is this my best side

e-Therapy: online CBT programmes for people with chronic pain

There are many problems with helping people access timely and appropriate chronic pain management programmes. In the US, comprehensive multi or inter-disciplinary programmes have been decreasingly funded compared with single discipline approaches. In New Zealand, the chance of being accepted into a Pain Management Centre in some cities is 1:10 if you’re not covered by ACC. Finding, resourcing and keeping clinicians in this specialist area is challenging.

So…many people have looked for alternative ways to deliver this vital and effective management approach, and with increasing use of the interwebs and smartphone apps for health information, it’s not surprising there have been some attempts to develop online pain management programmes, usually following a broadly cognitive behavioural approach.

How well do they work?

Good question. And one that needs to be answered before rushing out to set them up.  The first caveat, though, needs to be a reminder that when we look at comparing online programmes with face-to-face, we may not be comparing apples with apples. Here are the differences I’ve identified:

  • Group process in face-to-face approaches is different from online versions. This is because so much of our communication relies on visual feedback, and even with video/web cams we’re not getting the rich information we rely on in face-to-face discussions.
  • Many online programmes don’t use group approaches at all. Treatment can be carried out individually, and even in face-to-face approaches, treatments can be conducted with individual people rather than in groups. I personally think this is only more useful than group approaches for the small number of people who find it hard to be in a group: distractible, angry, dominant people, and those who don’t speak the language or can’t hear what’s going on. There’s a lot to be said for being able to watch other people and learn vicariously from them. But online programmes typically don’t have the capacity for group discussions in real time, except perhaps for moderated chat rooms.
  • Behaviour change is less likely with online approaches. The group process directly influences what people do, and without that face-to-face contact, it’s much easier for people to talk the talk while not walking the walk. Even if the behaviour change only occurs during the face-to-face sessions, that’s more than nothing at all!

Just as face-to-face cognitive behaviourally-based pain management programmes differ in content, form and duration, so do online versions. This makes comparing the approaches challenging. We also need to remember that most of the research showing that pain management programmes are effective do so when comparing the programme against a waiting list, or a non-treatment or placebo control. When the comparison is between a pain management programme and another active treatment, the results are less stunning. We should also remember that the outcomes being measured are important: is it pain reduction (not so likely, but possible)? Is it increased function (likely)? Reduced distress (probable)? Increased confidence (generally yes, at least for a while)?

To the studies:

I’m going to draw from three recent studies published by the same group, all three studies vary slightly in their scope, and were conducted in Sweden. Participants were recruited from the University-based Pain Centre, and had received a medical examination but no multidisciplinary treatment.  Participants were screened over the phone, and randomly allocated to one of two groups. In the first study, the two groups were the control group which was an online discussion group, with the second group an online ACT-based programme consisting of seven sections (Buhrman, Skoglund, Husell, Bergstrom, Gordh, Hursti et al, 2013).

The second study was an online “refresher” programme for people who had previously attended the Uppsala University chronic pain programme. Participants were invited if they had completed their programme 1 – 5 years before, had been recently screened medically, and were interviewed/screened to ensure their eligibility.  Participants were also randomised into two groups: the control group as above, and the treatment group which had eight sessions incorporating action planning, exercise, applied relaxation, cognitive restructuring, mindfulness and sleep and stress (Buhrman, Fredriksson, Edstrom, Shafiei, Tarnquvist, Ljotsson et al, 2013).

The final study by this group has yet to be published, and is a similar programme to that in the second one, and again the research design was as above. Participants in this study were those with depression and anxiety, and treatment was tailored to directly address these problems, drawing from the content above, but tailored to meet the individual needs as assessed in the screening interview (Buhrman, Syk, Burvall, Hartig, Gordh, & Andersson, in press).

What happened?

For all three programmes, outcomes showed improvement in the areas we want to see (reduced distress, anxiety, depression, increased activity engagement and willingness). This was maintained for six – twelve months. All well and good, the programmes are useful.

The questions that arise for me are whether some of the steps required for a research project might influence programme usefulness – and even participation. The authors of the in press article acknowledge this, finding that they did not provide telephone support for this last group, and therefore had more drop-outs. But of course this could happen if participants don’t think they’re getting any new information, so we’re not sure if this is important. But there is information suggesting that personal phone contact, the interview process and follow-ups by clinicians form an important part of helping people maintain interest and engagement in a programme. Could this be a potential barrier to “real world” success for internet-based programmes?

Other issues have been identified in other studies of self-management, such as the need for GP’s to actively endorse these programmes, giving authoritative sanction for them so people participating are encouraged to use them. Where this isn’t carried out the programmes don’t seem to have as much uptake.

There’s also the “I’m in a research study” effect. Simply by being in a research project people can be more enthusiastic about participating, and completing all those questionnaires. There’s the emailed reminders, the “specialness” of having your opinion valued, the enthusiasm of the researchers themselves.

What do I conclude?

By comparison with pain-related apps for smart phones (Lalloo, Jibb, Rivera, Agarwal & Stinson, in press), internet-based cognitive behaviourally-based programmes for chronic pain are broad in scope, usually based on some theoretical position, and some have been scientifically studied. In fact, Lalloo and colleagues point out that many apps don’t have health professional input, and haven’t been tested for effectiveness. While apps may offer some support for self-management, they are probably not your best choice for e-therapy.

CBT-based programmes, on the other hand, seem to have some effectiveness at least on some parameters, and within the constraints of a research format.

I’d like to see a programme developed for people in the community without requiring medical assessment, and based on a model of how people move from “Limbo Land” where pain doesn’t make any sense, through to “Living well with chronic pain” where a range of ways of getting on with life are used in a flexible and persistent way. I’d love to see this kind of programme operating without obstacles to getting involved like being screened, or medically assessed, and where participants can choose the elements that interest them. People with pain might just choose what they’re ready for more effectively than if a professional gets in on the act – what do you think?


Buhrman, Monica, Skoglund, Astrid, Husell, Josefin, Bergström, Kristina, Gordh, Torsten, Hursti, Timo, . . . Andersson, Gerhard. (2013). Guided internet-delivered acceptance and commitment therapy for chronic pain patients: A randomized controlled trial. Behaviour Research and Therapy, 51(6), 307-315. doi:

Buhrman, M., Fredriksson, A., Edström, G., Shafiei, D., Tärnqvist, C., Ljótsson, B., . . . Andersson, G. (2013). Guided Internet-delivered cognitive behavioural therapy for chronic pain patients who have residual symptoms after rehabilitation treatment: Randomized controlled trial. European Journal of Pain, 17(5), 753-765. doi: 10.1002/j.1532-2149.2012.00244.x

Buhrman, Monica PhD, Syk, Martin, Burvall, Olle, Hartig, Terry, Gordh, Torsten, & Andersson, Gerhard. Individualized Guided Internet-delivered Cognitive Behaviour Therapy for Chronic Pain Patients with Comorbid Depression and Anxiety: A Randomized Controlled Trial. Clinical Journal of Pain. in press

Lalloo, Chitra, Jibb, Lindsay A. , Rivera, Jordan , Agarwal, Arnav , & Stinson, Jennifer N. . “There’s a Pain App for That”: Review of Patient-Targeted Smartphone Applications for Pain Management. Clinical Journal of Pain. in press

Cold Georgina

Routines, habits, boredom & variety: Life skills for living with chronic pain?

