Balance, control & passion

Yesterday a couple of colleagues were talking about balance in life, and making it plain that they think people who spend a lot of time and energy on their work are sad.  Their opinion? Work is the means to pay for your ‘real’ life, to spend more on working means less on what is really important to them. And musing on this, as I do, I thought about values and what we bring in to pain management and how this influences our practice.  It also started me thinking about the goals and values of the people we see with chronic pain and disability.

One way of looking at the distress and disability associated with chronic pain might be to think of it as a result of conflict between what can be done (resources) and both values (what is important) and goals (how I want to express my values).  An ongoing problem with life itself is the limited resource we have to do what we want!  The whole of life is really about this balancing act.  And I suspect that one of the major sources of distress for people with chronic pain is that they carry on using the same strategies to express values but with limited resources to achieve it.

I’m not the only one to think of it this way – several authors have talked about the concept of ‘psychological flexibility’ (McCracken & Vowles, 2007).  Psychological flexibility involves several processes such as acceptance, mindfulness, values, and cognitive defusion.  This is a bit of jargon from ACT (Acceptance & Commitment Therapy) and basically means being able to allow oneself to experience all that life brings, while at the same time choosing to act according to what is important and valuable to you – and being prepared to alter the way in which this is achieved, depending on the situation.

So one way of looking at people with disability from their chronic pain is that they are stuck.  Stuck using old and unhelpful ways to achieve what is important to them.

ACT and several other similar mindfulness therapies makes a point about control.  Basically, we can’t control much in life except our actions.  If we try to control our thoughts, our emotions, other people’s reactions, and events in the environment we’re doomed to use a ton of energy and probably not succeed.  We can control our actions, and we can choose to act according to our values.  BUT we can’t predict the outcome of our actions because so many other variables influence this.

CBT teaches attention to automatic thoughts, processing their helpfulness and replacing or substituting unhelpful thoughts with ones that are in line with what the person wants.  ACT can be similar in that one focus for therapy is to recognise that our thoughts are not US.  We can stand back from our thoughts, be aware of them, but at the same time remain able to act according to other important values.  One problem I have with CBT is that when my own resources are low (I’m really tired, maybe I’m a bit depressed) the energy it takes to process and evaluate my automatic thoughts can be really hard to find.  It takes a lot less energy to simply allow the thoughts to be there but not act on them and remain focused on achieving things that are important to me.

One of the problems with pain management IMHO is that patients (and therapists) often want to ‘control’ the pain, and regain control of life again.  But chronic pain is so seldom completely under ‘control’, it’s characterised by fluctuations, and we risk focusing on trying to prevent pain from fluctuating by talking about ‘controlling’ pain. Actually what we are trying to achieve in pain management is living according to what is important (valued) and being flexible enough to find ways to achieve this despite pain. Pain itself can become irrelevant, a bit like being too hot or too cold, or being in a noisy or smelly environment.

I am clearly a very sad person, because one of my passions is learning about pain and pain management.  It’s also my work.  I love spending time reading about pain management, I obviously blog about it, I talk about it, I use the skills personally every day, and I get to work with people who have chronic pain.  I’ve learned I can’t control my own pain, but it can be irrelevant ‘noise’ that doesn’t need to distress me.  What’s important to me, and what I value, is being able to keep on learning, keep on sharing what I’ve learned, and to live a life that is balanced – for me!

What this means is that there are times when I choose to act according to what is important to me, despite my own thoughts (which might be automatic, and wanting affirmation from people that I’m OK and not ’sad’), and despite my own energy levels.  To be able to choose whether I persist with some things and drop others, knowing that I’m living out my important values gives me that freedom that we call ‘being in control of my own life’.

It looks, from the literature, that being flexible, being able to accept what is without judging, to hold onto specific goals lightly and to act in line with our values makes an enormous difference to wellbeing.  I hope that in pain management we can help people live well, maybe ACT is another way to do so.

I’ll leave you with this saying from my shopping list jotter:

‘The world is full of people who will go their whole lives and not actually live one day.  She did not intend to be one of them.’

Yes, that’s me!

MCCRACKEN, L., & VOWLES, K. (2007). Psychological Flexibility and Traditional Pain Management Strategies in Relation to Patient Functioning With Chronic Pain: An Examination of a Revised Instrument The Journal of Pain, 8 (9), 700-707 DOI: 10.1016/j.jpain.2007.04.008

GUTIERREZ, O., LUCIANO, C., RODRIGUEZ, M., & FINK, B. (2004). Comparison between an acceptance-based and a cognitive-control-based protocol for coping with pain* Behavior Therapy, 35 (4), 767-783 DOI: 10.1016/S0005-7894(04)80019-4

How do you establish who will do well with pain management?

