Is Past Adjustment of Unhelpful Thinking Associated with Greater Cognitive Flexibility Among People Seeking Musculoskeletal Specialty Care?

Abstract

Background

Unhelpful thoughts are associated with greater levels of pain intensity and incapability. Difficulty cultivating a healthier inner narrative regarding sensations is associated with lower tolerance of uncertainty and lower cognitive flexibility. Among people seeking musculoskeletal specialty care we analyzed associations between mindset factors and awareness of prior experiences adjusting unhelpful thinking and trust in the clinician.

Methods

In a cross-sectional study, 163 adults completed measures of mindsets (intolerance of uncertainty, cognitive flexibility, and distress and unhelpful thoughts regarding sensations), awareness of prior experiences adjusting unhelpful thinking, and trust and experiences with clinicians. We measured associations between mindsets (both individually and in statistical clusters) awareness of prior experiences and trust in the clinician.

Results

Both awareness of prior experiences adjusting thinking and trust in the clinician were modestly associated with greater cognitive flexibility in bivariate analysis, but neither were associated with statistical groupings with healthier mindsets identified in cluster analysis.

Conclusion

The modest associations with cognitive flexibility suggest that both the inability to describe a past experience rethinking one's interpretation of bodily sensations, as well as difficulty establishing trust with the clinician, might signal unhealthy fusion with unhelpful thoughts that are known correlates of greater levels of discomfort and incapability.

Keywords

pain intensity level of incapability mental health mindsets cognitive flexibility tolerance of uncertainty

Introduction

Background

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.¹ The cognitive and emotional aspects of pain are apparent in the associations between unhelpful thoughts and feelings of distress regarding bodily sensations and greater pain intensity.² There is also evidence that people may be more likely to regard unhelpful thoughts about sensations as facts (cognitive fusion) if they are experiencing higher levels of distress.³

Intolerance of uncertainty – low willingness to accept potential negative and uncertain health outcomes – is an unhelpful thinking tendency that is also associated with greater levels of discomfort and incapability among patients with both traumatic and nontraumatic musculoskeletal conditions.⁴ Cognitive fusion is the regard of thoughts as facts or reality, and cognitive flexibility is the awareness that thoughts are possibilities that may be partially or completely incorrect or unhelpful. People who can readily shift between automatic thoughts (heuristics, mental short cuts) and critical/analytical thinking have higher performance during specific tasks such as the computerized “four-armed bandit” game as an example of a well-structured problem and the “think-aloud” protocol as an example of an ill-structured problem.⁵ People with high intolerance of uncertainty and low cognitive flexibility have greater difficulty disengaging from worry about future threat or rumination about past threat when they are safe.⁶ A study of women who have experienced interpersonal victimization suggested that experiential avoidance may account for part of the relationship between cognitive flexibility and symptoms of post-traumatic stress and depression.⁷ A study of people presenting for specialty care of upper extremity illness found that greater cognitive flexibility was associated with greater accommodation of pain (pain self-efficacy).⁸ This line of evidence suggests that an adaptive and accommodative interpretation of sensations—flexible thinking in particular—is a key aspect of health.

Rationale

Humans encounter situations where their automatic thoughts based on mental short cuts or heuristics are discovered to be partly or completely inaccurate. In the midst of illness, it's healthful to cultivate an awareness of past experiences of the utility of rethinking first impressions and intuition, reserving judgment pending critical eye, and enlisting experts to help with the necessary analysis. Patients may have previously mastered a challenge benefiting from flexible thinking and accommodation of unresolvable uncertainty related to specific symptoms. For instance, in the absence of a specific diagnosis, a person may have interpreted their body's sensations as a pathophysiology that would get worse and need treatment. But even without a specific diagnosis, the symptoms may have resolved and never returned. One would hope that this arguably common experience would prepare people for the next sensations and the mind's often less healthy interpretation of those sensations. At the same time, the state of feeling overwhelmed or ruminant in relation to symptoms might be associated with limited awareness of prior experiences navigating feelings of distress or unhelpful thinking regarding sensations and limited benefit from knowledge gained from those prior experiences.⁹

Most people have a good experience visiting with a musculoskeletal specialist, but some people feel unheard and misunderstood, or that their problem was dismissed or trivialized. Experiments have not identified factors with notable and consistent associations with lower patient ratings of experience with care.¹⁰ In our experience, some of the least satisfied patients seem to experience discordance with the specialist's explanation of the condition, which can feel negating of their experience and inner narrative understanding of the condition. For example, new symptoms from gradual onset conditions are often misinterpreted as a new condition,^11,12 and new pains can be misinterpreted as an injury.^13,14 This discordance can diminish the patient's sense that the clinician cares about their wellbeing and it can diminish trust. This study will also address whether mindsets characterized by less flexible thinking are associated with worse patient experience, measured using the Trust and Experience with the Clinician Scale (TRECS).