I’ve just had a wonderful week on holiday. I escaped the internet, social media, telephones, power, flushing toilets, running water… and it was awesome! There’s something good about taking a break from my usual world to do things completely differently. Now that I’m back I’m reflecting on routines and habits, and how they form an important part of my life.

Routines are sets of behaviours (occupations if you know occupational science) that regularly occur in a certain sequence. Habits are behaviours or occupations we do without needing to directly think about them – maybe because we’ve done them so often they’ve become semi-automatic. Both routines and habits are useful because they reduce the demand on our attention and therefore draw less on our cognitive resources.

This can be a good thing – who would want to have to think about every single thing we have to do to get up and off to work each day?

One of the things people working in chronic pain management often discuss with those they see is how to manage activity levels so that important things can get done without leaving the person feeling exhausted, flaring up their pain, or omitting to do things they value. Activity pacing is one of the main strategies discussed, and although the evidence base for this strategy is skinny, it’s a very common approach. BUT, and it’s a big BUT, it requires people to plan and organise both what they want to do, and how and when they do them.

Many people would think this is pretty self-explanatory. Who doesn’t sort out a To Do list and prioritise what needs doing in a day or week?

Ermmm – actually, there are plenty of people who don’t do this regularly. That’s why one of the most common tools in business is time management! Remember the Day Runner Diary? The Four Quadrants (Steven Covey) Approach? The ABC of prioritising? All tools used to organise what does and doesn’t need to be done.

While these tools are readily used in business, it’s rather less often that we think about helping people organise their lives outside of the workplace. I guess this is because most of us think this just happens naturally – intuitively, if you will. Intuition, though, can be defined as “over-learned habits” that we have learned so well we’ve forgotten we ever needed to learn them in the beginning.

The field of habits and routines is part of self-regulation. Self-regulation includes these components, but also incorporates the ways we raise our energy, calm ourselves down, maintain time awareness, set our sleep/wake cycle, and manage emotions.  Self-regulation theory has been proposed as a model for helping people with some forms of chronic pain cope more effectively with their pain and fatigue (Sauer, Burris,  & Carlson, 2010). There’s some neurobiological evidence to show that some forms of chronic pain, notably fibromyalgia, have greater connectivity and baseline activity between regions of the brain involved in self-regulation including the really important parts involved in executive functioning. This means things like switching attention from one thing to another, or responding to threat appropriately (then settling down afterwards) are more difficult.

And some people are born with, or perhaps develop, less effective self-regulatory neural processes – these are perhaps the people who seem to forget deadlines, arrive late, don’t take medications at the right time, perhaps don’t have regular meals, maybe run out of ingredients (or clean clothes!), and generally find it more difficult to get their life together.

Self-regulation treatments are often concerned with ways to down-regulate breathing, heart rate, and to manage attention. Habits and routines, on the other hand, are larger chunks of behaviour that might not be addressed. Maybe this is why some people forget to do their CBT thought records and don’t do the exercises they’re meant to do. As clinicians, we can think these “forgettories” are a sign of noncompliance, lack of motivation, or not really understanding the importance of the things we ask them to do. I suggest that maybe, for some people, it’s more about failing to have some of the foundational skills needed to get organised into a routine so that there’s enough brain space for people to add new tasks into their day.

What to do about this?

I think we can draw from three main sources of literature here. The first is self-regulation theory where people like Nes, Roach, & Segerstrom (2009), Sauer, Burris & Carlson (2010) are looking at some really useful models. By helping people develop mindfulness, relaxation skills, and awareness of internal physiological states, greater ability to self-regulate is developed. But this only addresses the internal states – what about the bigger chunks?

The next source of literature is probably that from mTBI, or post-concussion rehabilitation. One of the features of post-concussion syndrome is difficulty switching attention, becoming fatigued, recognising when and how to stop or slow down. There are plenty of fun games (yes, even Lumosity!) that can be used to help people develop greater cognitive flexibility, memory, and to improve concentration, attention and so on.

But this still doesn’t address the bigger chunks of activity we need to do. So here’s where I think occupational science and occupational therapy might be really useful: all the tools of time management, cognitive props like using a cellphone alarm to remind you to take medications, daily planners, post-it notes, identifying values and using these to prioritise tasks, having a diary, writing lists – all of these can help, provided they’re tailored to the individual’s needs and lifestyle.

So, before you think that habits and routine are boring, and that planning removes variety – or that the person you’re working with who just doesn’t do those exercises is really Just. Not. That. Motivated. Maybe it’s to do with not being all that great at habits and routines or self-regulation, and maybe you can help them get better at these foundation skills.


Clark, F. (2000). The concepts of habit and routine: a preliminary theoretical synthesis. Occupational Therapy Journal of Research, 20(Sup 1), 123S-137S.

Nes, Lise Solberg, Roach, Abbey R., & Segerstrom, Suzanne C. (2009). Executive functions, self-regulation, and chronic pain: A review. Annals of Behavioral Medicine, 37(2), 173-183. doi:

Sauer, Shannon E., Burris, Jessica L., & Carlson, Charles R. (2010). New directions in the management of chronic pain: Self-regulation theory as a model for integrative clinical psychology practice. Clinical Psychology Review, 30(6), 805-814. doi:

Whiteford, G. (2007). Artistry of the everyday: connection, continuity and the context. Journal of Occupational Science, 14(2), 77-81.

Wiese, Dunn W. (2000). Habit: What’s the brain got to do with it? Occupational Therapy Journal of Research, 20(Sup 1), 6S-20S.

Perfect poise

The OOV – Fabulous or familiar?

I love gadgets! New, innovative, groovy – I feel special when I have a new toy to play with. I justify my pleasure by saying “Oh it saves me SO much time”, or “I can do SO much more” – but really, it’s the wow factor that gets me every time. So it is with new and groovy treatments for pain. It used to be all “leg length discrepancy” and “muscle imbalance”, now it’s “neuroplasticity” and “educational neurophysiology”. So I think I’ve stumbled upon the Next New Thing. The OOV.  I attended a one day fundamentals workshop – incidentally, paid for by the University Department in which I work, so this is an unbiased review.

The OOV is a neat foam device shaped somewhat like a goose (if you use your imagination), or perhaps like an insect thorax. It’s curved side to side and from front to back on the bottom, while the top has two concave and one convex curve roughly approximating the curves of the spine.OOV1OOV2Designed by an osteopath, there are several principles the inventor and educators indicate underpin the rationale for the OOV. These are:

  • Functional movement training
  • Developing stability via the pelvis and deep “core” muscles, with joint mobility where this is needed (shoulders and hips)
  • Developing motor control
  • Establish endurance
  • Refine balance
  • Relaxed performance

The exercises performed on an OOV are therefore carried out slowly (almost meditatively), in time with breathing (deep diaphragmatic breathing), and with control.

