Weekly Pulse: The Psychology of Pain and the Future of Care

Chronic pain isn't just a clinical challenge, it's a human experience that demands we evolve beyond traditional biomedical models. This week's literature roundup explores five perspectives that illuminate how psychology, technology, and patient-centered care are reshaping pain management. From locus of control to virtual reality, from telehealth barriers to self-management empowerment, the message is clear: effective pain care requires understanding the whole person, not just the painful part.

Monday: Beyond Pills and Procedures—A New Pain Management Paradigm

📖 Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain El-Tallawy et al., 2021

Chronic musculoskeletal pain affects nearly half the global population, yet our approach remains frustratingly fragmented. This comprehensive review advocates for a fundamental shift toward multimodal, multidisciplinary management that integrates interventional tools, patient education, and conservative therapies into a coherent treatment hierarchy.

The authors propose a revised WHO-style analgesic ladder specifically tailored for MSK pain, starting with education and exercise before progressing to interventional techniques. What's revolutionary isn't the individual components, it's the systematic integration of bio-psychosocial frameworks into mainstream practice, not just specialized clinics.

The reality check: We've been treating symptoms while ignoring the system. NSAIDs and topical agents remain first-line, but success depends on addressing central sensitization, fear-avoidance, and lifestyle factors simultaneously. The review details 15+ interventional procedures, from trigger point injections to spinal cord stimulation, each mapped to specific conditions and risk profiles.

Strategic insight: The future of pain management isn't about choosing between conservative and interventional approaches, it's about orchestrating them intelligently based on individual patient presentations and psychological profiles.

Tuesday: Telehealth's Promise and Pitfalls in Chronic Pain

📖 At My Own Pace, Space, and Place: A Systematic Review of Qualitative Studies of Enablers and Barriers to Telehealth Interventions for People with Chronic Pain Fernandes et al., 2021

This meta-synthesis of 21 studies reveals the complex human reality behind telehealth adoption for chronic pain management. While technology offers unprecedented access and flexibility, success depends on far more than bandwidth and apps, it requires understanding how people actually experience digital care.

The enablers that matter:

• Flexibility and autonomy ("at my own pace, space, and place")

• Safe digital environments that reduce stigma

• Hybrid models combining video with apps/web platforms

• Evidence-based content that builds trust and self-efficacy

The barriers that block engagement:

• Impersonal experiences lacking nonverbal cues and touch

• Technological challenges and privacy concerns

• Irrelevant content and information overload

• Limited digital health literacy

The deeper truth: Telehealth isn't just a delivery mechanism, it's a relationship platform. Success hinges on self-efficacy, adaptive design, and meaningful engagement, not just screen time. For chronic pain patients who often feel dismissed by traditional healthcare, thoughtful telehealth can provide validation and empowerment.

Clinical implication: Digital platforms must be flexible, humanized, and digitally inclusive. The future isn't about replacing human connection, it's about extending it through technology.

Wednesday: Virtual Reality—Distraction or Transformation?

📖 Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Huang et al., 2022

This meta-analysis of 31 randomized controlled trials involving over 1,900 patients reveals both the promise and limitations of virtual reality exposure therapy (VRET) for pain management. The findings challenge us to think more precisely about when and how immersive technologies can serve therapeutic goals.

Where VRET excels:

• Acute procedural pain: Average VAS reduction of 1.62 units vs. control

• Pediatric populations: Children show greater engagement and pain reduction

• Auxiliary benefits: Reduced anxiety, shortened procedure times, less time spent thinking about pain

Where it falls short:

• Chronic pain conditions show minimal benefit

• No improvement in objective pain tolerance despite reduced perception

• Limited sustained effects beyond the virtual experience

The mechanism matters: VRET works through attention redirection and emotional engagement, not by interrupting nociceptive pathways. It's distraction-based therapy, which explains why it excels in acute, time-limited scenarios but struggles with persistent pain conditions.

Strategic consideration: VRET represents high-value integration into perioperative and outpatient workflows, especially when paired with standard treatments. For chronic pain, future research should explore hybrid models combining VRET with CBT, graded exposure, or neuroplasticity-based interventions.

Thursday: Self-Management as the Backbone of Back Pain Care

📖 Self-Management at the Core of Back Pain Care: 10 Key Points for Clinicians Kongsted et al., 2021

This article advocates for a paradigm shift from clinician-driven diagnosis and treatment to collaborative, patient-led management of low back pain. Self-management isn't about removing healthcare, it's about empowering patients to manage pain beyond the clinic with knowledge, autonomy, and support.

