal, and guide practice, Keefe said.

Coping strategies used at medical centers like the University f Washington, which performed a virtual reality intervention for children with pain, and the University of Vermont College of Medicine, where Dr. Magdalena R. Naylor performed a study on chronic pain patients that utilized a telephone feedback system after cognitive behavioral therapy to ensure positive outcomes, were highlighted by Keefe as examples of effective therapies.

Using pda systems and electronic devices to stay up-to-date on a patient’s pain management program was also recommended.

By focusing on coping strategies and appraisal, physicians and health care practitioners will enhance their capacity to “understand disease related pain and disability,” according to Francis J. Keefe, who gave a plenary lecture at APS’ 29th Annual Scientific Meeting, Thusday May 6.