Among people seeking musculoskeletal specialty care, we asked: Are there associations between 1) Awareness of prior experiences adjusting unhelpful thinking and 2) Trust and experience in the clinician, and mindset factors including unhelpful thinking, feelings of distress, cognitive flexibility, and intolerance of uncertainty, both individually and in statistical groupings or clusters?

Methods

Study Design

In an Institutional Review Board (IRB)-approved, cross-sectional study, adult (age 18 to 89 years) English or Spanish speaking patients with musculoskeletal illness who presented to one of 3 musculoskeletal specialists in an urban area in the United States were approached and invited to participate to complete surveys before and after their visit with a specialist in a private examination room, using Health Insurance and Portability Accounting Act-compliant software (Research Electronic Data Capture; Vanderbilt, TN) on a tablet. Patients were excluded if they had cognitive dysfunction or were illiterate. Efforts were made to recruit at multiple clinics by multiple researchers to eliminate potential selection bias associated with a cross-sectional study. The IRB accepted verbal consent and completion of the questionnaires in lieu of formal, written informed consent. Additionally, the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were employed in order to bolster the study.¹⁵

Patients were asked to complete a set of questionnaires pertaining to location of symptoms (upper extremity, lower extremity, or back/neck/spine) and demographics including age, gender, ethnicity, race, marital status, level of education, annual household income, and insurance status. They also completed the following measures: Intolerance of Uncertainty (12-item assessment); Cognitive Flexibility (12-item scale); and Trust and Experiences with Clinicians (TRECS-7 a 7-item scale). They also rated 5 items addressing past experiences with adjusting one's thinking about sensations, 3 items addressing distress about sensations, and 3 items regarding distress about sensations.

Outcome Measures

Awareness of past experiences adjusting one's thinking about sensations was measured with five items, such as “I was able to do more than I thought in spite of the pain” and “Over time, you changed your way of thinking about the pain,” rated on a 5-point Likert scale between 1, “I don’t agree at all,” and 5, “I completely agree.” We summed the scores with a maximum score of 25, representing notable awareness of past experiences with cognitive flexibility regarding pain.

The Trust and Experience with the Clinician Scale (TRECS) uses seven items, including “The clinician seems concerned about me and my family” and “I trust the clinician so much I will always try to follow their advice,” rated on a 5-point Likert scale between 0, “Strongly disagree,” and 4, “Strongly agree.” We summed the scores with a maximum score of 28, representing complete trust in the clinicians.

Other Variables

The Intolerance of Uncertainty instrument is a 12-item measure of discomfort navigating uncertainty.^4,14 The items are rated on a 5-point Likert scale ranging from 1 (“not at all characteristic of me”) to 5 (“entirely characteristic of me”). The total score is the sum of all item scores, which ranges from 5 to 60, with higher scores representing greater intolerance of uncertainty.¹⁴

The Cognitive Flexibility Score (CFS) measures awareness of potential alternative interpretations and readiness to think differently. The items are rated on 6-point Likert scales ranging from strongly agree to strongly disagree. Scores are summed and range from 12 to 72, with higher scores representing greater cognitive flexibility.^7,8

Patients were asked to enter their personal information on a tablet, including age, self-reported gender, ethnicity and race, insurance type, marital status, education level, employment, and household income. The location of symptoms was categorized as upper extremity (UE), lower extremity (LE), or spine. Three items identified in a factor analysis were used to measure levels of distress about sensations, and three measured levels of unhelpful thinking regarding sensations.³

For the Spanish translation of the surveys, instruments available in Spanish were used, and the others were translated using a standard forward and backward translation method (Raja et al, 2020). One native Spanish speaker translated the survey into Spanish, and the second translated it back to English to identify and revise inconsistencies in the translation.

Tables 1 and 2 highlight all demographic information as well as recorded measures in this study.

Table 1.

Demographics of 142 Participants.

