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The Psychological Impact of Foot and Ankle Pain: Coping Strategies and Mental Health Support

by Simmy

Coping Strategies for Foot and Ankle Pain

A similar result was seen in a study looking at an intervention based on a self-efficacy model for patients with chronic musculoskeletal pain. The intervention resulted in improved self-efficacy and mental health, and decreased catastrophization and depression, and there was less use of passive pain coping strategies.

One such study compared an educational intervention based on a coping model of pain with standard care for patients with osteoarthritis. The intervention aimed to increase pain coping efficacy, which is the perceived ability to control pain and its effects, and encourage the use of active pain coping strategies. At 6 and 12-month follow-ups, the intervention group showed significant improvement in pain coping efficacy and active coping strategies and reported less depression and perceived limitation due to arthritis. This led to decreased use of NSAIDs and an increase in perceived improvement.

A wide variety of pain coping strategies have been reported in the literature. These can be either cognitive (psychological) or behavioral in nature. Cognitive coping strategies are based on the idea that changing thought patterns can change emotional and behavioral responses to pain. It has been suggested that patients with chronic pain use more passive coping strategies such as resting and a reliance on others, and less active strategies. This has led to a number of studies that have attempted to shift patients towards more active coping styles.

In a non-disease specific study looking at barriers to exercise in the elderly, it was found that the most common issues were related to pain, confidence in ability, and the perceived benefits of exercise. A variety of subjective and objective measures of physical activity have shown that these patients are less physically active, indicating that these issues may also apply to patients with foot and ankle pain. This suggests that while exercise may be an effective tool in managing pain and improving function, it may be necessary to use other coping strategies in order to facilitate its implementation.

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Two studies have looked at the effect of exercise on pain and function in lower extremity joints. In a study examining the effects of aerobic conditioning on patients with rheumatoid arthritis or osteoarthritis, it was found that there was an increase in pain during the initial 2-4 weeks of the program, but pain decreased in subsequent weeks and by the end of the study, arthritic patients reported a 65% increase in function and a 20% decrease in pain. Similarly, a 16-week strength training program for patients with knee osteoarthritis was shown to result in increased muscle strength and function and decreased pain. However, it is not always easy to find the motivation and determination to carry out these programs.

To combat the negative physical and psychological effects of chronic pain, several strategies have been employed which center around reestablishing normal function. Physical therapy and exercise have been shown to be effective forms of pain management and can sometimes result in complete alleviation of pain. However, they can sometimes result in increased pain during the initial stages.

Physical therapy and exercise

Overall, there are a wide range of strategies that constitute symptom management coping for FAI, and our understandings of their effects on health and well-being can have implications for both healthcare and clinical psychology interventions tailored at increasing the use of more efficacious coping strategies.

Emotion-focused coping is directed at the management of the emotional impact of the stressor. This involves attempts to relieve emotional distress, and involves various internal and external strategies aimed at changing the appraisals of the stressor. This type of coping may involve aerobic exercise programs aimed at gaining a feeling of well-being through fitness, or cognitions and efforts to reduce negative emotional responses during tasks which are known to exacerbate FAI symptoms.

Problem-focused coping involves attempts to do something constructive about the stressful conditions that are harming an individual’s well-being. This involves trying to change things that are causing stress, or changing the way the stress is being appraised. In relation to FAI, problem-focused approach coping will involve fitness and strength-based exercise with the intentions of restoring joint function, or strengthening and stretching exercises to instigate changes on the conditions that are causing pain. Problem-focused avoidance coping may involve task re-appraisal and alternative tasks aimed at increasing comfort levels during activity.

Approach coping is defined as efforts to increase the state of health, or to ward off, eliminate or reduce the threat that is posing the stress. This is contrasted with avoidance coping, which involves efforts to escape or avoid the threat, or alter the stressor and appraisals of it so that the emotional impact of the threat is reduced. A further division can be made into problem-focused coping and emotion-focused coping. These two broad types of coping can be either approach or avoidance coping, and the distinctions depend entirely on the aims of the coping strategies.

To address this gap in knowledge, symptom management coping strategies for FAI will be investigated. These are cognitive or behavioral efforts to manage specific external or internal demands that are appraised as taxing or exceeding the resources of the person. This definition encompasses an extremely wide range of strategies, and there is evidence that the distinction between coping strategies is not always clear-cut, as some strategies could be seen as both cognitive and behavioral, and some only appraised accurately as to their exact nature by the person utilizing the strategy. However, a binary and simplistic but useful distinction will first be made between approach and avoidance coping.

