Posts Tagged ‘chronic pain’

Reassurance: Help or hinder in the treatment of pain

Friday, July 31st, 2009

Reassurance is a frequently recommended intervention for pain and is included in many national practice guidelines for musculoskeletal pain management. Reassurance is usually recommended on the basis of an implicit conceptualisation model that assumes that information presented to patients effectively corrects mistaken beliefs, which reduces fears based on those beliefs, which, in turn, leads to healthier behavioural functioning. However, according to Linton et al.1 in a recent topical review published in Pain, the efficacy of reassurance has a surprisingly thin evidence base and the current recommendations do not accommodate complexities in the pain experience.

Linton et al.¹ explain that reassurance is a complex process involving interactions between patient experience, thoughts, beliefs, and emotions and occurring within a dynamic interaction between the patient and a practitioner. Reassurance is achieved if the patient changes their understanding, thoughts and/or behaviour. The method of reassuring is the behaviour of the practitioner and includes the provision of information, instruction and persuasion.

Reassurance is commonly provided in the form of potentially corrective information, and may involve physical explanations for symptoms, results of diagnostic tests, or prognosis. Although such information may be accurate it does not guarantee that patients will respond with reduced fear and changed behaviours. For example, evidence from a cited study demonstrates that when patients receive information that is not directly related to their concerns or experience the information as a lack of understanding of the legitimacy of their complaint (“don’t worry, it’s not serious”) they respond by elaborating or asserting the symptoms more vigorously. Reassurance was accepted only when it included an explanation that was relevant to the patient’s concerns and linked physical and psychological factors.

The complexity of patient characteristics may influence the effects of providing reassurance, and the authors suggest that this may explain the inconsistencies in the current literature. For example, the effectiveness of information as reassurance can vary according the a patient’s level of health anxiety, with those experiencing higher levels responding less to attempts at reassurance. Furthermore, some studies have shown that reassurance, such as stressing the mildness of a problem and the likelihood of recovery, can actually increase disability and fear of future pain. Reassurance may also complicate a patient’s problems by reinforcing safety-seeking behaviours such as requests for information and diagnostic tests.

According to Linton et al.,¹ the current literature indicates that evidence for the effects of reassurance on pain-related problems is limited and inconsistent. They suggest that general recommendations for reassurance appear premature and a better understanding is needed. Although providing didactic information may help reduce fear and change behaviours in some patients and in some situations, direct attempts to change thoughts or beliefs by providing reassurance in the form of information may not be as effective as experience based methods; for example, direct (in vivo) exposure or direct verification procedures.

The authors also point to evidence suggestive that providing empathy and enhancing acceptance, rather than attempting to suppress fear and anxiety, may be an appropriate alternative in reducing the development of avoidance and other restrictive behaviours. A more solid evidence base for utilising reassurance in clinical practice must await further research.

1. Linton SJ, McCracken LM, Vlaeyen JW. Reassurance: help or hinder in the treatment of pain. Pain. 2008;134:5-8.

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