A case of mistaken identity? The role of injury representations in chronic musculoskeletal pain.

PURPOSE

To explore how patients construe bodily injury, examine how injury representations change over the course of a rehabilitation program and how injury representations influence adaptation and recovery trajectories.

METHODS

A case study method was used with qualitative interviews as the primary data source. Qualitative semi-structured interviews were conducted three times over the course of a 12-week intensive interdisciplinary occupational rehabilitation program with one interview 1 month following discharge. To capture changes in rehabilitation trajectories, data analysis employed a narrative approach informed by Bury (progression, regression, and stability) and Frank's (chaos, restitution, and quest) approaches.

RESULTS

Sixteen patients (10 men and 6 women) were disabled as a result of persistent pain and impairment from a variety of work injuries participated. Progression/restitution narratives were characterized by the transformation of bone and nerve problems to include soft tissue elements. These participants expanded their scope of injury representations and appraisal to include neurobiological aspects of chronic pain and dimensions of psychosocial well-being, and linked diagnostic representations to self-management strategies in a functional manner.

CONCLUSION

Body representations of injury morphology and pain mechanisms are important objects of fear and acceptance for injury recovery. Active strategies that encourage a "hands on" understanding of diagnosis may prove most effective in treating persistent pain.

IMPLICATIONS FOR REHABILITATION

Patient representations of pain and body injury are windows into the personal experience of individuals with chronic musculoskeletal pain. When patients enter programs, practitioners need to assess what the patient believes is wrong with their body and what will be helpful in rectifying the problem. Based on their initial assessment, practitioners need to direct education and activity toward shifting patient beliefs to include elements of soft tissue and a broader scope of pain sensitization and psychological impact. Activity-based intervention is essential for creating coherence between injury and pain representations and coping action. During rehabilitation, practitioners need to monitor patient beliefs about their injury. Shifting beliefs are signs that the patient is adopting a more adaptive cognitive stance toward their injury. Lack of movement indicates that the message is not getting through and the approach needs to be modified. When working with patients to transform beliefs, a collaborative approach might be best to increase trust and reduce reactance.