Friday Funnies

Husband 1.0
Tech Support
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Subject: Service guide for husbands
Dear Tech Support:
Last year I upgraded from Boyfriend 5.0 to Husband 1.0 and noticed that the new program began making unexpected changes to the accounting modules, limiting access to flower and jewelry applications that had operated flawlessly under Boyfriend 5.0.
In addition, Husband 1.0 uninstalled many other valuable programs, such as Romance 9.9 but installed undesirable programs such as NFL 5.0 and NBA 3.0. Conversation 8.0 no longer runs and House Cleaning 2.6 simply crashes the system. I’ve tried running Nagging 5.3 to fix these problems, but to no avail.
Desperate
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Dear Desperate:
Keep in mind, Boyfriend 5.0 is an entertainment package, while Husband 1.0 is an operating system. Try to enter the command: C:\>I THOUGHT YOU LOVED ME and install Tears 6.2. Husband 1.0 should then automatically run the applications: Guilty 3.0 and Flowers 7.0. But remember, overuse can cause Husband 1.0 to default to GrumpySilence 2.5, Happyhour 7.0 or Beer 6.1. Beer 6.1 is a very bad program that will create “snoring loudly” wave files.
DO NOT install MotherInLaw 1.0 or reinstall another Boyfriend program. These are not supported applications and will crash Husband 1.0.
In summary, Husband 1.0 is a great program, but it does have limited memory and cannot learn new applications quickly. Consider buying additional software to improve performance. I personally recommend HotFood 3.0 and Lingerie 5.3.

Friday funnies!

It’s Canterbury Anniversary Day today, so the neighbourhood is all quiet, and it’s a beautiful day outside.  Forgive the dreadful funnies today – groan-inducing I know!

Emotions and self-regulation in chronic pain

I posted about the reciprocal effect of emotions on goal content and today I want to look a little further into this.

A profound statement in the paper by Hamilton, Karoly & Kitzman is this: ‘If emotional well-being influences the selection and the valuation of a particular goal, then it is likely that the relationship between goal content and affective outcomes is mediated in the social context within which a person pursues his or her goals.…Health goals that depend on cooperation from other people … may set the stage for the experience of personal distress.‘ Emphasis is mine.

And don’t we see this so often. Not only in people with chronic pain – those who set goals while seeking social validation (warm fuzzies!) and then don’t get that support or validation, are likely to feel more distressed, give up their goals and consequently feel even less efficacious. Karoly suggests in an earlier paper (1999) that there must be consideration of the ‘fit’ between goals and social resources.

A practical example might help illustrate this. A farmer hoping to return to work is learning how to set limits on how much he does at any one time. His pesonal view is that ‘a real man’ always does what is necessary, no matter the cost. He has struggled for months to feel ‘OK’ about doing less, and is highly sensitive to implied criticism – anything suggesting that he is ‘not pulling his weight’. He’s felt unaccepted by others since he stopped work, and his main goal is to get back to work and ‘be normal’. His risk is ‘overdoing’ things in order to fit in with the others at work, and as a result he has a great deal of trouble asserting himself.

A key point in terms of looking at self regulation and emotion – and relating back to the post I wrote a couple of days ago about the effect of depletion of resources to carry out self regulation – is that how a person is feeling (emotionally and in terms of energy) influences how that person chooses to spend his or her energy in pursuit of goals.

Hamilton, Karoly and Kitzman identify that managing chronic pain reduces the range of goals in terms of energy available to pursue goals, and in terms of choosing to pursue harm-avoidant goals (things that reduce pain, or the effect of pain) rather than forward-looking and intrinsically rewarding goals. At the same time, when choosing self management goals in pain management, the social context is vital because of the internal desire for us to want to be accepted, when many of our pain management goals require doing things that will have an impact on others.

For these reasons, developing appropriate goals at the beginning of pain management is fraught with tension. I’ve always reflected that at the beginning of a programme of therapy, people have little idea of the possible goals they can achieve. This is where I find the COPM (Canadian Occupational Performance Measure) both somewhat helpful and somewhat unhelpful. In this assessment, participants are asked to identify activities they ‘need to do’ or ‘want to do’, and rate them in terms of importance and satisfaction with performance. While this starts to uncover some of the practical and personal goals of therapy, it is often confounded by several factors.