Variables	Value ^a
Gender
Women	59% (84)
Men	41% (58)
Self-reported ethnicity
Not Hispanic	64% (91)
Hispanic	36% (51)
Self-reported race
White	71% (101)
Black	10% (14)
Asian	7% (10)
Other	12% (17)
Marital Status
Single	30% (42)
Married	45% (64)
Separated	4% (6)
Divorced	17% (25)
Widowed	4% (5)
Education
Elementary school	4% (6)
High school	24% (34)
2-year college	17% (24)
4-year college	26% (37)
Post-college graduate degree	29% (41)
Location
Spine	6% (9)
Upper extremity	27% (38)
Lower extremity	67% (95)
Income
< $15,000	13% (19)
$15,000 - $30,000	11% (16)
$30,001 - $50,000	8% (11)
$50,001 - $100,000	25% (35)
> $100,000	30% (43)
prefer not to answer	13% (18)
Insurance
Medicare	20% (29)
Medicaid	4% (6)
Private	35% (50)
Military	4% (5)
Uninsured	4% (5)
County Safety Net	30% (43)
Other	3% (4)

Table 2.

Means and Standard Deviations Recorded Measures.

Age	51 ± 16
Unhelpful thoughts regarding symptoms	7.1 ± 3
Distress regarding symptoms	7.6 ± 3
Intolerance of Uncertainty	26 ± 9
Trust and Experience in the Clinician Score (TRECS-7)	6.7 ± 3
Cognitive Flexibility	59 ± 9
Awareness of prior adjusting of thinking	16 ± 3

Higher scores for unhelpful thoughts and distress regarding symptoms and intolerance of uncertainty reflect a less healthy mindset. Higher scores on trust and experience with the clinician (TRECS-7), awareness of prior adjusting of thinking, and cognitive flexibility indicate a better experience and a healthier mindset.

Value is displayed as mean with standard deviation for continuous variables, and as percentage with number for categorial variables.

Statistical Analyses

Out of 163 patients who began surveys, 142 completed all surveys (87%). Descriptive statistics were performed for all patients, even those who were unable to finish the questionnaires had their data included in analysis. Thus, all data collected was included in analysis. The data that support the findings of this study are available from the corresponding author upon reasonable request. Categorical variables were reported as percentages with frequency, and continuous variables as mean with standard deviation. We first performed bivariate analysis to seek correlations between various explanatory variables and a) Intolerance of Uncertainty scale, b) Cognitive Flexibility Scale, and c) TRECS-7 scale. We used the Shapiro-Wilk test and histogram to identify the data distribution of each response variable. After determining which response variables had a Gaussian distribution and which had non-normal distribution, the student t-test was used to assess the correlation with dichotomous explanatory variables with normal distribution, and Mann-Whitney for non-normally distributed variables. One-way ANOVA was used to assess categorical explanatory variables with normal distribution, and Kruskal-Wallis for non-normally distributed. Pearson and Spearman correlations were used to assess continuous explanatory variables. We used the Dunn test, a non-parametric post-hoc test used with the Kruskal-Wallis test, to determine which specific groups in a dataset are different from each other.

Results

Factors Associated with Variation in Past Experiences Adjusting One's Thinking About Sensations

There was no association between levels of prior experiences adjusting thinking regarding sensations and statistical groupings with healthier mindsets (Appendix 1). In bivariate analysis, prior experiences adjusting thinking about sensations was associated with greater cognitive flexibility (Pearson coefficient = 0.18, p = 0.03), education level of post-college (p = 0.02), and women (p < 0.001), but not with feelings of distress and unhelpful thoughts regarding sensations, or intolerance of uncertainty (Appendix 1) (Insert Appendix 1 at end of this paragraph).

Factors Associated with Greater Trust and Experience with the Clinician

Levels of trust and experience with the clinician were not associated with statistical groupings with healthier mindsets (Table 3). In bivariate analysis, greater trust and experience with the clinician was associated with greater cognitive flexibility (Pearson coefficient = 0.30, p = 0.003) and education level of high school or less (p = 0.02), but there was no difference between subcategories, and no association with levels of distress, unhelpful thoughts, or intolerance of uncertainty (Table 3).

Table 3.

Cluster Analysis.