Some people just won’t do well with pain management.  In just the same way as a surgeon selects good candidates for surgery, so people need to be selected for self management.  Although there is some truth that getting even a little pain management is good for everyone, the cost of doing so in staff energy and the effect on other participants can make it a very unrewarding task.

How do you work out who is in and who is out?

I’ve used a ‘readiness for change’ model, following Prochaska and diClemente’s ’stages of change’ approach for some time now.  This uses the idea that if we work with people at their level of readiness, we’ll reduce resistance to our efforts, and we can target our approach to suit.

The problem with this lies in trying to establish just what they’re ready for – there’s a huge difference in approach needed for someone who is contemplating beginning to exercise but is precontemplating returning to work!  Self management is no simple behaviour change choice, it’s a whole series of changes in most areas of a person’s life.

Another approach is a ’stepped care’ approach, where everyone gets the same initial management, and as their recovery progresses (or not as the case may be), new and more intensive initiatives are introduced.  So everyone who fronts to a primary care clinicians gets ‘reassurance and advice to gradually return to normal activity’ for an acute low back pain.  If the person isn’t making adequate progress after four to six weeks, he or she might get a more in-depth assessment and targeted input from maybe a physiotherapist or occupational therapist, or a referral to a brief, functionally-oriented reactivation programme.  If this still doesn’t produce recovery and return to function, a more intensive approach with psychological or psychosocial input can be introduced until, after a long time, the Big Guns of an interdisciplinary pain management programme get brought out.

Recently there have been some interesting studies looking at more detail at the characteristics of those who seem to do well despite experiencing chronic pain, versus those who don’t do so well.  Some unsurprising results in some instances, with Foster, Thomas, Bishop, Dunn & Main (2009) finding ‘Patients’ perceptions that the problem will last well into the future, that many symptoms are related to their back problem, their weak beliefs about personal controllability and low confidence in their own ability to perform normal activities despite the pain‘ predicted disablity at six months – and somewhat surprisingly, found that fear avoidance, depression and catastrophising didn’t predict so well.

This is truly interesting, because it demonstrates that the factors that are identified in people later in the life of their pain may not be the same as those in the earlier stages.  It’s also interesting because once again, it’s patient’s perception of the effect of the problem, and their sense of helplessness and lack of control that predict disability. Perception is reality.  (I say this, because self efficacy has been found to be such an important indicator of whether someone returns to work – if they think they can, they probably will; if they think they can’t, they probably won’t)

Foster, Thomas, Bishop, Dunn & Main point out that this finding suggests that two models related to health are implicated: the self-regulatory model and the self-efficacy model.  In both, where an individual views their situation as helpless, and a future with pain and problems is inevitable, the person begins to become passive, inactive, doesn’t engage in coping behaviours, and doesn’t follow advice to remain active despite pain.

In another recent paper by McCracken and Zhao-O’Brien(2010), a concept of psychological flexibility, or the ability to accept and experience negative emotions, was found to be related to wellbeing and disability in people with chronic pain.  Their paper suggests ‘when people with chronic pain are willing to have undesirable psychological experiences without attempting to control them, they may function better and suffer less. General acceptance may have a unique role to play in the disability and suffering of chronic pain beyond similar processes such as acceptance of pain or mindfulness.’

This is another aspect of how an individual presents that might be important to identify when deciding who is ready for and will benefit from developing self management skills.

The problem is that it’s precisely those people who are not psychologically flexible, who lack effective self-regulation and have low self-efficacy, and who are not ‘contemplating’ self management who really need the input!  The next step is to identify how to help people move towards psychological flexibility and self regulation and self efficacy, probably through using a ’stages of change’ manner where resistance is rolled with, and our approach is tailored to help people look at their situation and see how it’s not helping them to move towards what they want.  That is our mission.  Next thing is world peace!

If someone is not ready for self management – is it worth pushing this concept onto them, or is it better to ‘contain’ costs and put the effort into someone who is ready and can do well? This is an ethical judgement, but just as a surgeon chooses good candidates for surgery, maybe we need to choose good candidates for pain management.  And then be prepared to look at new and different ways for people who are not, because they’re the ones who are suffering and costing us, our economy and our health systems.

Foster, N., Thomas, E., Bishop, A., Dunn, K., & Main, C. (2009). Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care Pain DOI: 10.1016/j.pain.2009.11.002
McCracken, L., & Zhao-O’Brien, J. (2010). General psychological acceptance and chronic pain: There is more to accept than the pain itself European Journal of Pain, 14 (2), 170-175 DOI: 10.1016/j.ejpain.2009.03.004

How long does it take to get there?