Training also requires attending to feedback from using the device itself – use it with inefficient motor control and you fall off. Use it with fluid control and, over time, develop strength. The materials included in the training manual state that motor control learning requires a “closed loop feedback” process of attending to sensory information as new movements are learned. After the movements are mastered, then and only then is speed acquired. Exercises focuses on using eccentric contractions to keep movements slow and smooth – and “allows for kinetic chain sequencing to improve”, “increases cross bridge connection between muscle fibres thereby increasing strength, activates the deep muscles, stimulates the low threshold slow twitch fibres building stamina, lengthens the fascia due to long, slow and sustained load”.

The training manual also discusses myofascial slings and suggests that by training the deep core muscles (transverse abdominis, multifidus and the pelvic floor – and don’t forget the diaphragm), and the superficial units (posterior oblique, deep longitudinal, anterior oblique and the lateral muscular slings) coordination and recruitment patterns will allow for stability, strength and speed as forces generated by limbs are transmitted through the body.

Next, the manual describes several postural types. There is the so-called “ideal posture”, kyphotic-lordotic posture, flat back posture, and sway back posture – and of course, we must correct the variants so we can achieve the ideal. I’ll leave you to draw your conclusions as to the rationale for this.

Finally, there are the four pillars of movement:

  1. Axial elongation – for efficient spine articulation, the “safest” environment for movement, preventing compression and shearing forces, and providing the optimal position for the core muscles to work. Just by lying on the OOV, the spine is placed in this wonderful position, provided of course that you lie with your lumbar region in the right spot, which can be just an inch or so from where you may really want to lie.  Efficient breathing – Axial elongation allows for diaphragmatic breathing, with the head lower than the hips which apparently inhibits the secondary respiratory muscles.
  2. Hip mobilisations – to develop correct posture and proper alignment begins with the feet, by dissociating the lower half of the body from the upper half, the stationary half provides stability and support so that forces are directed towards the moving half.
  3. Shoulder and thoracic spine mobilisation – to enhance, strengthen and extend the fluid range of movement at the shoulder which, because of our terrible working environments, seems to produce faulty movement patterns.
  4. Core control – as the manual says “not enough can be said about the importance of a strong core. But strength means nothing if all the muscles that make up the core are not working efficiently during movement”.

OK, so far so good. Training is based on the principles above, with the addition of balance and proper alignment, interspersing new exercises with a balance position, adding new movement patterns to increase the challenge to the nervous system (yes! neuroplasticity!), practice to develop complex movement patterns, and finally repeated practice using weights, increased repetition etc. And if you perform a new set poorly, step back a bit, reduce the demands until motor control develops.

I spent a day using the OOV. With my sensitive nervous system letting me know three days later that I’ve been using muscles I don’t usually demand so much from, I think it does what it says it does – you definitely work a range of muscles more intensely than in everyday life. It’s fun, and because of the slow pace where control is the aim, it’s achievable even for people who wouldn’t ordinarily want to “do exercise”.

What do I think of it? Well, I predict there will be classes for OOV training in many gyms in New Zealand and the world. During the workshop I heard that performance athletes (yes! the Australian swim team!) are using it, that you can rehabilitate sore backs, shoulders, hips, whatever; I learned that you must be SO careful with your back because the discs can be smashed; that posture patterns are dysfunctional; that the reason we have back pain is because of poor core stability, that we can have an unstable pelvis; that this is the way of the future. Even 70 year old women with osteoarthritis can now manage things she couldn’t do before.

Warning: I am skeptical of any new thing. After seeing so many variations over the years I’ve worked in pain management, particularly within the musculoskeletal world, I guess I’m a bit wary of fads. Here’s the thing: While I think the OOV functions well as an option for exercise, and novelty can be a good thing to maintain motivation, let’s not inflate the potential. Buzz words like “motor control”, “neuroplasticity”, “core strength” are going to have grab. The exercises, many based on Pilates, will be familiar and yet challenging on the unstable platform of the OOV. BUT the basic assumptions that:

  • there is one ideal posture and lordosis is associated with back pain and disc degeneration (Been & Kalichman, 2014; Murray, Dixon, Hollingworth, Wilson & Doyle, 2003; Nourbakhsh & Arab, 2002)
  • backs are fragile and must be coddled, particularly the discs  (Bakker, Verhagen, van Trijffel, Lucas & Koes, 2009; Claus, Hides, Moseley & Hodges, 2008; O’Sullivan, O’Keefe, O’Sullivan, O’Sullivan & Dankaerts, 2012);
  • core stability and motor recruitment are at fault in back pain, therefore they need to be retrained ( Laird, Kent, & Keating, 2012)
  • that myofascia can be effectively stretched (Scleip, Dureselen, Vleeming, Naylor, Lehmann-Horn, Zorn et al, 2012; Turrina, Martinez-Gonzalez & Stecco, 2013)

are, I think, arguable. I particularly dislike the language associated with the reasons for developing core stability – that backs are easily damaged, that great care must be taken to avoid damage, and that a critical reason for back pain is either lack of core stability or pelvic instability. While these notions are logical from a biomechanical viewpoint, they don’t accommodate natural bony, ligamentous and muscular variations (how many clavicle variations have been identified?), they omit the nervous system, and they fail to include the active, dynamic and ever-changing, self-regulating, homeostatic human systems involved.

Consider the OOV as an adjunct, a toy, a nice way to introduce movement to people who are fearful of movement. Use it to vary an exercise routine. Have fun with it. But please don’t base your back pain rehabilitation on the idea that this device is the bees knees.

Quick addendum: GREAT critical questions about a ten-year follow-up of strengthening vs flexbility exercises with or without abdominal bracing –; the original article is


Bakker, E. W., Verhagen, A. P., van Trijffel, E., Lucas, C., & Koes, B. W. (2009). Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies. Spine, 34(8), E281-293.

Been, E., & Kalichman, L. (2014). Lumbar lordosis. Spine Journal: Official Journal of the North American Spine Society, 14(1), 87-97.

Claus, A., Hides, J., Moseley, G. L., & Hodges, P. (2008). Sitting versus standing: does the intradiscal pressure cause disc degeneration or low back pain? Journal of Electromyography & Kinesiology, 18(4), 550-558.

Kirilova, M., Stoytchev, S., Pashkouleva, D., & Kavardzhikov, V. (2011). Experimental study of the mechanical properties of human abdominal fascia. Medical Engineering & Physics, 33(1), 1-6.

Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. BMC Musculoskeletal Disorders, 13, 169.

Murrie, V. L., Dixon, A. K., Hollingworth, W., Wilson, H., & Doyle, T. A. (2003). Lumbar lordosis: study of patients with and without low back pain. Clinical Anatomy, 16(2), 144-147.

Nourbakhsh, M. R., & Arab, A. M. (2002). Relationship between mechanical factors and incidence of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 32(9), 447-460.

O’Sullivan, K., O’Keeffe, M., O’Sullivan, L., O’Sullivan, P., & Dankaerts, W. (2012). The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics, 55(8), 898-908.

Schleip, R., Duerselen, L., Vleeming, A., Naylor, I. L., Lehmann-Horn, F., Zorn, A., . . . Klingler, W. (2012). Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. Journal of Bodywork & Movement Therapies, 16(1), 94-100.