	Intolerance of Uncertainty	Feelings of distress	Unhelpful thoughts	Cognitive Flexibility	Awareness of prior adjusting of thinking	Trust and Experience in Clinician
					Mean ± SD
					P = 0.33	P = 0.57
Group 1 n = 23 (16%)	z = 1.3 Mean = 38 (9.9)	z = 1.0 Mean = 11 (3)	z = 1.0 Mean = 10 (3)	z = -1.6 Mean = 45 (7)	16 ± 4.1	21 ± 4.6
Group 2 n = 51 (36%)	z = 0.50 Mean = 31 (5)	z = 0.07 Mean = 8 (3)	z = 0.04 Mean = 7 (2)	z = 0.14 Mean = 60 (6)	17 ± 3.0	22 ± 4.2
Group 3 n = 68 (48%)	z = -0.80 Mean = 19 (3)	z = -0.39 Mean = 6 (3)	z = -0.36 Mean = 6 (2)	z = 0.43 Mean = 62 (6)	16 ± 3.1	22 ± 4.5

Discussion

Among people with musculoskeletal disorders, the variation in levels of discomfort and incapability is accounted for by aspects of mental and social health more so than measures of the severity of the pathophysiology. The least healthy mindsets are characterized by unhelpful thoughts (misreads) and feelings of distress regarding the body's sensations. Flexible thinking and accommodation of unresolvable uncertainty can help people navigate and ameliorate the human mind's automatic protective and worst-case thoughts. Humans frequently navigate unhelpful thoughts regarding the body's sensations, and awareness of past experiences adjusting one's thoughts could be associated with healthier mindsets.³ Healthier mindsets might also be associated with greater trust and experience with the clinician.⁸ We identified statistical groupings representative of healthy and less healthy mindsets and found that they were not associated with either awareness of past experiences adjusting thinking or trust and experience with the clinician. The modest association of greater awareness of past experiences adjusting thinking and greater cognitive flexibility suggests that there is some association, but that it may be too complex to characterize with our measures and techniques.⁷

Limitations

The findings of this study should be interpreted in light of some limitations. We do not routinely collect additional information on people who decline to participate. We estimate a small number of people (approximately 10) declined participation, which, in our opinion, is unlikely to alter the results of the analysis. Our population was relatively white, non-Hispanic, and privately insured, which might limit the generalizability of our results to other populations with different demographic distributions. That said, studies of human traits tend to identify reproducible associations provided there is sufficient variation in mindsets, which occurred in our sample. The inclusivity of the study with a range of diagnoses, typical of people seeing an upper-extremity specialist, has advantages and disadvantages. It represents daily practice, but studies of specific diagnoses or populations might identify variations in the relationship of intolerance of uncertainty to incapability.

Association of Awareness of Prior Experiences Adjusting Unhelpful Thinking

The finding that a higher level of awareness of past experiences with adjusting one's thinking was modestly associated with greater cognitive flexibility in bivariate analysis, but not with statistical groupings of feelings of distress regarding symptoms, greater unhelpful thoughts, and intolerance of uncertainty individually or in combination in statistical clusters, suggests a small, complex relationship between current cognitive flexibility and awareness of past cognitive flexibility. There is evidence that a stronger tendency to extract meaning from past experiences is reflected in a person's interpretations or conceptions of imagined future events. In other words, the mindset with which a person anticipates their next musculoskeletal ailment reflects, to a degree, how they processed their last condition.¹⁶ Musculoskeletal specialists can leverage this insight by helping patients recognize moments in which they successfully reframed negative or catastrophic thoughts in the past. Clinicians might incorporate brief reflective exercises or guided discussions into clinical visits, encouraging patients to draw connections between previous coping successes and current symptom interpretations. Doing so may promote more adaptive cognitive patterns and greater tolerance of uncertainty in the face of chronic or recurrent musculoskeletal symptoms.⁴

Factors Associated with Greater Trust and Experience with the Clinician

The finding that greater trust and experience with the clinician was modestly associated with greater cognitive flexibility in bivariate analysis, but not with levels of distress or unhelpful thoughts and intolerance individually, nor in statistical groupings of mindset factors, suggests there may be an association between greater cognitive flexibility and trust in one's clinician that merits additional investigation. It is plausible that limited patient cognitive flexibility could be a potential source of discordance with clinician advice and expertise. Cognitive inflexibility may limit the ability to navigate one's automatic, heuristic, intuitive inner narrative regarding sensations in the face of clinician suggestion of an alternative, often healthier and more accurate narrative. We know from qualitative studies that poor patient experiences can be associated with feeling unheard and misunderstood. Additionally, qualitative studies have shown the utility of employing a short YouTube video portraying findings from a qualitative evidence synthesis about living with pain to help patients in care for persistent pain feel heard and understood, highlighting the importance of giving voice to suffering and empathizing with patients and their illness (Raja et al, 2020). Further research might examine the effectiveness of such an intervention in a musculoskeletal context with the ultimate goal of validating patient emotions and generating dialogue.⁷

