There is a common belief amongst some people involved in pain and pain management that a person with chronic pain should be consistent in their presentation. That is, be consistent in various settings, and consistent across various measures. This assumes that if inconsistencies are present there must be something going on to cause suspicion about the validity of the person’s presentation.
Returning to yesterday’s post , I discussed the distinction between nociception (activation of receptors in the nervous system), pain (the experience produced by the brain once it has interpreted the nociceptive action), disability (the changes in functional performance attributed to the experience of pain), and impairment (tissue changes). These are not the same! Today’s post refers mostly to pain and disability.
Pain is, as I keep spouting, a personal, subjective experience – you and I can’t share our pain except through our behaviour. And even when we describe it, we can’t actually experience what it feels like to have each other’s pain. What this means is that our behaviours, or what we do, are what conveys our experience to others but only to a certain extent.
While our experience of pain remains individual, our behaviour is shaped by all the influences around us. And just to make things more complex, the meaning of our pain experience is shaped by what we learn and believe about pain from interactions between ourselves and all those influences that shape our behaviour. Complicated? Oh yes.
So if I grow up in a family that is generally stoic, where my complaints of pain are ignored and I see that others in my family don’t generally cry or stop doing things when they are hurt, it’s likely I’ll also be less demonstrative about my pain than another person in a family where this is not the norm.
We also learn to behave differently in different contexts. It’s common to say a few choice words when we hit our thumb with a hammer in the garage on a Saturday afternoon, but we usually wince and gasp quietly if we thump that same thumb in Church the next day!
What this means in terms of consistency is that people often do different things in different settings when they have pain – maybe when they drive from home to a clinic they’re a bit anxious about what the consultation might mean. They get out of the car and walk quite carefully into the clinic and sit down rather gingerly. They’re not sure whether they’re going to hear good news, or not. They go through the examination and consultation, and get told they’re going to try a new medication that might help. Oddly enough, as they walk back out to the car someone looking out the window might see them moving fluidly and getting into the car quite smoothly. Suspicious minds might start to wonder if they really had “that much pain”.
Turning to assessment of pain now, it’s been said that pain assessment should incorporate a number of different dimensions. At the very least, assessment needs to consider the location of pain, the intensity and quality of pain, and some sort of measure of the interference pain has with everyday activities. Some commentators consider pain assessment should also make a diagnosis of the type of pain disorder present (or the cause of the pain), while others also think that psychological aspects of pain need also to be included (such as pain catastrophising, measures of avoidance and measures of mood and anxiety). And of course, assessments of range of movement, strength and reflexes are also often part of a pain assessment.
Should these measures all present a “consistent” picture?
Where we hurt and what it feels like (the quality of pain) don’t directly correlate with the amount of interference a person experiences from their pain. If I’m a pianist I might be really bothered by tingling and burning fingers, while less bothered about the same pain qualities in my feet. If I’m really anxious about my future as a nurse, I might be really concerned about my low back pain. If I’ve developed some effective coping strategies for managing my overall body aching, I might not be particularly anxious or have low mood despite having quite intense pain.
Inconsistency between various aspects of a person’s presentation doesn’t mean they’re faking, or that their pain is not real. It does mean we need to generate some hypotheses about the relationship between the various factors that could be influencing the person’s behaviour. To decide, on the basis of our own experience (which is always limited!) that another person’s pain is not real just because we don’t understand why they are doing what they’re doing, is a judgement call we can’t make, in all honesty. More than that, it doesn’t help work out what to do next to move the person from being disabled (or getting a benefit they don’t “deserve”) to returning to function.
Personally, determining the validity of a person’s claim to have pain is not the province of a health professional – it’s a task for administrators of a compensation scheme. We can describe what we see, we might even make a diagnosis, but we can’t tell whether someone’s cheating the system. Bring out the investigators and be honest that health professionals can’t do what some insurers want us to.
Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0