The conceptual clarity we need:

• Self-care: General healthy behaviors (sleep, exercise)

• Self-management: Managing chronic conditions and their impact

• Symptom management: Collaborative efforts to reduce distress

Core clinical actions organized by care phase: Planning: Guide care with value-based patient goals, facilitate shared decision-making, assess readiness for change Delivery: Help patients make sense of symptoms without pathologizing, use supervised exercise to build problem-solving, provide emotion regulation tools Evaluation: Reframe success in patient-centered terms, discuss beliefs and barriers, create action plans for relapses

The evidence base: Self-management interventions yield small to moderate improvements in pain, function, and self-efficacy. They're more effective when grounded in theory (CBT, fear-avoidance, social cognitive) and when delivered through mobile platforms rather than static websites.

Organizational requirements: Success demands clinician training in communication and behavioral techniques, adequate time for meaningful dialogue, and reimbursement models that support education and coaching.

The bigger picture: Most patients manage LBP outside clinical settings. Persistent pain often relates more to beliefs, fear, and low self-efficacy than to structural damage. Our job isn't to fix patients, it's to enable confident, informed self-management.

Friday: The Power of Belief in Pain Recovery

📖 The Influence of the Locus of Control Construct on the Efficacy of Physiotherapy Treatments in Patients with Chronic Pain: A Systematic Review Álvarez-Rodríguez et al., 2022

This systematic review of 13 studies explores how Locus of Control (LoC), whether individuals perceive health outcomes as internally controllable or externally determined, affects physiotherapy treatment success in chronic pain patients. The findings reveal that psychology isn't just relevant to pain management, it's predictive of outcomes.

The internal vs. external divide: Internal LoC patients (belief in self-control) showed:

• Better pain relief and higher self-efficacy

• Improved physical function and mood

• Greater satisfaction with PT outcomes

External LoC patients (belief that others or chance control outcomes) demonstrated:

• More depression, anxiety, and catastrophizing

• Higher perceived disability

• Greater dissatisfaction and poorer long-term results

Treatment interactions matter:

• Active therapies (exercise, CBT) fostered internal LoC and self-efficacy

• Passive therapies (manual modalities) risked reinforcing external LoC

• Multidisciplinary programs proved most effective when aligned with internal LoC reinforcement strategies

The clinician factor: Patient-therapist alliance and expectation-setting were crucial in shifting LoC. Therapeutic success depended not only on PT technique but also on belief reinforcement and communication quality.

Clinical implication: LoC assessment should be part of clinical intake, and treatment approaches should be tailored to either reinforce internal control beliefs or strategically shift external orientations toward greater self-efficacy.

Final Thoughts: A Weekly Reflection

Across these five studies, a shared truth emerges: effective pain management requires understanding the person experiencing pain, not just the painful condition. Whether through multimodal treatment hierarchies, thoughtful telehealth design, strategic technology integration, self-management empowerment, or psychological profiling, success depends on recognizing pain as a biopsychosocial phenomenon.

To advance pain care, we must evolve:

From symptom treatment to system transformation

From provider-driven to patient-empowered care

From technology adoption to human-centered design

From standardized protocols to personalized approaches

In a healthcare system increasingly driven by efficiency and standardization, we must defend what makes pain care uniquely complex: the need to address biology, psychology, and social context simultaneously. The evidence is clear, pain is personal, multifaceted, and manageable when we respect its complexity rather than reduce it to simple solutions.

As we look ahead, let this be our guiding principle: the future of pain management isn't about choosing between high-tech and high-touch approaches, it's about integrating them intelligently to serve the whole person in pain.

References

El-Tallawy, S. N., Nalamasu, R., Salem, G. I., LeQuang, J. A. K., Pergolizzi, J. V., & Christo, P. J. (2021). Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain. Pain Therapy, 10, 181–209. https://doi.org/10.1007/s40122-021-00235-2

Fernandes, L. G., Devan, H., Fioratti, I., Kamper, S. J., Williams, C. M., & Saragiotto, B. T. (2021). At my own pace, space, and place: A systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain. Pain. https://doi.org/10.1097/j.pain.0000000000002364

Huang, Q., Lin, J., Han, R., Peng, C., & Huang, A. (2022). Using virtual reality exposure therapy in pain management: A systematic review and meta-analysis of randomized controlled trials. Value in Health, 25(2), 288–301. https://doi.org/10.1016/j.jval.2021.04.1285

Kongsted, A., Ris, I., Kjaer, P., & Hartvigsen, J. (2021). Self-management at the core of back pain care: 10 key points for clinicians. Brazilian Journal of Physical Therapy, 25(4), 396–406. https://doi.org/10.1016/j.bjpt.2021.05.002

Álvarez-Rodríguez, J., Leirós-Rodríguez, R., Morera-Balaguer, J., Marqués-Sánchez, P., & Rodríguez-Nogueira, Ó. (2022). The influence of the locus of control construct on the efficacy of physiotherapy treatments in patients with chronic pain: A systematic review. Journal of Personalized Medicine, 12(2), 232. https://doi.org/10.3390/jpm12020232