Cultural Differences and Pain Management

The issue of adequate pain management in private offices and hospitals has become a topic of major debate as healthcare makes a push toward better control of patient pain. In addition to our pharmacological arsenal, as osteopathic physicians, we have unique training that allows us to help alleviate patient pain with the use of Osteopathic Manipulative Medicine (OMM). However, com-plicating this picture is the issue of cultural understanding of pain.¹ With America’s reputation as a “melting pot” of vast cultural diversity in the people that live in our communities, it is challenging but necessary for physicians to incorporate cultural understanding into all patient encounters.

The significant influence that cultural identity has on a patient’s interpretation of health and illness is well documented.²˒³ It has been implied that cultural background can affect the “pain experience,” including how the pain is assessed, how it is treated, and whether there is satisfaction with the treatment outcome.⁴˒⁵ There is also an indication that the emotional, psychological, physiological, and spiritual interpretation of the pain experience can, in part, be culturally determined.⁶⁻⁹

Example of Patient-Physician Communication with Cultural Differences

Southwestern Alaska is home to a unique patient population, approximately 69% of which are Native American, and is served by the Kanakanak hospital in affiliation with the Alaska Native Tribal Health Consortium (ANTHC).¹⁰ The maj-ority of these Native Americans recognize affiliation with the Yup’ik people and have a set of cultural mores and traditions distinct from that of “mainstream” Americans. This manifests a unique group of challenges for the osteopathic physician treating with OMM. During my time at Kanakanak, I treated a total of seven Yup’ik patients with OMM and worked to adapt textbook osteopathic styles of treatment, including counter strain (CS) and facilitated positional release (FPR), to this situation.¹¹

The Yup’ik culture differs from the traditional American physician training populace, making it difficult for the non-Yup’ik practitioner to elicit a traditional history of present illnesses (HPI) during an interview. The numerical rating scale quantifying pain as 0-10 is problematic as Inuit adults have difficulty relating pain through numerical scale due to intuitive differences from other American ethnicities. In their case, a high priority is placed on spatial intelligence and observational skills.¹² Additionally, cultural attitudes toward pain generally require a greater degree of stoicism in the face of hardship.¹³ Using a modified Wong-Baker FACES scale, also known as The Northern Pain Scale (NPS), can improve the communication of pain between physician and patient, as this scale depicts Native faces that incorporate portions of Native culture and observational intelligence into the pain scale.¹² Telling a Yup'ik patient to make a comparison of the current pain with pain that has been previously experienced as “the worst pain of your life” to equate a 10 has a cultural disconnect because the numbers are divorced from their traditional learning styles without a picture representation.

During my time doing patient interviews, Yup’ik patients had difficulty comparing previous, treated pain on this scale and, when utilizing the numeric scale, patients often reported current pain (which may have been a 10 out of 10) as >7/10, regardless of the location or type of pain reported. Patients also had difficulty reporting decreased pain symptoms as a lessening number. Affect was generally not congruent with reported pain levels and patients often appeared comfortable or in only mild discomfort. Miscommunication based on the misunderstanding of stated pain ultimately leads to a discrepancy in pain treatment in the Yup’ik population compared to the mainstream population; it puts the culturally unfamiliar practitioner in the position of having to interpret patient pain without practiced aids.

Without a pain scale that can be understood by both patient and doctor, traditional methods of determining treatment success must be adapted. The implications for treatment with OMM can be seen in the application of CS and FPR, where treatment relies heavily upon patient report of discomfort and improvement. The patients that I treated set their initial pain high (>7/10) and during positioning were unable to distinguish on a numeric scale any change in discomfort. Instead of being able to report whether the pain had become a higher number, a lower number, or a percentage of the original pain, the patients reported that the pain was still present. However, when asked explicitly if the pain was exactly the same, the patients would report that the pain was not the same but then could not explain the difference. No quantifiable change could be elicited.

While using FPR and CS, I relied primarily on tissue texture changes and muscle softening to determine the end point for treatment. The results of these encounters are listed in the table below. At the time of the treatment, only two patients reported any improvement in pain, with the other five reporting no change. However, subsequently two additional patients reported relief from the treatment when encountered informally the next day.

Adapting the Physician’s Approach

Of the Yup’ik patients that received OMM for their complaints, four out of seven reported improvement with treatment. No patients were seen for follow up of their presenting complaint at the clinic during my time at Kanakanak and none received a second treatment for their pain. This made it difficult to determine if OMM had long term effects on their chronic complaints.¹⁴

With CS and FPR being some of the most commonly used techniques during OMM treatments, it is important to find ways to adapt textbook modalities to suit various patient populations.¹⁵ Pain management in the Alaskan Native and specifically the Yup’ik patient requires physicians to change their language when using CS and FPR to find positions of maximal comfort. While this can be facilitated by using a modified NPS sheet to communicate levels of pain between physician and patient before treatment begins, it also requires that physicians target how the pain has changed during treatment, rather than how much—both for the current treatment and when comparing to other visits. Asking the patient to explain how they feel, rather than getting a quantified numeric rating will also broaden the information given and received during treatment.

Conclusion

One of the biggest challenges facing physicians today is providing comprehensive pain management since unrelieved pain continues to be a public health problem. Improving patient-physician communication and cultural understanding will create better, more goal-directed treatments for the patient and a successful patient-physician relationship—whether through the use of traditional pharmacologic management or OMM treatments for effective pain control. To be truly successful, physicians and other healthcare providers must recognize the confounding effect of cultural differences in reporting pain and partner with cultural and spiritual leaders and community-based organizations to achieve a mutual understanding.