With so many people experiencing long term pain and disability, you’d think health care providers (and funders) would be doing all they could to make sure referrals to specialist centres were made as early as possible – and yet it’s still just not happening.  I took a brief look through the referrals to our tertiary pain management centre recently, and apart from finding that over half of the referrals were for people who had already been seen by us, the majority of the rest were for people with ongoing pain for more than 12 months.  In fact, although I didn’t calculate it, the ‘average’ pain duration varied between 8-9 months and over 10 years, roughly 3 or 4 years being the modal time. That’s a long, long time for someone to be seeing doctors for treatment before being seen by an interdisciplinary team.

Why does it take so long?

Good question, and not one I think to which many clear answers are found.  Maybe it’s reluctance on the part of the person being referred – chronic pain sounds horrible, and there are always mixed reviews from people who have been seen at Pain Management Centres.  Sometimes the results are mixed, depending on what the person is looking for from a referral to us.  If they’re wanting pain reduction or abolition, I guess they will be disappointed.

But I think more of the problems lie with the continuing emphasis on ‘finding a cure’, or the belief that chronic pain is only a symptom of ’something else going on’. The search for that ’something else’ to be treated takes people away from the focus on reducing the impact of the pain on function (ie disability) and fixates them on reducing the pain intensity alone.  A positive outcome is confined to removing the pain rather than looking at reducing the effects of the pain on the person.

After some 20 years in pain management, I’d hoped that this view might have changed, and I suppose it has to a certain extent.  There are not quite as many people attending with multiple surgeries, but instead we have people coming in with multiple injection interventions, on multiple medications, and STILL with a belief that pain equals something terrible is ‘making this happen’ that ‘must be removed’ before the person can start to get back into life.

Why is a delay such a problem?

Lots of reasons, but here are some that strike me off the top of my head:

• the emotional and social costs to people with pain from having daily activities limited by pain
• the time it takes to go to appoinments and the waste of resources being spent by the person and their family
• the multiple failed treatments and the effect this has on the person and their family
• the myriad diagnostic labels the person gets from the treatment providers – without necessarily hearing that their pain doesn’t equal harm
• the opportunity for the person to get trapped in a downward cycle of not doing much, then not feeling like doing much, then not being able to do much
• the cost to the health care system from repeated failed treatments
• the eventual cost to the health care system because interdisciplinary pain management often takes longer with someone who has had years of disability from their pain
• the financial and economic costs of pouring money into being ‘ambulances’ at the bottom of the cliff – job loss, family stress, other ill effects of not working, flow-on effect throughout the health system

The sad thing is, this long delay isn’t isolated to New Zealand.  In fact, I’d say it happens right around the world and will continue until I’m long gone.  It’ll take the medical model to be well and truly ditched in the case of chronic pain, it’ll take the negative stereotyping of mood and chronicity to be removed, it’ll need a huge investment in funding for chronic disability services, and it will take training for health care providers to know what to do and get the focus off the pain intensity and on to the disability from pain.

This paper from Bonezzi, Pitino, Allegri (2010) shows the same situation in Italy.  Their analysis shows patients were an average age of 62 years, while the referrals to Pain Management Centre are more in the mid-40’s or 50’s.  Their pain intensity rating was 7-8, pretty similar to those who are referred to us.  And like our patients, they’d been to see numerous specialists who ‘did not focus on the pathogenesis of pain but only on the disease underlying it’.

Their parting comment strikes true here also: ‘a suboptimal approach to pain management in Italy not only relative to its correct treatment (too few and sometimes inappropriate drugs prescribed), but also because there are too many patients who do not have access to a specialist pain centre despite being in pain. This could also be one of the main reasons of the increase in health care costs related to pain treatment.’ Worth thinking about, isnt’ it.

Bonezzi, C., Pitino, E., & Allegri, M. (2009). Analysis of a population of patients who were referred to a second level pain center: Clinical and demographic characteristics European Journal of Pain Supplements, 3 (2), 17-20 DOI: 10.1016/j.eujps.2009.08.003

Friday Funnies!

Oh yes, it’s back again – Friday Funnies, and more opportunities for me to ‘treat’ you to my warped humour.  My apologies in advance.

First up, a quick quiz…

Can you cry under water?

How important does a person have to be before they are considered assassinated instead of just murdered?

Why does a round pizza come in a square box?

How is it that we put man on the moon before we figured out it would be a good idea to put wheels on luggage?

