As a long-time social media commentator (since listservs and message boards!) it’s tempting to think that health professionals have shifted to a modern understanding of pain. And then I hear or read something to remind me there are people who haven’t ventured into this complex world…
Sales, Miyamoto & Valim (2024) conducted a study of ‘non-specialist’ pain professionals working in primary and ‘medium complexity’ care in Brazil. Their aim was to characterise the beliefs and attitudes of this group of clinicians in a publicly funded health service, and they used a measure called ‘Inventory of Attitudes towards Pain-Brief’ validated in pain services in Sao Paulo. This inventory has 20 items covering six sub-scales (or domains): control, emotion, disability, harm, solicitude, and cure.
Unfortunately I had to use Google translate to read about the original development of this instrument (it’s written in Portugese) – but the Sales et al (2024) paper gives the items and frequency distribution from their survey.
Onto the study itself. This was distributed to a convenience sample of health professionals working in a healthcare network of a municipality in the state of Espiroto Santo (Brazil). Participants were included if they treated people with chronic pain in daily clinical practice, and came from a variety of clinical backgrounds, but were excluded from the study if they specialised in pain or didn’t want to take part. It looks as if the survey and demographics were completed in the presence of one of the researchers.
What did they find? Seventy participants responded, with 5 who didn’t choose to take part. Most of them were nurses (30%) and medical practitioners (27%) and a good number of dentists (nearly 16%). The remaining participants were allied health. The authors say the participants were a representive sample for this health network.
The authors present an analysis of means and standard deviations for each of the subscales finding that four of the six were scored towards the ‘desirable’ end of the scale, but two (solicitude and cure) averaged towards the ‘undesirable’ end.
What strikes me (and the authors!) is that most of the respondents (72.9%) believed pain can be curedthat people with pain should receive more help (71.4%), be treated with more concern (72.9%) and that others should help people when they feel pain (71.4%). Nearly as many believed that movement/exercise is a good thing (65.7%) and will reduce pain (82.8%) – but in contrast, respondents were more equivocal about whether a person with pain could lead a physically active life (37.1% identifiying ‘neither true nor false’). Finally, respondents in this survey were inclined to believe that it’s possible to learn to deal with pain with thoughts, concentration and relaxation techniques, and that depression, stress and anxiety can increase pain.
There is further analysis regarding where respondents worked: some were in a specialty centre (the specialty isn’t identified) while others were in primary care, and there were differences in responses between these two work settings. This was particularly relevant to beliefs about pain and disability, where primary care clinicians had more undesirable beliefs.
So what? Firstly, let’s pick apart the study methods, because this directly impacts how we interpret the results. Convenience samples can be a problemand as a New Zealand reader I’m not familiar with the Brazilian healthcare system and context – and this will influence my interpretation of these results.
The measure itself doesn’t appear to identify the type of pain respondents should consider. Remember I haven’t seen the English instructions (or items), so I may be wrong but it seems to just identify ‘pain’ – and participants are likely to respond to these items on the basis of their clinical experiences. This matters because answers to items such as those in the Disability and Cure subscales will be more or less ‘true’ depending on the type of pain being considered.
I looked at a Google translated version of the measure which was developed from the Survey of Pain Attitudes (Brief), itself developed from the Survey of Pain Attitudes originally developed by Tait and Chibnall (1997). The SOPA was developed to assess patient’s beliefs, and has been adapted for use with clinicians. Its development was robust, and it looks (at first glance) as though the Inventory of Attitudes towards Pain-Brief (Garcia, deMattos Pimenta, de Almeida Lopes Moteiro da Cruz, 2007) is similarly robust.
Nevertheless, a good measure, measuring the wrong thing, doesn’t do a lot. The Garcia et al (2007) instrument was intended for use and validated with clinicians working in chronic pain centres – so content and construct validity probably refers to pains these clinicians most encounter. I don’t know that the authors fully considered this when adopting it for this study. That’s a shame, because it makes interpreting the results a little tricky.
Their conclusion was that some clinicians have unhelpful expectations about a cure for pain, pain-related disability, and pain and tissue damage. Their conclusion is that clinicians need more education – I don’t disagree.
The echo chamber. Much of my day to day interactions are with people who are interested in pain. Many of those people have an interest in chronic pain, but not all. I’ll bet, if I administered an English version of the measure Sales et al (2024) used, prefaced it with ‘think of chronic or persistent pain’, my results would not be all that different from this study. Some clinicians firmly believe there are treatments for chronic pain – we just have to look hard enough to find them, and if they don’t ‘work’ it’s not the fault of the treatment. Some, on the other hand, would be well aware that our treatments aren’t all that flash, that often it’s an N=1 situation where we have to try things out based on good hypotheses but the odds are not all that wonderful especially for neuropathic and nociplastic pain.
I’m also painfully (no pun intended) aware of the tendency to think ‘exercise’ or ‘mindfulness’ or ‘trauma therapy’ or ‘CFT’ or whatever the latest treatment being promoted on social media is The Thing for All.
Here are some things to ponder based on the items in this questionnaire – and think about acute/inflammatory pain, and those weird complex pains that hang around:
(1) How much can a person influence their own pain intensity? How much can pain be reduced by concentrating or relaxing? How much can pain be ‘controlled’ by changing thoughts?
(2) How much can a person ‘get around’ their pain to lead a physically active life? (Is this in all cases? What if the pain is really intense, intrustive or intermittent?) Can people ‘do almost everything’ they did before their pain? And if there are exceptions to these two items, what are those exceptions?
(3) How much should family and friends help a person when they’re experiencing pain? Is this always a good thing? If it depends – what are those exceptions?
(4) Is ‘physical’ pain curable? (not sure why ‘physical’ is included because I thought the definition of pain indicates it’s ‘always a personal experience influenced to varying degrees by biological, psychological, and social factors’) If some pains aren’t ‘curable’ how do we know? When do we decide? If there’s no medical procedure that helps with pain, does this apply to all pains or just some? and how is a clinician (or the person) to know if their pain will respond?
(5) How much does exercise reduce pain intensity? what kind of exercise, how often, what happens if life changes? What if the person doesn’t respond to ‘exercise’ but does respond to other forms of movement? And is pain intensity the most important outcome?
The problem with surveys is they reduce contextual considerations, they lose nuance as they simplify constructs. Yet they do offer some insights into broad constructs. They’re a bit like blood pressure readings: one reading in isolation might not be as ‘accurate’ as watching trends and patterns over time.
Take a look at your echo chamber. Who are you exposed to? What if you sought contrasting opinions? What if you ask awkward questions? What if you were curious about what others think and how they got there? Can they (and you) find exceptions to the rules – and can you be curious and allow yourself to be OK with ambiguity?
Garcia, DM, Pimenta, Cadm, & Cruz, Ddalmd (2007). Validation of attitudes inventory in the face of chronic-professional pain. USP School of Nursing School, 41636-644.
Sales, P. T., Miyamoto, S. T., & Valim, V. (2024). Beliefs and attitudes about chronic pain among public health professionals: cross-sectional study. Brazilian Journal Of Pain, 7. https://doi.org/10.5935/2595-0118.20240031-en