Turrina, A., Martinez-Gonzalez, M. A., & Stecco, C. (2013). The muscular force transmission system: role of the intramuscular connective tissue. Journal of Bodywork & Movement Therapies, 17(1), 95-102.

you are my sunshine

Pain is not a “thing”
I’m reading some fascinating books at the moment. I’m such a pain geek I take pain books away with me on holiday! Anyway, the two books to hit me between the eyeballs recently are The Pain Chronicles by Melanie Thernstrom (published 2010), and The Story of Pain by Joanna Bourke (published 2014). What makes both of these books fascinating is that these both look at the history of pain and pain management, and explore the “what it is like” to be in pain. Reading them, I’m forcefully reminded that the ways in which we conceptualise pain is an incredibly social process. Social in that while we have discovered much about the neurobiology underpinning our experience of pain in the last 40 years or so, the ways in which we understand pain as it is experienced (and pain is always an experience) depend on prevailing attitudes towards suffering.

I’ve written before that pain and suffering are not the same thing. I’ve also pointed out that the language we use is one way to convey the “what it is like” to have pain, and so expressions like “cutting, burning pain” or “stabbing pain” or “grinding pain” are metaphoric descriptions that use visual imagery possibly to elicit activation of mirror neurones so that the listener can begin to experience the “what it is like” to have pain.

The reason this is important when we talk about pain and pain behaviour is that the things we do when we’re sore are framed within our own culture, and reflect what we know and understand about what-it-is-like to be experiencing pain. This changes over time, and Joanna Bourke gives excerpts from two different editions of the same textbook:

  1. The jolting of a carriage is insupportable to him… As the evil increased, micturition becomes more and more frequent and distressing; the pain following the act is very severe – patients writhe with their bodies, and grind their teeth in agony (1852 edition)
  2. The jolting of a carriage increases his symptoms… As the stone increases in size, micturition becomes more frequent and distressing, and the pain or uneasiness at the end of the penis becomes more constant and severe (1881 edition)

Bourke points out that earlier editions focus more on the suffering of the patient, as opposed to the increase of “symptoms”, the “evil” becomes “the stone”, and “the act” of micturition is turned into “pain in the penis”. The pain itself is even downgraded to “pain or uneasiness”, Furthermore, patients no longer “writhe with their bodies and grind their teeth in agony”, but penises simply hurt more (p.86). Pain, over time, and within our socio-cultural heritage, has moved from being readily acknowledged as distressing, an evil, and agonising (all very emotive words), to a far less emotive process of a “stone” and “uneasiness” at the end of the penis.

Our responses to other people who express their pain is also shaped by social processes. Here’s another excerpt from Bourke’s book in which a physician was attending “a spoiled…society woman” who was “accustomed to enjoy to the full the pleasures of life” and developed heart pain. The doctor says “My lady, you are suffering from a pain which you are right in supposing is due to your heart. I might give you something which would relieve the pain, but I don’t propose to do so. The pain is a warning to you to curtail your activities and live a different life.” (p. 128) So much for sympathy! This was the 1930′s.

In times when life was short, hard and often painful, and people lived close to one another, were exhorted to be mindful of their afterlife (because this, it was promised, would be far better than their current life – if, and only if, they were pious and quietly accepted their suffering as a gift from God, sent to test them, or to punish them). Even children were advised to remember that God gave pain, therefore they should ask for “grace to submit to his will”, continue with their chores without complaining, and “draw strength from the ‘Ominpotent arm’ of Christ, anticipating future bliss in paradise.”

I think we’re inclined to forget that how we demonstrate to others that we are hurting is intimately connected to social processes we’ve been immersed in since birth. This is why the paper “Impact of pain behaviors on evaluations of warmth and competence” is a very good one, impeccably carried out with wonderful experimental design, but must still be seen in our current social context. The study examined individual’s interpretations of pain behaviours, using a wireframe animation (generated by computer but based on an individual firstly walking normally, then walking with evident pain behaviour). The observers indicated that the recording of the individual walking with pain behaviours was more depressed, less fit, and not as competent as the recording of the individual walking normally. This suggests that when people observe individuals demonstrating pain behaviours, even without any other cues, our social impression is that they are less competent and we are more likely to withdraw from them – or, and I’m extrapolating a bit here, if we’re in the business of helping people, we may believe they are especially vulnerable and need our help.

However: in our society, bombarded as we are with advertisements for a pain-free existence, putting forward the notion that we should never have to experience pain, I think this study shows us very clearly what-it-is-like to be socially rejected on the basis of not being “perfect”. I wonder what the results would have been if it could have been carried out in the 1880′s.

I wonder too, when we’ll begin to look at health providers levels of empathy and catastrophising (Thanks to Lisa for this idea!). If we’re inclined to be highly empathic, perhaps to the point of unhelpfully over-identifying with our patient’s suffering (where we become distressed because our patients are distressed), and if we also catastrophise or think the worst, I think we’ll over-interpret the pain behaviour of others and attempt to compensate by treating the person so that our own distress is reduced. And because this is a social process, and we’re probably not aware of it even occurring, perhaps we’ll be completely oblivious to the adverse effects of doing so. I’d love to see the study carried out by Ashton-James and colleagues repeated in a sample of health professionals – that would be very interesting indeed.

Ashton-James, C., Richardson, D., Williams, A., Bianchi-Berthouze, N., & Dekker, P. (2014). Impact of pain behaviors on evaluations of warmth and competence PAIN® DOI: 10.1016/j.pain.2014.09.031

A pierless morning

Fabulous FREE pain education resource from Cardiff University

It’s amazing what you find on the interwebs. Thanks to Pete Moore from Pain Toolkit -you can find him on Twitter as @paintoolkit2 – I’ve been introduced to Cardiff University’s amazing Pain Community Centre. This is a site developed by pain educators and clinicians to provide authoritative and practical information on a wide range of pain topics. FREE CPD, a chance to chat amongst others with the same inclination, clear video recordings, a list of events in the UK, and a set of “Pain  Toolkits” on topics such as migraine, central post-stroke pain, general management of osteoarthritic pain and so on. This is by far the most comprehensive and well-organised site that I’ve stumbled on in a long time. Well worth the visit (and you’ll probably lose some hours as well!). Oh, and Pain Community Centre is also on Twitter as @paincommunity

solving the problems of the world

…but I thought a new knee would fix my pain!
Working in an orthopaedic surgery department is quite enlightening. Along with discussions about ceramic vs metal implants and cartilage regeneration (I work with a team of researchers looking at how to create replacement cartilage), the topic of what counts as a surgical success in knee surgery also comes up from time to time. Knee joint replacement isn’t as successful as hip joint replacement for a number of reasons including the complex nature of the joint, the way the joint capsule is disrupted during surgery, and the knee can apparently feel quite different from the original knee.

What this means is there can be quite a mismatch of expectations for people who believe very strongly that there should be no pain and they should have a completely normal knee joint after surgery. In fact, in the NZ National Joint Registry, the main reason recorded for knee joint revision is pain.

Naturally, the problem of pain after surgery is something surgeons and researchers are also interested in. Many studies have shown psychological factors such as catastrophising (thinking the worst) and low mood are associated with poorer outcomes (Riddle, Wade. Jiranek, & Kong, 2010; Roth, Tripp, Harrison, Sullivan & Carson, 2007; Shelby, Somers, Keefe, Pells, Dixon & Blumenthal, 2008).  The outcomes looked at so far include length of stay in hospital at the time of surgery, analgesia use during surgery, increased disability after surgery and revision rates.

