Implications of the motivational model and motivational issues for understanding and addressing the process from acute to chronic pain

The Motivational Model assumes that a key factor in adjustment to chronic pain is pain coping behaviour; adaptive coping is thought to contribute to positive adjustment (minimal pain, minimal pain impact, and maximum functioning) and maladaptive coping is thought to contribute to poor adjustment and maladaptation. Along these lines, and according to the Motivational Model, an individual’s readiness to self-manage pain at the time of acute injury would be expected to influence his or her coping responses to that pain, and ultimately contribute to the course of that pain and its influence.

While a number of studies have been performed to determine the predictors of movement from acute to chronic pain, and psychosocial factors are often identified as the factors most strongly associated with the development of chronic pain (cf. Schultz et al. 2004), coping responses, and self-efficacy and importance for adaptive coping, are rarely studied. When coping is studied, it consistently emerges as a significant predictor of future functioning in patients with acute pain (e.g. Potter and Jones 1992; Prkachin et al. 2007). We hypothesize that the ability to predict the development of chronic pain in individuals with acute or (sub)acute pain would be enhanced if researchers assessed a broader range of coping responses, self-efficacy for pain selfmanagement, and the importance of pain self-management as the predictors in their model, and readiness to learn new coping strategies.

Similarly, in order to minimize the development of chronic pain, it would be useful to consider methods for maximizing adaptive coping and for encouraging the development of perceptions of self-efficacy for pain self-management and beliefs in the importance of pain self-management very early (or even before) the development of acute pain. For example, general education programmes provided to the population, through television and radio (public service) announcements, concerning the importance of remaining active following an acute injury (Liddle et al. 2007), and provided that this is supported following an appropriate medical evaluation, might decrease the incidence of the development of chronic pain in populations of individuals.

In health care settings, physicians and other health care providers who see patients who have been recently injured should strive to assess the patients’ coping responses, and use interventions, as appropriate, to increase patient self-efficacy for and perceptions of the importance of adaptive responding (e.g. activity), in order to increase the changes that the patient will actually respond to the acute pain in an adaptive way. For these reasons, we view skills in Motivation Interviewing (briefly described above) as a key skill for health care providers who work with patients with both acute and chronic pain. In support of this idea, one recent study investigated primary care providers who were trained to utilize Motivational Interviewing and patient-centred counselling to increase the likelihood that patients would accept a referral to a multidisciplinary pain treatment programme (Heapy et al. 2005). In this study, pretreatment PSOCQ scores on the contemplation scale significantly predicted adherence to the therapist’s recommendations for inter-session practice of pain-coping skills (e.g. relaxation, activity pacing). Furthermore, inter-session adherence was correlated with forward stage movement and behavioural goal accomplishment.

In a study in progress at the VA Connecticut Healthcare System, we are currently evaluating the efficacy of a modified cognitive-behavioural therapy approach that explicitly incorporates patient preferences, perceived importance, and expectancies of effectiveness for learning specific paincoping skills, using a modified version of the MPRCQ and motivational interviewing in an effort to enhance forward stage movement and adherence. The treatment, labelled Tailored Cognitive- Behavioural Therapy, is informed by the Motivational Model of Pain Self-Management and by observations of the inherent flexibility in cognitive-behavioural therapy that allows for prescriptive treatment planning. The model also encourages the development of alternative strategies that attempt to match patients’ apparent degree of readiness to change with specific interventions. Preliminary results have begun to help tease apart processes of change during the delivery of this pain self-management intervention (Burns et al. 2008a, 2008b; Kerns et al. 2008). These results further highlight the potential value of specifically targeting the beliefs and attitudes emphasized in the Motivational Model of Pain Self-Management.

It seems reasonable to conclude that theory driven research in the area of motivation has already proven useful in advancing our understanding of mechanisms and processes of change in persons adoption of adaptive pain self-management. Central to this work is the availability of reliable measures of core constructs of the model and the use of these measures in the context of trials of self-management treatment programmes in order to better understand these processes. Continued efforts to apply and study the model in this area appear to have the potential to enhance the effectiveness of self-management treatment and to promote the engagement and participation of a larger proportion of persons with chronic pain who may benefit from the interventions. The model similarly appears to have relevance for understanding the transition from acute to chronic pain, at least among persons who are vulnerable to this transition. It is intuitive that interventions informed by the Motivational Model and research designed to complement the provision of reassurance by providers when confronted with persons experiencing acute pain may have utility in promoting an adaptive response to acute pain and in reducing the likelihood of persistent pain and disability. Research informed by this interesting possibility is encouraged. Ultimately, we believe that a greater clinical and research focus on motivational issues will result in more adaptive adjustment to acute and chronic pain overall, and therefore contribute to less suffering.