• At the commencement of therapy, people are often not confident about achieving their goals from the past, and can constrain their range of goals, or reduce the difficulty of those goals to reflect this
• It’s often difficult for participants to conceptualise the need to develop skills in order to begin working towards some of these goals.  There is a parallel process in pain management of developing skills to manage pain, then applying these skills in order to achieve personally-relevant goals.
• COPM goals at the beginning of therapy may continue to constrain goal selection even when the person can now see that there are more possibilities.  The original activities identified in the assessment act as a cognitive  anchor that may need to be raised before new goals are introduced.
• The level of importance of various activities can change along the process of therapy – initially return to work may be a high priority, with developing something like activity regulation or assertiveness much lower down but as therapy progresses and the person becomes aware of other important goals, the original value placed on returning to work may reduce until these other goals are achieved.

Karoly suggests that we can liken the goal achievement process as a journey, and that how people appraise this journey (as a challenge or a demand, or both!) influences progress.  The ‘map’ or mental model of the goal achievement journey includes appraisal of self efficacy, plans, praise and criticism around progress and emotional arousal relevant to the goal (is this a goal that is exciting, or is it a goal that feels scarey).

A study by Affleck and colleagues looking at goals and progress with goals in women with fibromyalgia found that on days when pain and fatigue were at their greatest, progress toward goals was reduced by perceived barriers to goal attainment.  At the same time, days when women were feeling more pain and fatigue, they also felt less positive – and vice versa.  So it looks like the way we feel influences our perception of obstacles in the way of achieving goals, and pain intensity can influence mood, adding to the perception that goals may be unattainable and making it less likely for people to recognise that progress has been made. Women who were generally more positive in their explanatory style (ie the way they talked about their day) experienced less influence from pain and fatigue.  It pays to develop the ‘positivity muscle’!

The conclusion drawn from studies like Affleck and colleagues, and those of Karoly and colleagues, is that chronic pain may act as a constraint on engaging emotionally with the activities carried out on a daily basis in order to achieve goals – and to bias the way people view their progress negatively.  Hamilton, Karoly and Kitzman put it this way ‘people…were able to do what they needed to do, but pain made it harder and less enjoyable.’

Plenty to reflect on there, I believe, as clinicians we start to work with patients to set personally relevant goals.  There probably needs to be a real balance between allowing the person to set their own goals (bearing in mind they may set goals that are too low, but are perceived as too hard when progress is slow), and encouraging them to lift their sights a little higher (remembering that their energy to maintain engagement with goals is probably lower, and their cognitive efficiency in how they go about achieving these goals may be also low.)

I’ve said before, and will probably say again, goal setting is much harder than we often give credence to. Is it really possible to set a goal in an hour session on the first day of seeing a patient?  Especially when we are unlikely to have a good case formulation to understand what is going on, and when the person we’re working with may not have past experience with effective self regulation, and currenlty views goals negatively.  Can this be something to discuss with funders and purchasers when they draw up contracts for services? Maybe spending a little longer developing a goal could help the whole process move more smoothly, and even increase the achievement level?

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

Chronic pain management is NOT just like ‘any other chronic disease’

The other day someone said to me that managing chronic pain was just the same as managing something like diabetes, hypertension, asthma or any other chronic disease.  It irked me at the time and I couldn’t put my finger on just what it was that bothered me, but after a couple of days thinking about it I’ve got a few thoughts to share.