Now, one solution to this problem could be simply not performing joint replacement surgery in people who are depressed and tend to think the worst. The problem is that two of the strongest predictors for looking for treatment are – you guessed it: low mood and catastrophising (and disability). Another solution is to provide intervention after surgery to target the people who tend to become fearful – perhaps an enhanced level of physiotherapy for this group, while the less vulnerable may even require less. Some studies have also looked at giving better education about what the surgery entails and the expected outcomes, and doing this before the person undergoes surgery, while another study has looked at providing a pain coping skills training course prior to surgery (Riddle, Wade, Jiranek & Kong, 2011). The outcomes from this last approach were promising, although it was a very small sample size, and the follow-up was for only two months.

There are a number of problems with implementing any of these approaches in clinical practice, at least in the system I’m most familiar with (NZ):

  1. Many orthopaedic surgeons still discount the importance of psychological factors, and consider the information they provide completely adequate for presurgical preparation
  2. It’s difficult to give someone different or special treatment based on psychological factors within a usual clinical setting without also inadvertently giving people a label that may change how they are responded to
  3. Any additional intervention will have an up-front cost (not good for cost accountants!)
  4. These treatments need specially trained clinicians who understand the measures being used, the rationale for treatment, and the type of treatment needed – and because these are psychological factors and surgery is conducted in a “physical” hospital, this is unfamiliar territory for many
  5. Patients may not be very comfortable with a treatment that focuses on thoughts, emotions and pain

It seems to me, and from the results from a recent study looking at analgesic use after surgery, that an argument simply based on the cost of failing to go ahead with effective management of psychosocial factors would make sense. Here’s the detail:

Fuzier, Serres, Bourrel, Palmaro, Montastruc and Lapeyre-Mestre (2014) conducted a large study of patients in the Midi-Pyrenees region of France. They examined the medical records of all 1939 patients who had knee arthroplasty, and compared the drug use (what was dispensed) at four times – 12 months before surgery, 2 months before surgery, and 10 months before and after the knee surgery.  What they found was an increase in analgesic, antineuropathic and opioid drug use in the 12 months after surgery. The actual percentage of patients requiring more medication is astonishing: 47% of people needed more analgesia, 8.6% needed more antineuropathic medications, and 5.6% needed more opioids. That’s a whole lot of drugs!

These researchers also analysed a number of other variables associated with the medication changes, and made some more understandable findings:

  • people having total knee replacement surgery were at a greater risk of using more medication than those having unicompartmental surgery (half a joint)
  • people with high levels of preoperative pain along with “psychiatric vulnerability” were at greater risk of having increased neuropathic medications prescribed
  • but older people were less likely to be prescribed additional medications

Unfortunately, this study didn’t identify the particular “psychiatric vulnerabilities” of the patients who participated – from the paper it looks like data was extracted from clinical records, so psychiatric disorders such as depression, anxiety and so on are the likely culprits. We don’t therefore know whether catastrophising contributed to the medication use – but given the results from at least 20 studies I have in my database, I think it’s probably likely.

Medications are not cheap. While they’re quick to prescribe, dispense and take, they cost not only in fiscal terms (which is a serious consideration, nevertheless), but also in side effects – and more importantly, in loss of personal locus of control. What I mean by this is that these are people who haven’t been given the opportunity to develop pain self management skills. They will continue to catastrophise, and perhaps even more so after surgery because their fears have been confirmed. Maybe it’s cheaper and more humane to bite the bullet and begin giving people appropriate psychosocial treatment before, during and after surgery.

Fuzier, R., Serres, I., Bourrel, R., Palmaro, A., Montastruc, J., & Lapeyre-Mestre, M. (2014). Analgesic drug consumption increases after knee arthroplasty: A pharmacoepidemiological study investigating postoperative pain PAIN®, 155 (7), 1339-1345 DOI: 10.1016/j.pain.2014.04.010

Riddle, D. L., Keefe, F. J., Nay, W. T., McKee, D., Attarian, D. E., & Jensen, M. P. (2011). Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Archives of Physical Medicine & Rehabilitation, 92(6), 859-865.

Riddle, D. L., Wade, J. B., Jiranek, W. A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Roth, M. L., Tripp, D. A., Harrison, M. H., Sullivan, M., & Carson, P. (2007). Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Research & Management, 12(3), 185-194.

Shelby, Rebecca A., Somers, Tamara J., Keefe, Francis J., Pells, Jennifer J., Dixon, Kim E., & Blumenthal, James A. (2008). Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients. Journal of Pain, 9(10), 912-919.


I’m so easily distr….oooh look! Shiny!
Wouldn’t it be great if there was a simple way to help people avoid focusing on their pain, allowing them to just watch a TV programme or something, and not be bothered by some painful procedure? This is a dream for those health professionals who have to carry out painful procedures like take blood, drill teeth, change dressings, stretch body parts and so on. It’s also an area of great interest for researchers, because studying how distraction affects our experience of pain shows us a great deal about how our brains detect threat, process incoming information, encourage an adaptive response and so on. It’s probably also a really interesting area for people who like to inflict pain on others – in the name of science.

While the form of pain is different in experimental pain studies compared with chronic pain, we have learned a great deal about “psychosocial” factors through the many and varied experiments carried out. This study is yet another, but this time asked people with chronic pain to participate in a study that incorporated mechanical temporal summation, a distraction task, thermal threshold and tolerance testing, pressure threshold and tolerance testing, cuff pressure testing, followed finally by a conditioned pain modulation test. That’s a lot of pain!

The distraction test involved asking the participants to squeeze a handgrip dynamometer with their dominant hand. Two readings were averaged, and the participants told to “maintain a grip strength as uniformly as possible”, using their nondominant hand, with the maximal grip strength aiming to reach 20% of the dominant hand. This while the participants were undergoing a mechanical dot probe test.

In addition to these painful experiments, participants also completed a number of psychometric questionnaires: The Brief Pain Inventory, The Beck Depression Inventory, the Pain Anxiety Symptoms Scale and the Pain Catastrophising Scale. All well-known measures often used in chronic pain management.

After some statistical wizardry, what did these researchers find?

Well, very interestingly indeed, what they found was that people who tended to score highly on the PCS obtained a greater effect (reduction of reported pain intensity) on the temporal summation test than those people with lower PCS scores.

This is interesting for several reasons. The first is that temporal summation of pain was greater in the people who catastrophise – and this is a group of people who usually fare quite poorly in clinical situations including both acute and chronic pain. What I mean by this is that people who tend to catastrophise often become more distressed, have difficulty distracting themselves from their pain, and can “think the worst”and  therefore become more disabled by their pain. This applies in many different situations such as after orthopaedic trauma (Williamson, Gabbe, Cameron, Edwards, Richardson et al, 2009), after knee joint replacement (Riddle, Wade, Jiranek & Kong, 2010), low back pain (Sieben, Vlaeyen, Tuerlinckx and Portegijs, 2002) and many more. In this situation, however, they seem to fare better when they’re being distracted by doing something else – even something as simple and boring as squeezing a dynamometer.

