Today I’d like to introduce the concept of Reassurance as a Treatment (RaaT).
(You may have heard of the acronym Saas (short for Software as a Service). Many of the world’s biggest software companies utilise this business model (think Microsoft, Atlassian etc), where they sell cloud based services instead of more traditional software. The concept of RaaT is a play on that.)
This is not meant to become an official acronym, or even an unofficial one. It’s just an easy way to abbreviate the concept of utilising reassurance as a treatment for pain.
This article is general in nature, and based on a few assumptions:
- Guidelines for the management of many pain conditions include reassurance as a treatment intervention
- Practitioners of all disciplines often believe they deliver reassurance during a consultation
- Despite this, many patients demonstrate pain, disability, loss of function and catastrophising tendencies even after they have consulted with health professionals
- Delivering reassurance takes both knowledge and skill to do, both of which are likely to be lacking from many primary care practitioners’ direct training
So let’s have a look at these assumptions, and see where reassurance as a treatment sits in the spectrum of pain mangement.
A Look At The Guidelines: Where Does Reassurance Sit?
In Australia, reassurance is part of the acute low back pain clinical practice guidelines:
Guidelines recommend that patients be advised to remain active and avoid bed rest, and be reassured of the favourable prognosis of ALBP. This is arguably the most important aspect of care that health professionals can provide.NSW Agency for Clinical Innovation
Reassurance is also recommended as part of the treatment process for the management of rotator cuff injuries (in the workplace):
One of the first priorities for the clinician is to provide information and reassurance to the injured worker presenting with rotator cuff syndromeClinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace
In the acute pain management guidelines from the ANZCA, reassurance is only recommendend for low back pain specifically:
Targeted reassurance in acute back pain by physicians in primary care can result in improved changes in psychological factors such as fear, worry, anxiety, catastrophisation and healthcare utilisation (N) (Level III-1 SR).ACUTE PAIN MANAGEMENT: SCIENTIFIC EVIDENCE Fourth Edition 2015
How ever, the same guidelines also mention reassurance as a treatment for chronic abdominal pain:
The role of psychological intervention with reassurance and distraction in the management of acute pain in an anxious patient is often undervalued.ACUTE PAIN MANAGEMENT: SCIENTIFIC EVIDENCE Fourth Edition 2015
And in discussing non-pharmcological management of acute pain:
So while there is definitely mention of RaaT across multiple clinical practice guidelines, the lack of more global recommendations may be more related to absence of evidence, than any evidence of absence.
Given the low cost (both the actual and opportunity cost) of delivering reassurance, my position is that it should be provided generally, where possible, for both a minor potential effect on pain and disability, as well as simply being a good human thing to do.
How Effective Is Reassurance For Pain?
Like many “soft skills”, it is hard to quantify the delivery and impact of something like reassurance. And just because reassurance sounds like it should be a good thing, doesn’t mean it actually is.
We can still get a general idea of whether targeted reassurance interventions have an impact, and the rough magnitude of that impact.
A few studies have looked at that.
In 2013, a mixed psychology and osteopathic/allied health research group from the UK conducted a systematic review of the role of cognitive and affective reassurance in primary care.
They discussed the differences between both types of reassurance, based on earlier work from Coia and Morely on Medical Reassurance and Patients’ Responses:
- Affective reassurance is:
heuristic and rapid, and produces an immediate response in reducing concerns and worry. However, such responses are transient, and when
problems return to impact on patients in the absence of the reassuring practitioner, the patient has not been empowered with new tools to deal with them.
- Meanwhile, cognitive reassurance is:
systematic and time-consuming, but its impact
in changing beliefs and increasing understanding is preserved,
which in turn will improve adherence and self-management
They focused on clinical situations where uncertainty is high (like musculoskeletal and pain management clinics), where there is a high need for psychological support.
They found that:
affective reassurance was associated with higher symptom burden/less improvement, with lower rates of return to work in one and with reduced adherence in another
Four high-quality and 3 lower-quality studies found associations with improvement in symptoms at follow-up. Associations were also found with reduced further health care utilization in 3 studies, one of which
was of high methodology. The relationship between cognitive reassurance and adherence remains unclear
Another study, from 2007, looked at whether reassurance helped or hindered the treatment of pain.
They found that from a physician perspective, doctors typically provided reassurance with information, but:
The effects of information as reassurance may vary depending on the patient’s level of health anxiety.
They also looked at whether diagnostics tests were reassuring, and found:
Providing information about the MR did not show measurable value
for care or outcome but did decrease patient reported well-being.
They also looked at things from a patient’s perspective, and as you might guess, found that the two views did not align:
clinicians attempted to provide reassurance by underscoring the mildness or the early stage of the problem as well as the probability that the patient would recover. However, the results showed that this increased worry for future pain and disability
A more recent (2015) paper from Traeger et al looked at the effects of primary care based education on reassurance and found
There is moderate- to high-quality evidence that patient education increases reassurance more than usual care/control education in the short term and long term.
Of interest to allied health professionals, and no doubt something many of you may have experienced in one form or another:
Interventions delivered by physicians were significantly more reassuring than those delivered by other primary care practitioners (eg, physiotherapist or nurse)
What we can see from this small snapshot of the literature, spanning a couple of decades, is that reassurance seems to go hand in hand with education, but it is not as simple as providing information, and the effects can vary based on the practitioner delivering the reassurance and education, the clinical context, how they deliver it and the patient’s individual physical and mental health status.
How To Reassure A Patient In Pain
“Reassurance without listening is dismissal”— BeyondMechanicalPain (@beyondmpain) March 31, 2020
One of the most important aspects about providing reassurance to a patient in pain is to ensure they do not feel dismissed.
There is a fine line between saying “everything will be okay” and a patient interpretting it as “they said there is nothing wrong”.
You don’t need a doctorate in psychology to know that if you are not feeling well, being told (or perceiving it as such) that there is nothing wrong does not help validate your experience.
So, the first step in reassuring any person in pain is to listen and acknowledge their experience as real and meaningful.
The second step is to provide an accurate explanation for their experience. This is not easy, but the importance getting a diagnosis cannot be understated. Bronnie Lennnox-Thompson has written on this topic before, and I would highly recommend reading her thoughts.
This is another challenge, as it is very easy to fall into the trap of “structuralism”, and provide a patho-anatomical diagnosis, which will likely lead to increased pain, disability and loss of function in the long term.
Beyond these first two steps, working on a collaborative management plan that involves goal setting and regular check-ins allows you to set up a reassurance “positive feedback loop”, whereby each future session allows you to reinforce your initial reassurance, while allowing the patient to have time to integrate the education with their own experience.
Communication is called a “soft skill”, which are considered as part of the “human” skill set that are important for all professionals, no matter what you do.
However, good communication is actually quite hard; think about the challenges you face personally, professionally and as a customer and client of other service providers. How many times have you had to seek or provide further clarification, resolve conflict or follow up due to lack of communication or drop out?
Communication isn’t as simple as saying what you mean. How you say what you mean is crucial, and differs from one person to the next, because using language is learned social behaviorDeborah Tannen
If communication is hard, then reassurance is even harder.
Why? It is a subset of communication – you need to be able to do the first well in order to do the second well (cognitive reassurance at least).
So, just as you would study, practice, and refine your hard or technical skills, communication and reassurance can be studied, practised and refined so that you get better and better at it over time.
Though it is something that you never master – as every human interaction is different – you can definitely become quite adept at it, and use reassurance as part of your overall treatment process for people in pain.
This post was written by Nick Efthimiou, a contributor to Beyond Mechanical Pain.