Are you better? Comment on the article by Beaton et al

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Are You Better? Comment on the Article by Beaton et al

To the Editor:

I found the article by Beaton et al (Beaton DE, Tarasuk V, Katz JN, Wright JG, Bombardier C. Are you better? A qualitative study of the meaning of recovery. Arthritis Rheum (Arthritis Care Res) 2001;45:270–9) to be both original and thought provoking. The authors questioned 24 workers with work-related upper limb pain about their understanding of what was meant by the question, “Are you better?” “Being better” meant different things to different individuals, including a change in the state of the disorder (resolution), adjustment of life to work around the disorder (readjustment), or an adaptation to living with the disorder (redefinition).

It would be revealing to survey clinicians and find out what they mean when they ask their patients with chronic pain “Are you better?” I would like to describe my experience. I am involved in the rehabilitation of male workers' compensation beneficiaries with chronic back pain. I usually begin these potentially very difficult consultations by asking the patient to describe the long saga of their pain, suffering, and disability. By the time these patients reach me, their condition is usually not as bad as it has been. This is usually apparent when I ask about their present condition. I try to use this often slight improvement to show the patient he has already started on the road to independence. In the last few months, I can recall how three smoothly running interviews were brought to a jangling halt when I made the statement, “You are better now, then?” in what I believed to be an encouraging tone. In all three cases, the statement was met by an abrupt and definite “No!” It took me some time to determine that this scenario was occurring because the word “better” meant different things to me than it did to my patient. I was meaning to say, “You have improved, then?” while the patient believed the word “better” meant back to normal.

These patients have usually been seen by a dozen “specialists” who have all applied various medical, surgical, chiropractic, osteopathic, or physiotherapeutic models. These models assume the underlying cause of the pain will be found and corrected (i.e., made better). By specialist number 12, the by-now biopsychosocially crippled client's expectation of correction has still not been met, and he has lost all hope of being “made better” by specialists. In addition, if he were “better” he would lose entitlement to his worker's compensation benefit of 80% of his pre-injury salary. So it is little wonder that my poorly phrased statement, “You are better now, then?” should be met with such a hostile response.

A musculoskeletal rehabilitation specialist can hope to make the person better in two ways. First, to make the pain “better” (i.e. reduce the intensity), and second, by paying attention to biopsychosocial factors to improve self management of the pain and help the person regain control of his life. This involves making readjustments to work around the disorder and adaptation to living with the disorder.

The clinician using the biopsychosocial approach to the management of chronic musculoskeletal pain is attempting to resolve the pain somewhat, as well as helping the patient readjust to it and redefine the problem. Although Beaton et al report that two patients may mean very different things when they say they are “better,” their work has also shown that there are three different avenues clinicians should use to help the patient with chronic pain “get better.”

Jeremy G. Jones MD*, * Queen Elizabeth Hospital, Rotorua, New Zealand

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