The authors of this paper suggest that their experiment may have uncovered an important aspect of catastrophising – that when people are specifically tasked with something to distract their attention away from the painful stimulus, catastrophising has less effect. This could mean that an important aspect of catastrophising is the degree to which a stimulus grabs attention (or should I say, the degree to which people who catastrophise have their attention grabbed by something “interesting” or “threatening”).

It also suggests that perhaps one way of helping people who tend to catastrophise would be to facilitate distraction when they have to undergo painful procedures. Perhaps even use distraction as an effective means to reduce their overall pain experience, even in chronic pain – although this is pretty speculative.

Of course there are many if’s and buts about this study. The kind of painful stimuli used in this study is very different from that experienced by people with chronic pain in daily life.  These findings differ from some others in the literature, and it’s difficult to know how or why – perhaps the pain intensity was different, perhaps people who have to sustain attention over a long period of time such as for this study have some strange learning effects going on, and perhaps there are some other physiological effects of these kinds of acute pain tests. We don’t know.

What is really interesting, though, is that for once catastrophising had a benefit – and maybe we can learn more about how to use this benefit for people who otherwise struggle with their pain.


Riddle, D. L., Wade, J. B., Jiranek, W. A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Schreiber, K., Campbell, C., Martel, M., Greenbaum, S., Wasan, A., Borsook, D., Jamison, R., & Edwards, R. (2014). Distraction Analgesia in Chronic Pain Patients Anesthesiology DOI: 10.1097/ALN.0000000000000465

Sieben, J. M., Vlaeyen, J. W., Tuerlinckx, S., & Portegijs, P. J. (2002). Pain-related fear in acute low back pain: the first two weeks of a new episode. European Journal of Pain: Ejp., 6(3), 229-237.

Williamson, Owen D, Gabbe, Belinda J, Cameron, Peter A, Edwards, Elton R, Richardson, Martin D, & Group, on behalf of the Victorian Orthopaedic Trauma Outcome Registry Project. (2009). Predictors of Moderate or Severe Pain 6 Months After Orthopaedic Injury: A Prospective Cohort Study. Journal of Orthopaedic Trauma, 23(2), 139-144 110.1097/BOT.1090b1013e3181962e3181929.

textured gold

Numbers on a scale: How bad did you say your pain was?
Have you ever been asked to give your pain rating on a scale of 0 – 10 (where 0 = no pain at all and 10 = most extreme pain you can imagine)? Have you ever tried to work out whether today’s pain is worse than yesterdays? What does a pain rating tell us?

I’ve struggled to work out how “bad” my pain is many times, is it the pain intensity that makes it troublesome? Or, in the case of a migraine, is it the quality of the pain that makes it bad (or the nausea?). Health professionals often ask people to summarise their pain experience into a form that (hopefully) we can all understand – but just what does a pain that’s around 4/10 on a VAS actually mean?

Why do we use rating scales?

We know that pain is subjective, just like taste and colour. While we might be able to agree that both of us are tasting something we call “banana”, we don’t know whether the banana taste I experience is the same as the banana taste you experience. We can see that both of us are eating the same fruit, but we don’t know how our body/brain processes that experience. Instead we assume, or infer, that we’re experiencing it in a similar way because of the similarities in context.

With pain, the situation is even more complex: we can’t determine whether the pain I feel is similar to the pain another person feels, and we don’t even have the benefit of similar “tissue damage” in the case of a migraine headache.

So, we have to infer something about the experience through some sort of common mechanism. Mostly that’s language. We hope that someone can understand that a higher number means greater pain. We hope the person can recognise what “no pain” feels like and where it might be represented on a scale. We ask the person to remember their current pain intensity, translate it into a number that in turn represents to us some kind of common understanding of what pain given that number might feel like.

Of course, there are problems with numbers on a scale. For a child who doesn’t understand the association between numbers on a scale and intensity, we use the “Faces” scale. For a person with cognitive problems (brain injury, stroke, dementia), we observe their behaviour (and hope we can translate well enough). For a person who doesn’t speak the same language as us, we might try a sliding scale with green at the bottom and red at the top, to represent increasing intensity – appealing, perhaps, to a common understanding that green = OK and red = not OK.

Worse than the difficulty translating from experience to a number is the common misunderstanding that pain severity alone represents the “what it is like” to experience pain. We know personally that it doesn’t – after all, who has had a toothache that represents “Oh no, I need a root canal and that’s going to cost a bomb!”, or “Ouch! That lemon juice in the paper cut on my finger is really annoying”, or “I feel so sick, this migraine is horrible”.

Hopefully most health professionals are taught that to use just one measure of pain is not enough. It’s important to also include other aspects of pain such as quality, how it affects function (interference), how confident we are to deal with life despite the pain (self efficacy).

So we use rating scales as a shorthand way to get to understand a tiny bit of what it is like to have pain. But the Visual Analogue Scale (VAS) is used many times to estimate whether “this person’s pain is so bad they need medication”, or “this person’s pain means we can’t expect her to help move herself from the ambulance trolley to the wheelchair”. The VAS can be used in many ways it shouldn’t be.

Studying the relationship between VAS pain intensity and disability (SF36)

The study by Boonstra, Schiphorst Preuper, Balk & Stewart (in press) aimed to identify cut-off points on the VAS to establish “mild”, “moderate” and “severe” using three different statistical approaches.  They measured pain using a Verbal Rating Scale (mild, moderate and severe), the VAS, and used several scales from the SF36 (a measure of general health quality) to establish interference from pain.

What they found was that while “mild” pain was fairly equally determined (less than or equal to 3.5), and correlated with both severity and function, when it came to “moderate” and “severe” pain, there was far less agreement. In fact, this group found that individuals could verbally rate their pain as “moderate” but at the same time report severe levels of interference. This means verbal descriptors under-represent the impact of pain on performance.

They also found that the cut-off point between “mild” and “moderate” pain in terms of interference with activity ranged between 2.5 – 4.5, and for moderate to severe pain between 4.5 – 7.4.  The associations between pain intensity and disability or interference were low to moderate and as a result these authors argue that it is “questionable” to translate VAS scores into verbal descriptors, because the different instruments measure different things.

What does this tell us?

It should be easy by now to tell that although we use numbers as a shorthand for “how bad is your pain?” in reality, they don’t directly translate the “what it is like” to have pain. Neither does the VAS correlate well with measures of disability or interference from pain. While people with mild pain might be also experiencing only a little disability, when the numbers go up the relationship between intensity and function disappear.

I think we might be trying to quantify an experience as a quick way to make clinical decisions. Really, when we ask “how bad is your pain”, depending on the context, we may be asking “do you need pain relief?”, “do you need help to move?”, “did my treatment help?” or any myriad other questions. The trouble is in research, we can’t do statistics nearly as easily on a “yes” or “really bad” or “it didn’t change much” answer. But how many of us work routinely in research settings?

I wonder whether it’s worth asking ourselves: do I need to ask for a pain rating, or should I ask a more useful question? And take the time to listen to the answer.


Anne M. Boonstra, Henrica R. Schiphorst Preuper, Gerlof A. Balk, & Roy E.Stewart (2014). Cut-off points for mild, moderate and severe pain on the VAS for pain for patients with chronic musculoskeletal pain Pain DOI:

rush hour

Men and women: we’re different.