Pain management techniques

Non-pharmaceutical pain management approaches have been described as alternatives to medication and strategies to augment medication. There are several methods of pain management, with cognitive-behavioural therapy (CBT) being the most successful and most researched psychological method. According to the American Psychological Association, CBT is a form of psychological treatment that has been demonstrated to be effective for a range of problems, including depression, anxiety disorders, and severe health problems. It improves the quality of life for the patient. CBT for pain is designed to change the negative thoughts and beliefs about the pain, which could possibly influence the emotional experience and behaviour in a negative way. An example would be a chronic sufferer who believes they will make their illness worse by doing everyday activities, often avoiding activities and becoming sedentary, in turn creating more pain due to deconditioning and reinforcing the belief. This cycle is a direct cause of disability and depression. A CBT intervention could include setting activity goals and scheduling pleasant activities, which should increase the patient’s activity levels and reduce depression, and in turn, their pain experience. This will not take away the pain but can significantly improve the quality of life for the patient.

There are two major types of pain management: pharmaceutical and non-pharmaceutical. In psychology, the view has been exclusively biomedical, with psychologists concentrating on pain as a sensory/nociceptive experience. This has led to research into pharmaceutical pain management. The cognitive-behavioural approach to pain has led to research into non-pharmaceutical pain management. Psychological research is only concerned with chronic and severe pain and does not involve minor and passing pain. This is because major pain will have a significant impact on most, if not all, aspects of a person’s life, and there will be significant behavioural change due to the injury. Minor injury pain may not affect people in any way other than sensitivity around the injured area. This section will cover both types of pain under psychological, emphasising the proven importance of psychological approaches on chronic and severe pain.

Assistive devices and orthotics

An orthosis is one example of an assistive device that has been studied with various outcomes in different types of arthritis for the foot and ankle. They range from simple foam or felt pads custom fitted to a shoe, to rigid devices made of plastic. A positive outcome was shown in a study on patients with rheumatoid arthritis whose orthoses were custom made to achieve specific foot and ankle realignment. A randomized controlled trial of a specific bracing technique called the Arizona AFO (ankle-foot-orthosis) in patients with established RA revealed a reduction in pain and an improvement in patients’ perceptions of normalcy in gait and in activities of daily living. In contrast, a randomized controlled trial of a FO to correct flexible flatfoot in children with juvenile idiopathic arthritis did not demonstrate significant improvements in health-related quality of life compared to an intervention with shoe inserts. This illustrates that different types of orthoses can have different outcomes and it is important to study each one in a specific population with a defined outcome measure.

Patients with peripheral arthritis can benefit from assistive devices to reduce the stress on affected joints and minimize pain and fatigue during tasks. There are two sorts of assistive devices: simple, relatively inexpensive items such as shoe inserts or jar openers which can be bought in a store, and more costly items such as a scooter or orthosis which may require a prescription. Studies have demonstrated that assistive devices can enhance functional performance and delay functional decline, but patients often wait until they are no longer able to do a task before using a device.

Mental Health Support for Individuals with Foot and Ankle Pain

There are a range of support strategies which could benefit individuals living with foot and ankle pain who are experiencing distress and impaired mood. A referral to a clinical psychologist or psychological therapy initiated by a mental health care plan can assist individuals to manage distress more effectively, change unhelpful behavior which is contributing to their mood state, and address issues of loss and change which they may be struggling to adapt to. Specific types of psychological therapy which may be beneficial for those with foot and ankle pain include cognitive-behavioral therapy, which is effective for various forms of depression and anxiety, and acceptance and commitment therapy, which can assist individuals to live a rich and meaningful life whilst coping with long-term pain and impairment. In addition to individual therapy, there are a growing number of group-based interventions and programs which focus on peer support and skill development for coping with arthritis and chronic pain. These programs may be beneficial as they provide an opportunity for individuals with similar health issues to share experiences, provide each other with understanding and empathy, and learn from each other in a supportive and non-judgmental environment. An example is the Stanford Arthritis Self-Management Program, which has been demonstrated to have beneficial effects for a range of health and psychosocial outcomes among participants.

Counseling and therapy

Despite these limitations, counseling and therapy interventions should still be considered as an integral tool in the management of psychological distress in people with foot and ankle pain.

There are some limitations to the use of formal counseling and therapy interventions for people with persistent pain. First, many of the trials supporting these interventions focus on people with more generalized pain conditions and may not be generalizable to people with more localized pain in the lower limbs. This is important as it is likely that the nature and impact of pain conditions differs depending on location. Second, many psychological interventions are tailored to people with emotional conditions (e.g., depression, anxiety) secondary to their pain condition and do not specifically target the pain itself. This may be at the expense of pain-specific outcomes.