Conclusions

There is a modest relationship between current cognitive inflexibility and limited prior awareness of past experiences adjusting thinking about symptoms that was not clarified in cluster analyses, including current unhelpful thoughts, and intolerance of uncertainty. More research is needed to elucidate these relationships, but clinicians might consider a patient's lack of awareness of prior experiences with adjusting thinking (cognitive flexibility) as an indicator of current cognitive inflexibility. These findings emphasize the importance of communication strategies that prioritize summarizing, legitimizing, and normalizing concerns expressed by patients, even when those concerns are often based in unhelpful thinking. A trusting relationship is needed, and adjustments to thinking may benefit from time and incremental interactions.

Footnotes

Acknowledgments

Prakash Jayakumar MBBS PhD, provided invaluable support and helped to brainstorm ideas throughout the crafting and execution of this research.

ORCID iDs

Juan Pablo Flanagan

David Ring

Aydin Azarpey

Amin Razi

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Biographies

Juan Pablo Flanagan is a medical student. His area of research is orthopaedic surgery and its intersection with mental health.

Jefferson Hunter is a medical student. His area of research is musculoskeletal conditions and how it relates to mindsets.

Niels Brinkman is a PhD candidate in orthopaedic trauma. His research interest lie in orthopaedic surgery and its intersections with mental health and artificial intelligence.

David Ring is an orthopaedic surgeon. His research expertise is in musculoskeletal conditions and mindsets.

Aydin Azarpey is a medical doctor and researcher. His research is orthopaedic surgery and mental health.

Amin Razi is a medical doctor and researcher. His research is in orthopaedic surgery and mindsets.

Appendix 1: Bivariate Analysis of Factors Associated with Awareness of prior adjusting of thinking and trust with the clinician

	Awareness of prior adjusting of thinking		Trust and experience with the clinician
Variables	Pearson coefficient	P-value	Pearson coefficient	P-value

Age	−0.06	0.45	0.15	0.09
Cognitive Flexibility	0.18	0.03	0.30	0.003
Unhelpful thoughts	−0.12	0.14	−0.05	0.34
Feelings of distress	−0.04	0.66	0.04	0.87
Intolerance of Uncertainty	0.08	0.34	0.05	0.58
	Mean ± SD	P-value	Mean ± SD	P-value
Gender		<0.001		0.11
Women	17 ± 3		29 ± 5
Men	15 ± 4		28 ± 4
Self-reported ethnicity		0.26		0.05
Not Hispanic	16 ± 3		29 ± 4
Hispanic	17 ± 4		28 ± 4
Self-reported race		0.08		0.18
White	17 ± 4		29 ± 5
Black	16 ± 3		30 ± 4
Asian	15 ± 2		29 ± 4
Other	17 ± 4		27 ± 4
Marital Status		0.51		0.20
Single	17 ± 3		28 ± 5
Married	16 ± 3		29 ± 4
Separated	17 ± 4		29 ± 5
Education		0.02		0.02
High school or less	15 ± 4		27 ± 4
2-year college	16 ± 2		29 ± 4
4-year college	15 ± 4		30 ± 4
Post-college graduate degree	18 ± 3		29 ± 5
Anatomic region		0.46		0.08
Spine	16 ± 4		25 ± 4
Upper extremity	17 ± 4		21 ± 4
Lower extremity	16 ± 3		22 ± 4
Income		0.70		0.17
Less than $15,000	17 ± 4		21 ± 4
$15,000 - $30,000	16 ± 2		23 ± 4
$30,001 - $50,000	17 ± 2		20 ± 4
$50,001 - $100,000	17 ± 4		21 ± 4
> $100,000	16 ± 3		23 ± 4
prefer not to answer	16 ± 3		21 ± 5
Employment		0.64		0.75
Employed	17 ± 4		22 ± 5
Unemployed	16 ± 3		21 ± 4
Disabled	16 ± 2		23 ± 5
Other	16 ± 2		22 ± 4
Insurance		0.77		0.05
Medicare	16 ± 2		16 ± 2
Private/Military	17 ± 4		17 ± 4
Safety net / uninsured/Medicaid	16 ± 4		16 ± 4
Other	17 ± 2		17 ± 2

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