Pain Relief vs Functional Gain: As long as it’s specific and achievable…
By Drs Murray McDonald & Rowan Duys
If you’re reading this, I must first apologise for our appalling performance. Unless you really liked it, in which case you have excellent taste! It’s really hard to know how these things will go. In some ways it is like helping someone to manage their pain (tenuous link but just go with it) – you try to understand and reflect their needs, try your best to get through to them, but sometimes things get lost in translation and you’re both left feeling unsatisfied. It’s called a relationship, and it helps to know what you want out of it, and how to get what you want.
Goal planning is a way of creating a focus to guide and motivate treatment. Goal planning has shown to be effective for increasing adherence to treatment & patient performance, increasing their self-regulation, and is related with improved outcomes such as return to work. However, the relationship between goals and outcomes is more complex.
Achieving successful outcomes through goal planning seems to depend on the clinical setting and the nature of the goals. The nature of goal planning can be described by social cognitive theory, goal setting theory, and the health actions process approach. Goals tend to perform better when they are prescribed, specific, and challenging. However, goals that are too simple do not seem to motivate well and those that seem unachievable are often abandoned. It thus seems that setting SMART (specific, measurable, achievable, realistic, time-bound) goals are generally better. It is a more complex matter to choose which domain to address.
As a biopsychosocial phenomenon, pain can present with multiple aspects and multiple effects on the patient’s body, mind, and life which are interdependent. The ICF measures pain using domains such as body structure and function, activities and participation, personal, and socioenvironmental effects. These are also reflected in the IMMPACT report’s assertion that research should measure outcomes in similar domains such as pain intensity, function, emotion, satisfaction, side-effects of treatment, and the patient’s disposition to treatment. Therefore, goal planning can reasonably target any aspect of the patient’s pain or ability, but deciding on the best primary target is complicated.
The relative benefits of pain relief and functional improvement are variable. In review, reduction of pain intensity can often predict improvement in several functional areas. We also know that disability is likely driven by pain intensity and psychological distress than vice versa. However, clinical trials often show reduction of pain intensity to be underwhelming and side-effects intolerable (not to mention the current opioid crisis) while improvements in functional & psychological areas can often be more robust. Functional gain can mediate reduction in pain intensity & depressive symptoms via improvements in self-efficacy and other psychological constructs. Whether pain relief or functional improvement should be the primary target is a question that may need to be assessed on a patient by patient basis to optimise efficacy.
Patient satisfaction with care is a multidimensional construct affected by several variables. It can be affected by healthcare quality, multidisciplinary care, meeting patient values and expectations, and attainment of patient goals. Patient satisfaction should therefore be optimised by goals that are patient-centred, specific, and achievable while using treatments that are evidence-based and delivered in a multi/interdisciplinary setting. Find the reason that the patient is suffering – whether it’s pain intensity, fear avoidance, or emotional consequences – and target it as directly as you can using values-based goals and a holistic approach.
In conclusion, the purpose of goal planning is to focus and motivate treatments. Achieving successful outcomes through goal planning depends on the nature of the goals and the clinical setting. Pain is a biopsychosocial phenomenon and as such offers multiple options for goals and treatment targets. Pain relief can reduce functional impairment in certain cases and vice versa. Patient satisfaction is directly related to successful goal attainment. Therefore, goals should target the aspects of pain that will drive patient improvement and help meet patient values & expectations while being specific and achievable. Perhaps in a phenomenon with various interacting components, more than one primary goal is needed. But, as always, we should value the patient’s views, build their self-efficacy, and empower them to take back their lives.
Thanks for reading.