Men are outnumbered by women when it comes to having chronic pain. I don’t know the actual figures, but in almost every epidemiological study of chronic pain, it’s women who are more likely to have chronic pain .  Despite this, women can have a hard time getting appropriate pain management – receiving instead a range of treatments for anxiety and depression (Bernardes, Costa & Carvalho, 2013).  This can mean it’s more difficult for women to recover from their pain, or to return to better functioning, but at the same time it can make the whole experience of having chronic pain rather more isolating for men.

Notions of masculinity are fairly well-defined in popular media. I used Google to search for a definition of “what is masculinity”, and this is what I found:


So imagine if you’re a man and you have chronic pain. You feel exhausted, every time you move it hurts, you don’t sleep well, you have to ask for help to do things, and on top of that when you go to the medical centre to find out what’s going on, you’re confronted by a waiting room full of mothers with preschool children, stacks of aging women’s magazines, posters of breast examination and cervical smear testing, and even the reception staff are all women!

Ahlsen, Menghoel and Solbraekke from University of Oslo in Norway have published three really interesting papers looking at the narratives of men seeking treatment for muscle pain. They point out that because chronic pain is not often linked to anything that can be identified in physical imaging, or examination, people with it can feel they’re labelled as weak, sick, whiners, lazy or faking (Ahlsen, Menghoel & Solbraekke, 2012, p. 316).  These are not the terms we usually associate with being a man!

What is it like for men to attend a pain management programme? What are they looking for from being involved in rehabilitation? Is it different from what women are looking for? All good questions because the answers will directly influence how well we as treatment providers can  meet their needs. Can we do better?

In the first study by this group of researchers, Ahlsen, Menghoel and Sobraekke (2012) identify from the outset that men attending a pain management rehabilitation centre found their experience of participating quite different from their earlier treatment experiences. While early treatment had left these men feeling isolated and abandoned, being in a chronic pain specialist service was experienced as “the best place” and for these men “finally receiving medical based expert treatment”.  This makes me wonder what it was about the early treatment that left these men feeling so alone, and furthermore, what it was about a specialist service that made the difference.

These researchers found three broad types of narrative: “rebuilding a self”, “being comforted” and “being connected” to describe how men participating in this treatment felt.

Rebuilding a self – Initially, many men experience significant loss of social role and respect. By being surrounded by experts who accompany him as he learns more about his pain and begins to engage in exercises to “rebuild” his strength and health, he can rebuild an identity without the feelings of shame that he can otherwise have.

Being comforted – Some men “just get by”, keep on keeping on, perhaps engaging in short bursts of treatment that rarely have long-term impact. Men attending a comprehensive programme that includes psychological help, can feel it is acceptable to talk about what it is like to have chronic pain but not be able to grieve. Being able to talk about these otherwise hidden effects of pain provides comfort and support.

Being connected – Some men experience being “pushed from pillar to post” as each health professional has trouble clearly identifying what is going on. For some men this feels like no-one really knows what is going on, and attending a pain management centre becomes the best way to put all the pieces of the pain puzzle together, connecting each part to the whole, to make meaning of what is going on. By being connected again, he can solve his need for support, the company of others, and make progress.

In a second study by Ahlsen, Menghoel and Sobraekke (2012), stories men tell of having chronic pain and trying to make sense of what is happening is analysed using a narrative theoretical framework. This approach to analysis views what people say as attempts to make meaning on their experiences by telling them as stories, interpreting their experiences by looking back to the past, and projecting into the future as we do when we tell stories.

In this study, men describe working very hard in demanding environments, having difficulty with physical limitations, struggling with what is happening in their personal lives but trying to explain these events in terms of “objective facts” such as heredity, physical events, and the demands on them – but relatively little about what it is like to be men with pain. In other words, the narrative of being a man with pain is to try to “be rational”, to “be self-controlled”, to “be a man”. Because, of course, big boys don’t cry.

At the same time, we can interpret, as Ahlsen, Menghoel and Sobraekke (2012) do, that men actually DO feel vulnerability, loss, distress – but have difficulty being able to express this within the kind of stories we expect men to tell, and the kinds of roles men are thought to play in our society.

The lucky last in this trio of papers about men and pain, Ahlsen, Bondevik, Mengshoel and Solbraekke (2014)  present a further study of gender in rehabilitation, and argue that women’s stories demonstrate the ways they are trying to “transcend” their former identity, moving from experiences of chaos towards becoming more autonomous, while men’s stories tend more towards attempts to “find a solution”, often more closely aligned to a medical context in which they saw themselves with a future that depends on receiving health care.

This is at odds with the way we see male and female healthcare seeking. Most times, we see more women than men seeking treatment, with men being stoic (perhaps even stubborn?!), and trying to manage their health alone without help.

Why is this important?

So much of health research especially in chronic pain, is viewed in terms of biomedical and psychological frames. The social is rather less studied. Gender identities are both biological but also socially determined. The ways we view men and women depend on our own constructs of what it means to be a man or a woman in our own sociocultural setting.

Most of our healthcare culture, particularly a biomedical one, is focused on ways to “get rid of pain” or the source of the pain, to help people “return to normal”, to “get better”. As these authors put it, to enact a “restitution” story where people go through chaos, make sense of it all, put it all back together and get on with life, independent once more ( Ahlsen, Bondevik, Mengshoel and Solbraekke, 2014, p. 361).

From the studies these researchers have conducted, it seems that men tend more towards a slightly different story – I seek help, it gets fixed, and I go off – but I continue to have need for health professional support.  Maybe men in particular need to have the legitimisation of their pain through getting a label from a health professional to help them justify their decision to reshape their ideal of masculinity. The men in these studies seem to need to find a way to get “independence and control” that is so important in our society’s version of masculinity.

What does it mean for us?

I can’t pretend that reading these studies is easy. I’m a woman, I live in a world in which being a woman or a man is infused with all manner of expectations, and because I’m embedded in it, I don’t always notice that this is what’s happening. Culture is like that: it’s about what feels “normal” – until you’re confronted with something that doesn’t fit.

What I think it means for me is to learn much more about ways we can help each man learn to reframe what it means to be masculine in his own mind.  Is it OK for a man to ask for help? Is it OK for a man to need support? What is it like for a man to identify as someone who can’t “do it all”? To have a body that doesn’t “do what it should”?

Can we help men put their own puzzle of pain together? Do we need to look at the language we use? Perhaps part of the current explosion in “pain neurophysiology education” is one way that men can feel that their pain is understandable, that it’s not their personal weakness but it’s just how their body functions? Instead of messy emotional stuff, perhaps learning about the mechanics of pain neurobiology is a little like learning about a complex computer or machine.

Do we need to think about the language of rehabilitation too? What of the focus, for men, on how their bodies function? Should we think more about gently encouraging men to look at accommodating a different body, maybe reduce the talk of a “battle” against pain, “overcoming” pain, the narratives of “fighting with” or “winning”?

Against a pain problem that revs itself UP when people begin pushing against it, do we need to move towards a more Zen notion of fluidity, power expressed as going with, flowing – perhaps a more appropriate model of martial arts like Tai Chi, Qi Gong, or even Aikido?