Why is it that people say they ’slept like a baby’ when babies wake up like every two hours?

Why is ‘bra’ singular and ‘panties’ plural?

Why do toasters always have a setting that burns the toast to a horrible crisp, which no decent human being would eat?

Why, when you blow in a dog’s face, he gets mad at you, but when you take him for a car ride, he sticks his head out the window?

Our manager is keen to help us develop teamwork – perhaps this would work?

The loaded mini-van pulled in to the only remaining campsite. Four children leaped from the vehicle and began feverishly unloading gear and setting up the tent. The boys rushed to gather firewood, while the girls and their mother set up the camp stove and cooking utensils.

A nearby camper marveled to the youngsters’ father, “That, sir, is some display of teamwork.”

The father replied, “I have a system. No one goes to the bathroom until the camp is set up.”

Oh, I forgot – that’s why meetings are so long.  (on a more serious note: this is a good, albeit simplistic, paper on teamwork in health settings)

’nuff for today, except to leave you with something from my travels in Molesworth Station.

A wish list for a pain management programme

After coming up with some of the content and structure for a programme, and discussing the need for a stable clinical team with effective skills in group-based CBT and an applied behavioural focus, today I thought I’d add in something about selecting, assessing and follow-up that’s required.

I get absolutely frustrated with reading and hearing about interventions that are either not required to furnish, or don’t consider outcomes – both psychometric questionnaire results (thought to indicate change in the ‘real world’) and real world outcomes.  The art of making sure that what we do makes a difference, and knowing how to do this well seems to be quite lost on many clinicians and it really frustrates me.  I’d find it professionally unsatisfying if I carried out an intervention and never had a clue as to whether it made a difference long after I’d finished seeing the person, so I can’t understand why so many clinicians (a) don’t measure outcomes (b) measure them poorly either through inadequate pre-treatment measures, inappropriate timing of post-treatment measures, or using irrelevant measures (c) measure outcomes using only psychometric questionnaires, or unidimensional measures.

I’ve mentioned outcomes first because part of selecting people for a programme is about taking baseline measures so that you know where you’re starting from, and you can ensure the programme is appropriate for the person’s needs.  Selection also includes identifying the person’s readiness to move towards self managing pain, because if someone’s not ready they can become resistant (just think of all the ways people avoid doing what they don’t want to do! And include yourself), become ‘innoculated’ against the concepts (‘tried that, it didn’t work’), and influence group process negatively.

Just as a surgeon selects people for surgery after careful assessment, and declines surgery for people who are unlikely to benefit from it, so we need to be similarly selective in pain management.  Pain management programmes are not ‘the last resort’ after everything has failed, they are a positive step forward for people who need to and want to take over the management of their own situation.  Like any other self management programme like alcohol and drug rehabilitation, until the person is ready to do what will be very difficult and life-long, it’s unlikely they’ll benefit.

Every participant for a pain management programme needs to be comprehensively, and recently, assessed from a biopsychosocial perspective. Medical issues need to be managed before programmes commence, and the person needs to be reassured that they are safe to begin to do things again – and I’m afraid, this almost always needs to be reassurance from a doctor.  Psychsocial issues influencing the person need to be identified – note the word psychosocial. Without considering the social it’s unlikely the situational and contextual factors that often constrain behaviour change, including things like litigation, family, case management issues and work issues.  These factors influence beliefs, attitudes, behaviours and emotions and it’s critical that the person is seen as one person within a whole network of others.

When screening to establish readiness for pain management, other factors to consider are concurrent activities like vocational management, other investigations and pending treatments, evne things like holidays and training.  Some of the other areas that might make it difficult for someone to participate are communication style, cognitive functioning, learning style, fatigue, activity level, and needs that don’t ‘fit’ with the majority of the programme participants and content or structure.

I’ll post a screening semi-structured interview later today, that I’ve used to help identify whether a participant is ready and appropriate for a group pain management programme.

All participants need to have some baseline measurements taken before a programme.  In fact, there should be one set at comprehensive assessment, and a second set before a programme, another set at completion of the programme, then at least two, but preferably three times after – I think 1, 4 and 9 months later, or thereabouts.  As time progresses, the intervening variables confound outcomes, and the number of respondents also drops, so it can be a challenge to obtain enough responses and for them to reflect programme changes over time.

What to measure and how?  I’ll leave that for another day, suffice to say that questionnaire results are not enough.  Not that they’re unimportant, because they are – but until they have had predictive validity established within the community in which your patients live, they may not reflect much useful information.  Real world actions are far more valid, but are much more difficult to measure accurately – on the other hand, I think I’d like a valid measure that actually measures something important and useful, than to measure something irrelevant but do so incredibly accurately.  Otherwise we could all give participants a blood test for glucose levels and be done with it!