1. Chronic pain comes with a whole lot of misinformation that most other illnesses don’t have. Unlike diabetes or emphysema, people with chronic pain have usually spent a long time searching for a diagnosis, and have usually seen multiple health providers all with various names for what the person has, and promising some sort of cure.  Even for something as clear-cut as ankylosing spondylitis, it takes around 4 years from initial symptoms to eventual diagnosis and management.  This means that most people with chronic pain will have had a long time with hopes raised then dashed with each ‘cure’, lots of time feeling unrecognised and often mislabelled as ‘noncopers’ or perhaps even ‘malingerers’, and plenty of apprehension that every time they move they may be ‘causing more damage’.
2. Chronic pain is under-recognised within society anyway. We don’t even have clear data on how many people in our communities have chronic pain, nor how much it costs both our health system and our welfare system.  Many treatment providers (and others) think there is no such thing as chronic pain, and suggest the person is instead ‘depressed’ or is seeking attention.
3. As a result of both of these, people with chronic pain seek many ways to self medicate. So they may smoke cigarettes, drink alcohol, take medications (either prescribed or over-the-counter), and spend loads of money on ineffective gadgets like magnetic bracelets and massaging cushions and ‘energy treatments’.  While the latter may not harm the person, they cost a lot both financially and emotionally, and the former have serious health effects.
4. People with chronic pain present with other health problems alongside their pain. Most people with chronic pain have poor sleep.  They often meet criteria for depressive disorders, anxiety disorders and can be labelled with personality disorders.  As a result of not moving as much as they would, they can be overweight.
5. Other aspects of life are affected by chronic pain. Employment, relationships, leisure, general wellbeing, managing the home, caring for children, balancing the budget, communicating effectively.  All of these can be affected because chronic pain is invisible, and directly affects function and emotion.
6. Managing chronic pain means changing beliefs and behaviours across every part of life. Unlike taking medications, or changing diet, chronic pain management involves self regulating thoughts, changing expectations, adjusting goals, modifying activity patterns, expressing to others why things are being done differently.  Constantly reviewing how much energy is available against what needs to be done, because ‘overdoing it’ has such a high physical and emotional cost.
7. There are many people suggesting many different ways to manage pain and it’s hard for a person with pain to stick with self management. After all, if someone offered you a treatment to ‘take it all away’, wouldn’t you take it?  The resultant emotional rollercoaster ride makes it so much more difficult for someone developing active coping skills for their pain to stay with daily goalsetting, using relaxation, monitoring thoughts, exercising…
8. Relapse is normal, flare-ups inevitable and both can happen for no apparent reason. And both of these events can start the whole process of investigation, diagnosis, treatment and more treatment.  Or cause the person to doubt that they have the determination to carry on, or that what they’re doing is the ‘right thing to do’.
9. Treatment providers respond to distress and may not support a self management approach to chronic pain. During a flare-up, people with chronic pain are often distressed.  It’s difficult for treatment providers to resist wanting to help, wanting to ‘take it away’.  Helping someone manage their chronic pain is really hard work.  It’s tempting to offer yet another treatment, another medication, another investigation ‘just to make sure’.  This doesn’t happen in diabetes management, or depression management.
10. Services are often fragmented in chronic pain management. Someone with chronic pain can attend a clinic specialising in that body system rather than a specialised centre managing chronic pain.  It’s common for someone with fibromyalgia to be seen in a Rheumatology clinic, chronic abdominal pain to be seen in Gastrology, noncardiac chest pain to be seen yet again in Cardiology, temporo-mandibular joint pain to be seen in Dental, pelvic pain to be seen in Gynaecology.  Each of these departments will be treating what they consider to be the ‘underlying pathology’, and often don’t recognise that the chronic pain IS the disease, not a symptom of something else.

I’ve only just skimmed some of the reasons that chronic pain management is far more complex to manage than other chronic illnesses – I’m sure you can all think of other reasons.  To apply a generic ‘chronic health management’ model to chronic pain without recognising the additional challenges that come with the territory risks once again failing the person with the pain.  It risks remedicalising their problem, or managing only the biomedical aspects. It risks labelling the person as being the problem rather than the pain because ‘they didn’t get better’, or ‘they’re never satisfied’.

It also risks demeaning the team that work with the person who has chronic pain. Viewing pain management as simply ‘education’ or ‘exercise’ or ‘CBT’ misses the point entirely.  People with chronic pain have a hard enough time getting their heads around their pain, coping with the reality that their pain will not ‘go away’ without having a team that provides only partial management.

In many ways, chronic pain management is the ultimate interdisciplinary team approach – for every aspect of self managing chronic pain, the team need to back each other up and support the person to reconceptualise their part in making what are undeniably difficult changes.

Don’t ever think that chronic pain management is ‘just like managing any other chronic disease’.

‘What do I do when I’ve had enough’: The Effect of Emotions on Self-regulation & Chronic Pain

As soon as read the first paragraph of the paper I’ve used as the basis for this post, I knew I was onto something that resonated with my original occupational therapy values. It says this:

‘Living with chronic pain is a balancing act. People with chronic pain are required to make daily decisions about how best to cope with illness-related demands while managing other role-related obligations. Although some people become overwhelmed by the demands of illness and daily life, many, if not most, remain focused and well-adjusted, and do not require the services of a mental health professional. … Why do some redouble their coping efforts following a health set back, whereas others become demoralised?’

I concur with the idea that ‘most remain focused and well-adjusted’ – and that it’s the daily decisions, the little things that need to be prioritised and undertaken each day that require motivation and energy to keep doing when you have chronic pain.  Karoly and colleagues have written several papers on the ‘organising’ role of goals especially in chronic pain, and this paper by Nancy Hamilton extends the model proposed by Karoly to include the ‘energising’ influence of emotion.

How does this fit with self regulation?