Ahlsen, B., Bondevik, H., Mengshoel, A., & Solbrække, K. (2014). (Un)doing gender in a rehabilitation context: a narrative analysis of gender and self in stories of chronic muscle pain Disability and Rehabilitation, 36 (5), 359-366 DOI: 10.3109/09638288.2013.793750

Ahlsen, Birgitte, Mengshoel, Anne M., & Solbraekke, Kari N. (2012). Troubled bodies-troubled men: A narrative analysis of men’s stories of chronic muscle pain. Disability and Rehabilitation: An International, Multidisciplinary Journal, 34(21), 1765-1773.

Ahlsen, Birgitte, Mengshoel, Anne Marit, & Solbraekke, Kari Nyheim. (2012). Shelter from the storm; men with chronic pain and narratives from the rehabilitation clinic. Patient Education and Counseling, 89(2), 316-320.

Bernardes, Sonia F., Costa, Margarida, & Carvalho, Helena. (2013). Engendering pain management practices: The role of physician sex on chronic low-back pain assessment and treatment prescriptions. The Journal of Pain, 14(9), 931-940.

spring popped in today

“If I do that, I’ll be in more pain and won’t sleep and …” Tampa Scale of Kinesiophobia reformulated
The fear avoidance (or pain-related fear and avoidance) model has given the clinical pain management community much to think about. Based on the “phobia” paradigm, the model has helped clinicians think about ways to engage people with pain in activities that they’ve previously avoided by identifying exactly what it is the person is concerned about, then using a graded exposure approach so individuals learn that they can do these things while dealing with the associated anxiety they’ve developed.

I’ve had some problems with the usual measure of kinesiophobia: the Tampa Scale of Kinesiophobia (TSK). I have usually seen people many years after the onset of pain, and by then they’ve mainly heard the explanations for their back pain (or other pain), and can recite the “hurt does not equal harm” mantra off by heart. On the TSK they don’t score all that highly. Yet they’re very disabled, avoid doing anything that might exacerbate their pain and remain extremely distressed. They know what to say on an assessment, but in the real world they’re no better off.

The TSK has been used for many years now as a good measure of kinesiophobia. Usually scores of above 45 (from a possible 68) suggest that the person has beliefs that their pain represents ongoing damage (Somatic focus) and that they should avoid doing anything that provokes pain (Activity avoidance).  High scores have been associated with a wide range of negative outcomes including pain intensity, disability, distress – and in a wide range of individuals including people with chronic low back pain, acute low back pain, osteoarthritic knees and hips, shoulder pain and so on.  Originally the measure was believed to tap into the idea that pain represents damage or harm, and also to measure the belief that activities should be avoided.

In people who have been well ‘educated’ in pain neurophysiology, intellectually they know that their pain isn’t about what goes on in the tissues, so they may score fairly low on the Somatic scale of the TSK. Yet they avoid – and when asked about this, they say things like “I know if I do things it’s going to increase my pain and I’ll have a really bad night’s sleep” or “I’ll have a rotten day” or “I’ll be grumpy with my kids”. It’s not the potential damage that’s the problem – instead the problem is really about the way they see that pain will get in the way of what they want to do.

While I know this from taking time with individual patients, as far as I know there haven’t been many studies examining the meaning of pain in those people who DO score highly on the TSK, so I was very glad to read Bunzli, Smith, Watkins and colleagues (2014) paper still in preprint on a mixed methods study looking at exactly this.

What did they do?

Participants with chronic low back pain were recruited from a larger study.  Thirty six people were interviewed one month after they had completed the TSK, and asked “Tell me your pain story”, and then more detailed examination of exactly what individuals believed about their pain was conducted. The interviews were conducted by Samantha Bunzli, a PhD candidate and physiotherapist, as part of her PhD studies.

What did they find?

Firstly, many people in this study believed that pain during activity will damage them. Participants used words and explanations they had often heard from other health professionals to substantiate their belief that their backs are vulnerable, their bodies prone to damage, that they were inevitably going to deteriorate. Interestingly (but not unexpectedly) people with health training who were purposively sampled to be part of this study, also held strong beliefs that their backs were structurally damaged and without a diagnosis that fit with their beliefs about back pain, they were worried that pain was equal to harm.

Secondly, people believed that doing things that hurt would increase their suffering and result in greater interference or functional loss. Things like “I know if I do the wrong movement, the pain will get worse… Cos I know how bad the pain is and I don’t want to aggravate that area because I know that will cause the pain.”  Some felt helpless in the face of pain, and because of this avoided it. Others pointed out that if they had an exacerbation it would mean ongoing disruption to life for a long time or over many different aspects of life such as sleep, work, family life.

Quantitative analysis

Participants with high harm beliefs were selected into one group, and their TSK responses analysed. This group scored more highly on the Somatic focus scale than the participants who described pain avoidance beliefs (functional loss, suffering). Interestingly, people with beliefs that pain represented interference/functional loss didn’t score more highly on the Activity avoidance subscale.

What does this mean?

Most interventions using high TSK scores as their primary guide to inclusion involve graded exposure to reduce fear, and lots of behavioural testing and personalised information to help reconceptualise their pain as no longer representing damage. This won’t work for people who are fully aware their pain doesn’t mean damage, but instead are concerned about the broader  effect of pain on their lives. To me this suggests that the greater problem for these people is helping to increase their self-efficacy for dealing with pain fluctuations. Personally I like the Acceptance and Commitment Therapy (ACT) approach for helping this group of people.

To be able to nonjudgementally notice pain, then remain on track to do what is highly valued to me seems a good way for this group of people to deal with their avoidance of pain intensity fluctuations. As Crombez. Eccleston, Van Damme, Vlaeyen and Karoly (2012) say pain is “more than a sign of bodily harm; it is an obstacle to be coped with in the daily pursuit of valued activities and goals that matter” (p.477).  In my study, people who cope well with pain negotiate this delicate balance between exacerbating pain vs remaining engaged in important occupations by using “flexible persistence”. This is a process of planning and managing what is important at that time and in that context by using the entire repertoire of coping strategies people possess.

I can’t quite support Bunzli and colleague’s suggestion that “it is important that interventions not only target beliefs about pain, but also focus on the development of pain control strategies that are linked to individuals functional goals.” Well – actually I can to a point. Interventions must target beliefs and link interventions and strategies to functional (occupational, please!) goals – but to try to control pain is like holding onto water in your cupped hands. Yes, you can do it, but it’s frustrating, you don’t get much for the effort you put in, and it means you can’t do much else at the time. Control isn’t the answer to me: learning to accept and be willing to make room for pain might be a more useful approach.

A great study by Samantha Bunzli and co – and as a nearly-PhD myself, I love that she’s asked an interesting question, discovered some important new stuff, and got it out there where we can learn about it.

Bunzli, S., Smith, A., Watkins, R., Schütze, R., & O’Sullivan, P. (2014). “What Do People who Score Highly on the Tampa Scale of Kinesiophobia Really Believe? A Mixed Methods Investigation in People with Chronic Non Specific Low Back Pain The Clinical Journal of Pain DOI: 10.1097/AJP.0000000000000143

Crombez, Geert, Eccleston, Christopher, Van Damme, Stefaan, Vlaeyen, Johan W., & Karoly, Paul. (2012). Fear-avoidance model of chronic pain: The next generation. The Clinical Journal of Pain, 28(6), 475-483.