References?  Loads and loads of ‘em.  Where do I start?

The first and probably most comprehensive reference is either of the two editions of Pain Management: Practical applications of the biopsychosocial perspective in clinical and occupational settings by Main, Sullivan & Watson.  The first edition was by Main & Spanswick, it’s a Churchill Livingstone publication under the Elsivier imprint.  The first edition contains almost a ‘recipe’ for how to run this type of programme, while the second edition contains more conceptual material but provides excellent information to support clinical practice.

Further references:

Fordyce, W E (1976). Behavioral methods for chronic pain and illness.  CV Mosby, St Louis, MS.

Turk, D, Meichenbaum, D, Genest, M. (1983). Pain and behavioral medicine: a cognitive-behavioural perspective.  The Guilford Press, New York.

Loeser, J., Sullivan, M. (1995). Disability in the chronic low back pain patient may be iatrogenic. Pain Forum, 4: 114-121

Main, C., Parker, H. (1989). The evaluation and outcome of pain management programmes for chronic low back pain.  In Roland, M., Jenner, J. (Eds.) Back pain: New approaches to rehabilitation and education.  Manchester University Press, Manchester, pp 129-156.

Keefe, F., & van Horn, Y. (1993). Cognitive-behavioral treatment of rheumatoid arthritis pain maintaining treatment gains Arthritis Care & Research, 6 (4), 213-222 DOI: 10.1002/art.1790060408

A wish list for a pain management programme

As I review the last few people I’ve had the privilege to assess, I can see numerous factors that have lead them down the road to chronic disability from their persistent pain.  One of the most common would have to be multiple medical assessments with medical management that has failed to address the person’s disability, while in some cases actually increasing the person’s beliefs that they are not in control of their lives.  An example? A man I saw who, four years after the initial event firmly believes the annular tears must ‘heal’ before he can return to work.  Two orthopaedic surgeons indicated to him that surgery wasn’t an option (and he didn’t want it anyway) but also advised him ‘these things take time to heal’ – or at least that’s what he heard.

Another reason for ongoing disability is the failure of pain management programmes to address the person’s beliefs about pain.  As Bill Fordyce is reported to have said ‘Information is to behaviour change as spaghetti is to a brick’ – hence my concern when I read a very authoritative book written by three highly respected clinicians and researchers where ‘education’ is the term used for the process of helping the participants develop a new understanding of their pain and their role in managing it.

Education, information and teaching are often words used around the concept of helping people reconceptualise their pain.  Sadly, without very good skills by the clinician, this can turn into an ‘information dump’ and leave the participants only slightly less confused than before!  The processes that seem to work better involve ‘guided discovery’ or Socratic learning, and experiential learning with the opportunity to reflect.

There are arguably four broad groups of techniques for helping people to understand their pain and their role in pain management for themselves.

1. Learning the various connections between thoughts, situations, and emotions
2. Gathering evidence from their own experience, and becoming more objective about the patterns of thinking that each person has
3. Using mini experiments to try different approaches out
4. Exploring underlying beliefs and assumptions

This process is collectively called ‘collaborative empiricism’ where the participants and the facilitator join together to explore experiences and understand what is going on.  In a group setting this becomes a process where the participants both become exposed to their own processes, but also the processes of others – and by the end of the programme, become adept at being therapists for one another, asking questions rather than giving advice or feedback.

The process of helping participants become their own therapists is not easy.  It requires the facilitator to be very knowledgeable about pain in order to correct myths, and it also requires the facilitator to be very adept both with Socratic questioning and guided discovery as well as group facilitation.  No wonder facilitators get tired after a group session!

Often, clinicians who get involved in pain management group programmes come from a background of clinical psychology or occupational therapy.  Unfortunately, having professional registration does not mean that the clinician has specific skills or training in pain management or group facilitation.  It does take time to develop these skills.  Unfortunately in the literature on pain management within groups, there is a real dearth of research looking at the necessary skills clinicians require to help develop effective group therapy.  Instead, the majority of research into cognitive behavioural approaches for pain management is carried out by psychologists, with the assumption that this training is sufficient.  It’s great to read in Main, Sullivan and Watson’s book Pain Management 2nd edition (2008) that the skills required are emphasised rather than the professional discipline.  Certainly many other health professionals have specific training and skill in group therapy, amongst them social workers and occupational therapists.

