Risk factors for recovery?

This post is primarily targeted towards the MPT students in my 'Understanding Pain in Physical Rehabilitation' class here at Western University.  Of course, I'm always happy to hear from anyone else with comments on this or any topic.

Those familiar with my work will know I'm primarily interested in playing prognosticator when it comes to dealing with acute injury and pain.  This in fact stems from my clinical interest in treating complex chronic pain problems - in order to know how to treat something, you should probably have at least some idea of what caused it.  So, my research program focuses on predicting chronic pain whereas clinically I focus on treating it.  Hope that makes sense.

This week's 'Pain' class will focus on the nature of recovery, and what that means.  The students will already have an idea of my stance on this from reading one of the assigned papers for the week.  For those interested, this is the other assigned paper for the week.  The class is structured more as a round-table discussion and sharing of ideas, born from the belief that learning is richer when all 20 people contribute ideas rather than just me as 'lecturer'.  We will have several ideas and thoughts to share and reflect upon this week as with previous weeks.

I want to pose one now in order to stimulate those intellectual juices.  As a brief aside, I can't believe no entrepreneurial energy drink manufacturer has never made a line of drinks called 'intellectual juices'.  It just seems natural.  But back to the matter at hand, let's address this idea of recovery, prediction, chronicity and the like.  In the standard lexicon of the field, we frequently talk in terms of 'predicting the transition to chronicity' or some version of the word chronicity, like persistent disability or late [whiplash] syndrome or such.  The literature will generally then refer to things like fear or catastrophizing, low self-efficacy, greater baseline pain, exaggerated stress reactions, withdrawal, or any manner of predictors with a generally negative valence.  Ultimately we end up with something like 'people with greater fear of movement in the acute stage are at higher risk of transitioning from acute to chronic pain'.

I use this terminology as well, mostly because it's familiar.  But conceptually I've always had a bit of trouble with this.  If we take for example, this image that I tend to use when discussing issues of recovery:

For orientation, this is a conceptual model of the injury experience, the solid black line representing one's trajectory through life towards some abstract state of self-actualization and the level of health 'resources' (for example, strength, mobility, cognitive ability, etc...) required to achieve that state (the 'ought' level of health).  The dashed green line represents the perceived level of actual health.  Assuming our 'actual' health always hovers close to our 'ought' health, this model posits that we should be generally satisfied with our current health status, insofar as we probably don't require care or consider ourselves disabled to any important extent.  But when an injury occurs, or some other pathological process that robs us of some of those health resources, our actual health falls below our ought health, and we are now motivated to do something to mitigate this difference (ie. adopt coping strategies that we believe will be effective).  If all goes well then we recover our health resources (oh, there's that word!) and continue on our happy ways towards our ideal selves, whoever that may be.  Bob's your uncle.

So, here's my problem with the whole 'transition to chronicity' thing.  In this model, the transition is actually from the sick role back to the recovered or 'healthy' role.  If the person never transitions, then they would remain in the sick role, and that would then be labeled 'chronic' or 'persistent' problems.  It would be as awkward as saying I'm looking for factors that would facilitate my transition into my current healthy state (assuming I'm currently healthy).  I think of it like a train on a track - what we're looking for are things that might affect a switch of that train from one track to the other.  If we do nothing, the train stays on the same track.

So is this important or simply more mental masturbation?  I do think it's important and here's why - if we start talking in terms of factors that facilitate the transition from 'person in pain' back to 'satisfactorily healthy person', then we can switch our discussion from terms like 'fear', 'anxiety' and 'catastrophizing' to 'resiliency', 'self-efficacy' and 'satisfaction'.  Treatment paradigms switch from identifying and trying to remove the negative, to trying to promote the positive.  It's a conceptually simple shift that could have dramatic effects.  What if we had a scale to measure resiliency that we could use for our patients, wouldn't that be better than measuring fear?  And then, how much more pleasant would it be to work with our patients to improve their physical and emotional resiliency, rather than to focus on extinguishing their fear?  Or perhaps there's room for both, but it seems that treatment targets with a positive valence are missing from many clinical encounters - we tend to look for what shouldn't be there and try to remove it, rather than what should be there and try to add it.

So there you go, something to chew on a bit.  If you really want to get into this, in the comments section leave an item you think would fit on a scale of 'physical and emotional resilience', assuming the response options were frequency based (ie. never, rarely, often always).  Who knows, maybe we'll all end up creating a new community-driven scale together.  How cool would that be?