Person-centered pain management has been the center of recent literature emphasizing the complex and individualized nature of pain. While previous models in pain management emphasized treatment of the ‘average’ patient (ie, patient with non-specific low back pain), person-centered models put the patients’ beliefs, expectations, and goals at the center of the treatment plan. Clinicians who wish to practice evidence-based pain care should update their understanding of how and why person-centered care models should be the gold standard.
Pain is complex and fiercely individual. The recipe for success requires more than one ingredient, just as baking a cake requires more than flour.
Find the right ingredients
The specific ingredients (interventions) such as exercise,1,2 manual therapy,3,4 or pain education5 may be less important than the individualized response from the patient. This conundrum has contributed to years of endless searching for the ‘right’ ingredient (intervention) for different pain conditions. Rather than looking for the ‘perfect treatment’ clinicians should appreciate that different patients, even with similar pain complaints, will likely benefit from different interventions.
While clinicians may find their ‘favorite’ ingredient in the recipe to success, one ingredient in isolation will likely not be useful in managing pain; however, combinations of ingredients (multimodal pain care) produce a more effective product (just as flour combined with other ingredients produces a cake).6 The benefit of one REALLY GOOD ingredient developed through years and years of training is likely not as beneficial as having multiple ingredients and being able to identify which ingredients are needed for the right individual and at the right time. There are several factors to consider when putting together the ingredients for a successful treatment plan:
- Patients should drive the decision. Some patrons enjoy selecting the ‘chef's tasting menu’ but many of us prefer to make our own choices with some input and recommendations by the waiter and sommelier. Similarly, clinical providers should not apply interventions and make clinical decisions without involving patients in this decision. Shared decision making is a core component of person-centered pain care and should be used consistently throughout decision making not just at evaluation but at follow-up treatments as well.7 Just as patrons at a restaurant may modify their order based on their goals (‘weight-loss’ vs ‘bulking-season’), interventions provided should be modified based on the patients’ goals and expectations (within ethical consideration).
- Are you able to offer all the ingredients called for in the recipe or do you need another provider to assist in offering the proper ingredients? Multidisciplinary pain care has been recommended across guidelines for certain pain conditions.6,8
- Are the recipes you are offering supporting self-management, or do they require a health care provider as the active ingredient? While it is acceptable to have to go to the store to get some of the ingredients to keep repeating the recipe, you want the patient to be able to take control of the recipe rather than relying on others to cook them the whole meal. Similarly, passive treatments and modalities including manual therapy may be appropriate as an adjunctive treatment (side dish); however, self-management strategies should be perceived as the main course.8
- Perhaps just as important as the ingredients themselves is the dosage and timing of application. Recently, authors have suggested that pain phenotyping may be important for selection and timing of treatment ‘ingredients’.9 As with some cake recipes, the order/timing of added ingredients can determine whether we get a good rise or have our product fall flat.
Understand how external factors influence the final product
It is common to focus on the ingredients within the recipe (interventions) and forget about how important environmental and contextual factors are in determining the success of the recipe. Just as you would expect the temperature of the oven and the type of pan that you may be using to determine the success of your recipe, we expect contextual factors to have an impact on treatment outcomes. Contextual factors have been defined to include intrinsic and extrinsic factors which moderate/mediate therapeutic mechanisms of both pharmacological and non-pharmacological interventions.10 It is implausible to avoid the impact of contextual factors from the therapeutic process. Therefore, clinicians should try to leverage these to optimize their recipe.
If you find yourself doing similar interventions with most to all of your patients, then it may be time to reflect and ask yourself:
Are you making them a recipe that they prefer or are you making them eat what you have to offer?
Person-centered pain management emphasizes the individualized nature of pain and the importance of incorporating the patient into clinical decision making through shared decision making. While it is important that physiotherapists use available literature and past clinical experience in clinical decision making, person-centered pain care puts patients at the center of the clinical decisions. Finding the recipe for successful pain management takes time and practice, differs from patient to patient, and may leave the cook exhausted at the end of the day; however, the final product is well worth it.
Key Words: person-centered care, pain phenotyping, pain management
References
- Shire AR, Stæhr TAB, Overby JB, Bastholm Dahl M, Sandell Jacobsen J, Høyrup Christiansen D. Specific or general exercise strategy for subacromial impingement syndrome–does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord. 2017;18(1):158. doi:10.1186/s12891-017-1518-0
- Sullivan AB, Scheman J, Venesy D, Davin S. The role of exercise and types of exercise in the rehabilitation of chronic pain: specific or nonspecific benefits. Curr Pain Headache Rep. 2012;16(2):153-161. doi:10.1007/s11916-012-0245-3
- Keter D. Rethinking specificity in Orthopaedic Manual Therapy: It’s time for us to move forward. J Orthop Sports Phys Ther- Blog. Published online June 22, 2022. doi:10.2519/jospt.blog.2022062
- Nim CG, Downie A, O’Neill S, Kawchuk GN, Perle SM, Leboeuf-Yde C. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review. Sci Rep. 2021;11(1):23415. doi:10.1038/s41598-021-02882-z
- Zimney K, Van Bogaert W, Louw A. The biology of chronic pain and its implications for pain neuroscience education: state of the art. J Clin Med. 2023;12(13):4199. doi:10.3390/jcm12134199
- Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021;397(10289):2082-2097. doi:10.1016/S0140-6736(21)00393-7
- Hutting N, Caneiro JP, Ong’wen OM, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person. Musculoskelet Sci Pract. 2022;57:102434. doi:10.1016/j.msksp.2021.102434
- Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
- Cook CE, Rhon DI, Bialosky J, et al. Developing manual therapy frameworks for dedicated pain mechanism. JOSPT Open. 2023;1(1):1-15. doi:10.2519/josptopen.2023.0002
- Cook CE, Bailliard A, Bent JA, et al. An international consensus definition for contextual factors: findings from a nominal group technique. Front Psychol. 2023;14:1178560. doi:10.3389/fpsyg.2023.1178560
The author declares no competing interest.
Disclosure: The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Author Bio:
Damian Keter PT, DPT, PhD, OCS earned his Doctorate of Physical Therapy (DPT) from Chatham University and his Philosophy Doctorate (PhD) from Youngstown State University. He is a Board Certified Orthopaedic Clinical Specialist and holds certifications in dry needling and chronic pain rehabilitation. Dr. Keter currently works at the Cleveland VA Medical where he serves as clinical faculty and mentor for the Cleveland VA Orthopaedic Residency program teaching coursework in pain science. He is also a national biopsychosocial pain care program mentor for the Department of Veterans Affairs. Dr. Keter presents frequently at the local, state, and national level on topics related to chronic pain, pain science, and manual therapy. He has published several peer-reviewed works related to pain and manual therapy. Dr. Keter has previously served on the American Board of Physical Therapy Specialties Specialization Academy of Content Experts.