Something that has been investigated very recently is the stabiliy of membership within a clinical team working in group pain management.  Interdisciplinary teamwork has been identified as a strength in pain management – it requires that each profession become very familiar with a common model (cognitive behavioural approach within a biopsychosocial model), with each other’s strengths, and ultimately, to be able to work almost across disciplines to support each other’s interventions.  This takes time.  The communication between team members must be very strong, and decision making processes including conflict resolution need to be well-established.

A paper recently available by Amanda Williams and Henry Potts looked at two factors that they thought may affect outcomes achieved after group CBT for persistent pain.  Both group membership (who the participants were in the programme) and staff turnover were examined.  The data was collected over 16 years (3050 participants), and included pre- and 1-month post-programme questionnaires.

Their findings?  ‘Linear regression showed that high periods of staff turnover were significantly
related to poorer outcomes on self-efficacy and distance walked at end of treatment, with the
effect on self-efficacy persisting to 1 month follow-up.’

I’ll discuss the group membership findings in another post, but it’s interesting to see the areas that were directly influenced by staff turnover.

Membership of the teams were ‘… multidisciplinary teams of psychologists, physiotherapists, occupational therapists and nurses, with doctors working across teams. This meant that patients usually related mainly to a core team of four staff members, but up to seven if staff were part-time. The inpatient treatment programme remained largely consistent in content and process over the years covered by this study.’

One of the psychologists, one of the physiotherapists and one doctor remained constant throughout the study period.  New staff were usually less experienced than those who had left, and worked under supervision for several weeks before commencing with the programme.

The results showed ‘for each change in staffing, patients on average had a PSEQ score that was 1.2 points lower, a Normalized catastrophizing score that was 0.04 standard deviations higher, and walked 4.6 m less at the end of treatment.’

Some very useful ‘managerial’ aspects are considered in this paper: Therapist emotional wellbeing has been reasonably consistently related to better outcomes.  The treatment unit had periods of strengthened institutional support and growth and others when its future was uncertain. It is likely that these difficult periods were reflected in poorer team cohesion as well as in turnover, and that staff who were expending energies on the unit’s survival had less to offer patients.

I wonder what steps organisations take to address these issues, particularly when calls to ‘be efficient’ often demand therapists see more patients in less time.  In the end, outcomes are what matters – what is the point of seeing a large volume of patients, only to have them return as re-referrals later?

It’s clear that a combination of the right treatment for the right patient is important – but it seems equally clear that the role team members play, the level of skill, the level of support and the team processes are also important.

Williams, A., & Potts, H. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain Pain DOI: 10.1016/j.pain.2009.12.011

RTW and ACC in New Zealand – RTW Matters Analysis

This just in from RTW Matters – Dr Mary Wyatt analyses the New Zealand RTW Monitor results and makes her predictions about whether, in the light of financial pressures and declining RTW rates, NZ  is in for a RTW thaw or a snap freeze.  It’s available only for subscribers, but here’s a brief summary… (oh and subscription isn’t much in financial terms but packs a punch in information terms!)

• RTW rates are declining in both New Zealand and Australia

• ACC indicates that this is because of ‘a number of factors, including the ageing population, the increasing complexity of claims, and claims management inefficiencies. The resulting impact has meant that clients are staying on the Scheme longer and costing more.’

As an aside, I wonder how it can be that claims are becoming more complex?  Can someone enlighten me?  Certainly I don’t see this in pain management: people with chronic pain are, almost by definition, complex, and this has not changed on iota in the 20 years I’ve been working in pain mangement.  The only significant changes I’ve seen are that fewer people are attending for pain management with multiple surgeries, and more people are referred slightly earlier than the previous pain duration of 3.5 years.

• The focus of the Government for ACC is cost containment

• The ACC has taken the common scheme approach of dealing with financial problems by trying to moving long-term claimants out of the scheme.  Long term claimants are the most costly part of any scheme, and removing them is the most cost-effective ways to deal with cost blowouts.

• Mary Wyatt points out that one strategy used by ACC to do this is the increasing use of FCE to ‘predict’ whether someone can return to work.  As she says, ‘As a tool to define a person is having a work capacity and therefore no longer being eligible for scheme payments, they may be an effective, however this does not mean they are valid.  Moving people on from the system after a few years is basically declaring a failure of rehabilitation.  If they are capable of returning to the workforce at that point, why haven’t they done so earlier?’