Unfortunately, despite successful early trials of CBT for people with foot and ankle osteoarthritis, it is unknown whether this intervention is suitable for musculoskeletal foot and ankle pain in general. In light of the evidence supporting CBT for persistent pain, this is an area that may warrant further investigation.

Counseling and therapy is a common pain management strategy for people living with persistent pain conditions. Counseling may help a person to better understand the roots of their emotional distress and offer guidance for learning new and more adaptive responses to stress and adversity. A recent systematic review found evidence supporting the use of cognitive behavioral therapy (CBT) in reducing pain and disability in people with persistent musculoskeletal pain.

Support groups and peer networks

Comparison involves an assessment of one’s problems relative to others. This often results in the perception that one’s own situation is not as bad as it could be and, consequently, an increased sense of gratitude and decreased negative affect. Comparison can also lead to the development of alternative coping strategies. This resulted in increased motivation and positive affect. Finally, comparison can serve to validate one’s own feelings and experiences by demonstrating that others have gone through the same thing. This is related to the concept of catharsis, in which the expression of emotion serves to decrease the intensity of the emotion as a result of the acknowledgement and understanding of the feelings. Through feeling understood, individuals are able to transition from a stage of feeling as though nothing can be done to problem-focused coping.

Support groups can provide an environment in which individuals with foot and ankle pain can receive emotional and practical support from others who have experienced similar problems. It is generally recommended that participation in support groups, during which only individuals with foot and ankle pain are included, can provide several unique benefits through comparison and catharsis.

Mindfulness and relaxation techniques

Lastly, mindfulness involves an attitude, and this would be fostering the mindset of ‘acceptance’ in relation to the pain. Learning to observe the sensations before reacting to them and recognizing that there is a difference between pain and suffering. This is an extensive topic, but in a study of the effect of a mindfulness program for chronic pain, Kabat-Zinn and colleagues found that a daily mindfulness meditation helped to increase awareness of the body and ability to relax. It also helped to distinguish between judgment and experience regarding the pain. This manifested also in an altered relation to the pain and an increased mental functioning and reduction in symptoms of psychological distress.

In this instance, a mindfulness approach to the pain would involve bringing awareness to the present moment experience when the pain is noticed. This could be a negative thought, an emotion, any of the physical sensations associated with the pain, and what the pain is stopping the person from doing. This might be practiced informally at any time in the day when the person remembers or notices their pain. Though it can be helpful to set aside a specific time for practicing in this way, and having a guided meditation to lead the person through is often very beneficial.

Mindfulness is a specific way of paying attention to the present moment, on purpose and non-judgmentally. For individuals coping with foot and ankle pain, mindfulness can provide a means of observing the way in which they deal with the pain. Mindfulness is often developed through meditation, a body of practices that has the potential to contribute to the development of mindfulness for individuals with foot and ankle pain. However, it is important to remember that mindfulness and meditation are not the same thing. Meditation involves a formal practice of techniques to cultivate mindfulness. Although it is likely that greater mental health will be an automatic by-product of mindfulness practices, the primary focus of meditation is to develop mindfulness and awareness.

Education and self-help resources

It is said that persons with chronic pain who engage in mental health care utilize much more medical health care than those who do not. This is why self-efficacy enhancement is linked to functional capacity and is one of the goals of mental health intervention for persons with chronic pain. Treatment orientations in mental health care for pain patients are varied but often include methods of cognitive-behavior therapy and coping skill enhancement. Although pain can have a profound effect on mental health, it does not imply that pain and its effect on mental health cannot be improved.

The mental health of individuals suffering from chronic pain has been explored for some time now. There is a general consensus in the literature that has built up over the years that chronic pain in all forms and ranges has a profound negative effect on a person’s mental health and overall personality. Some of the more common effects include things such as increased depression and anxiety, general affective disturbances, decreased self-esteem and motivation, as well as the obvious decreased quality in lifestyle. High levels of anxiety and depression have been reported in persons with chronic pain. These symptoms can be intense and unyielding. They also can affect a person’s recovery rate and the outcome of physical therapy. And most treatments for chronic pain have a profound effect on the patient’s mood and thus further exacerbate the effect of the injury. Pain patients, whether in consultation or a physical therapy program, are encouraged to be aware of their mood changes in the course of their treatment and to have a discussion with a mental health care provider. Studies also indicate that the presence of depression and anxiety symptoms significantly predict who will obtain mental health services in the following year.

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