I’d mitigate this last statement by saying that because of legislation, economy and fear, amongst other reasons, people who are ‘fit to work’ in some capacity may not always obtain employment, hence the ‘work testing’ or ‘vocational independence assessment’ that ACC conducts in New Zealand.  The intention of the legislation is not ‘return to work’ but ‘return to work readiness’.  The end of rehabilitation assessment is a slightly different approach from some areas of the world and consists of:

(1) a review of the assessment recommendations that have been made over the course of the claim to establish whether all rehabilitative efforts have been completed

(2) a vocational assessment that details the work options a person may be able to do given ‘education, training and experience’ – without considering functional ability

(3) a medical assessment that reviews the medical status of the person and, in collaboration with the person reviews the various work options to establish whether he or she can sustain ‘35 hours or more’ in any of them

For those unfamiliar with New Zealand legislation, there is no ability to litigate for personal physical injury, as ACC provides 24 hour ‘no-fault’ cover forpersonal physical injury for all people whether working or not, funded by levies from employers, employees and various other taxes.  It was first introduced to New Zealand in 1974, and has continued to be a model for many commentators on accident compensation.

It’s difficult to establish why rehabilitation ‘performance’ appears to be less effective than previously.  I can only observe that management of claims is often fragmented, that multiple treatment providers are often involved with quite contradictory aims, that contracts for services to claimants appears very prescriptive and often clumsy, and that case management can be quite different depending on the individual case manager working on a claim.  Perhaps one factor could be the increased use of ‘multidisciplinary’ pain management but using teams of clinicians who rarely meet, may not have any specific education, training or experience in pain management, and who’s membership changes often, and within a programme framework that may be ‘pain management lite’ – or less than the recommended 50 – 100 hours of consolidated input (Main, Sullivan & Watson, 2008).

Back to RTW matters – as a taster, take a look at the free information available, and make your own mind up about its value.

Main, C., Sullivan, M.,  & Watson, P.  (2008). Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings. 2nd Ed. Churchill Livingstone, Elsevier, Philadelphia.

If you were designing a pain management programme from scratch…

… what would you include?

I’m a fan of using a group approach for pain management. Lots of reasons, but several that really spring to mind right now.

1. Groups offer participants a chance to learn from each other – this can be both good and not so good!  Provided the group is managed well, and both CBT techniques and the group process are attended to, participants become their own (and other’s) therapists. Participants often challenge each other far more strongly than clinicians, because they already have ‘face validity’ – in other words, they’re all on an equal ‘I’m in it with you’ level.
2. Groups enable each participant to be exposed to a broader range of issues and situations than individual therapy – as each participant discusses their own situation, it will be unique to them, but give an opportunity for the others to learn vicariously (by watching).  As each participant follows the process of identifying unhelpful thoughts and behaviours, becomes aware of different ways of viewing the situation and responding to it, they too learn how that might apply to their own situation (either now, or in the future).
3. Groups reduce the social isolation experienced by many people with chronic pain - by learning that their experience is not peculiar, that some people manage better while others struggle more, participants in a group can reality-test their beliefs about their own situation.  Courage can develop by watching others who cope well, and by helping others who are not managing so well, those who are managing develop more confidence in their own coping.
4. The therapist can use the group to generate coping alternatives, broadening out the range of options the group participants can consider.  Not all the options will be feasible, or helpful, but these can be examined in terms of the various outcomes, allowing the participants to arrive at their own solutions.
5. Groups provide opportunities for people to role play a range of different situations, and obtain feedback from a range of different people. This makes the learning opportunities afforded by groups broader than individual therapy.

Now, to be Devil’s advocate, there are good reasons for individual therapy too.  Some people don’t work well in a group setting, either because of difficulty communicating (hearing impairment, not speaking the language, or personality characteristics that make it difficult for a person to follow the normal ‘rules’ of social interaction), or perhaps because of cognitive or emotional problems.  Some people have very unique presentations, perhaps requiring specific therapy such as mirrorbox or exposure-based functional rehabilitation that most group participants might not need.  Others may have specific needs that others don’t, such as relationship problems or work problems.

What would it be like to combine both the best parts of group programmes with the best of individual sessions? In this case I’d like to set some assumptions about size of group and number of sessions/days a week.  I’d love to have a group of a maximum of 7 participants, meeting twice a week for about two and a half hours each time.  Two extra individual sessions of an hour for each participant, with input from therapists with both psychosocial and functional biases.  I’d like about 6 weeks to work with the participants, plus a couple of follow-up sessions one month and three months later.  And of course participants would also need to carry out ‘experiments’ where they use the skills in-between sessions.

Enough about format.  Onto content and approach.

Content is always contentious, but I’m sure there are at least four or five topics that just can’t be missed.

1. Goals and aims or purpose of pain management. Why participants are there, what they really want out of it.  Where the focus needs to be.  Most importantly, the functional activities the person wants to return to.
2. Helping people develop a personalised model of their pain, whether it be chronic or sub-acute/acute.  The various contributions of biology, psychology and sociology to that ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’ (IASP, 1979).  Working out the factors that particularly influence their pain and disability.
3. Activity regulation, or working out the optimal level of activity the person needs and helping them develop a plan for changing their activity pattern to achieve it.  This can mean increasing activity, or maybe reducing it, or even simply maintaining a consistent level of activity.
4. Working with resultant thoughts, beliefs, attitudes, behaviours and contingencies that affect how easily the person can make changes, and maintain them.

There will also be other common topics like:

• medication and how to use it well
• sleep and how to achieve it
• relaxation, breathing and mindfulness
• problem solving and goal setting
• communicating effectively about pain, including pain behaviour, assertiveness, intimacy
• working and returning to work

I think the main thing about pain management programmes is that they need to be applied. Either applied within the programme setting, or applied in everyday life.  As soon as people start to DO activities differently, the opportunity to observe how they work out, and to problem solve issues that come up as a result.  This will mean working with thoughts, beliefs and behaviours, and the responses of others (and other contingencies that operate on behaviour).

Applying pain management can be done is many different ways, I don’t think there is much agreement however, on exactly how this should be done.

Many programmes use exercise both as a pain management approach (yes, exercise helps reduce pain!) but also as a way for people to apply coping strategies.  The way people go about exercising offers a great opportunity to ‘catch’ thoughts as they occur, particularly fears about flare-ups of pain.

Exercising also offers a chance to use activity regulation – things like exercising to time rather than quantity, or to exercise consistently rather than according to pain levels – and doing these things almost always generates responses that need to be discussed so they don’t interfere with making changes in life.

But, doing exercise only and making no changes to how the rest of a person’s life is lived is just not worth it.  A person who goes to the gym or swims every day but is too scared to bend down to put on socks and shoes, or sit for more than 3 minutes, or pick up a pingpong ball when playing with the kids isn’t really managing pain and living life.  People can be very fit but still ‘disabled’.  So IMHO it’s really important to work on a daily routine that starts to include activities the person wants to do – AND needs to do.

Tomorrow I’ll add to this wish list for a pain management programme – and later in the week I’ll add in the literature to support my choices.

How to cope with pain blog carnival

How to cope with Pain’s monthly blog carnival is up and running! Take a look for a roundup of some of the pain bloggers best posts.

Rules for Doctors – and probably applicable to other health providers also

This was originally written by Dr Rob, reposted on sent from my teleportation device, pointed out to me by @amcunningham on Twitter – and deservedly republished here!
Rule 1: They don’t want to be at your office.

It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving. We work there, and being in a doctor’s office is normal to us. Not so with most patients. The spotlight is on them and their health. They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing….There is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table. The best thing to do in response to that is to show compassion.

Rule 2: They have a reason to be at your office.

They don’t come to the office to waste the doctor’s time. Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor. Why come in for a headache? Why come in for a cold?…It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in. Sometimes that reason is simple: they have terrible pain that needs to be treated. Other times, however, the reason is more subtle. When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer. If a person has chest pains, they are afraid it is their heart. On every visit I try to identify the real reason (or the real fear) that brings them to see me. I don’t end the visit until I have addressed that reason.

Rule 3: They feel what they feel.

Patients will often tell me their symptoms in a very apologetic tone. They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault. Sometimes those symptoms make no sense to me at all, and I am tempted to dismiss or ignore them. But as a physician, you have to trust your patient….Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint. I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense. If you don’t trust them, why should they trust you?

Rule 4: They don’t want to look stupid.

People are often worried that they are over-reacting. They wonder what I must think for a person to come to the office with that symptom. This is especially true of parents bringing their children in. Nobody wants to be “that mother that over-reacts to everything.” In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”

Rule 5: They pay for a plan.

What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action….They want to know what is going to be done to help. I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over – no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.

Rule 6: The visit is about them.

With all of the stresses in a doctor’s office, I get tempted to complain about things. Who better to complain to than someone who feels much the same way? But patients are paying for you to take care of their problems, not the reverse. I keep my personal gripes or frustrations to myself as much as possible.

via well.blogs.nytimes.com

Dr. Robs’ rules, initially published in NYT and on his blog in 2008 deserve to resurface in the blogoshpere every now and then.

The three questions is another way to make sure you and the people you see ‘get the message’

- what is my main problem?

- what do I have to do?

- why is that important?