Well, to achieve goals within life, we require the ability to control our thoughts, feelings, actions and physiology. We particularly need to do this when goals are not met immediately or are frustrated.  It’s a skill that incorporates multiple neural pathways, builds upon traits we are probably born with, but is able to be developed (otherwise we’d all have a paddy if we couldn’t have a piece of chocolate NOW!).   It seems that the importance we place on a goal, along with our confidence that we can achieve it, strongly influences how willing we are to attempt or persist with it.

Where emotions fit within this model is, according to Karoly, in terms of the level of arousal as well as in terms of the type of goals selected. Humans are generally goal-directed rather than simply reacting to situations.  In other words, what we do and the goals we choose are related to what we think is important, and what we think is important is developed from  interaction with our social environment (family and community), and all of this is influenced strongly by the emotions we feel.  Emotions generate ‘energy’ and focus, and enable us to recruit resources to work towards goals that we’ve chosen.

We all know that people with chronic pain vary tremendously in terms of how they go about adjusting to the experience of chronic pain.  The differences are not only in terms of ’success’ – or not -  but also in terms of the processes and strategies people employ.  Karoly’s model identifies 14 factors that influence goal-related self-regulation, and each of these introduce variation in how people adjust or self regulate.  Not all of these factors are directly influenced by emotions, but several most certainly are.

The first area to consider when looking at emotions and goals, is the role of emotion on the actual goal content – what the person wants to achieve.   Goal choice is underpinned by values, or what the person thinks is important – but deciding whether to approach or avoid certain activities is often motivated by emotions. Consider, for example, people who are fearful of experiencing pain who seek all manner of ways to avoid engaging in activities that ‘might’ increase their pain.

One client, for example, was highly fearful of bending to the floor from standing to put shoes and socks on so for three years she sat on the floor to do this.  She also avoided standing to shave her legs, wash between her toes, and to put her knickers and tights on!

In contrast, positive emotions such as joy and happiness influence us to pursue goals that increase the chance for obtaining rewards and have long-term pay-offs such as social activities or creative pursuits.

Pain is, as I’ve said before, by definition a negative experience.  The link between experiencing pain and feeling sad, guilty, frustrated, irritated, hopeless or anxious (just to name a few!) is incredibly strong – and dysregulation of affect is often a feature of chronic pain.  People do cry more often, feel irritable, get grumpy with others and become depressed.

In this paper, Hamilton and colleagues suggests that pain and negative emotion ‘tend to activate similar goal-related trajectories.’ What they mean by this is that both pain and fear, for example activate increased awareness of threat, more focus on the self, preparedness to avoid harm, and according to Affleck, quoted in this paper, ‘pain often activates the negative emotion systems, perhaps as a redundant alarm.’

Emotions also vary with the types of goal content chosen - from a study by Hamilton, Karoly & Zautra (2004), people with fibromyalgia were able to be divided into three groups on the basis of affective and disease-specific outcomes.

1. The groups were ’self-sufficient’ - this group endorsed goals such as ‘getting on with my life’ and gave low priority to social validation;
2. ‘treatment seeking’ people formed a second group characterised by goals to find a treatment provider who can ‘cure’ and gave low priority to social validation;
3. while the third group gave priority to social validation goals rather than finding effective treatment for their symptoms.

The three groups varied systematically in terms of negative affect – people in the last group also reported the highest levels of pain and negative emotions.  People who said they were ‘getting on with it’ reported lower levels of pain and negative emotion.  It’s not clear whether this is a causal relationship because of the correlational design of this study, so it will be necessary to watch and wait to see whether pain and negative affect tend to bias the goals that are selected and how they’re valued, or whether the goals chosen actually determine the emotional outcome.

Where does this leave us?

Well, it suggests that adjusting goals – both the type of goal and the difficulty of the goal – might be an incredibly important aspect of self regulation to focus on when we see people with pain.  Nothing new there.  But it might also influence and be influenced by the emotions the person is experiencing.  If we’re considering the role of failing to achieve goals, we’re likely to find that this experience of failure will have a dual effect on pain and emotion.   We may need to set goals that are very achievable, especially in the early stages of engaging in pain management.  We might need to reconsider the effect of, for example, failed attempts to return to work.

Conversely, achieving a goal, particularly a social or interpersonal goal, has an influence on mood – irrespective of pain and fatigue.  From this we could consider the role of group activities, particularly exercise or discussion groups, that engage people in positive ways and gradually increase the demands.  Success breeds success.

Recently I’ve used a ‘Plan to do’ and ‘Did do’ diary where people plan their day’s activities, then record what they actually did.  This provides immediate feedback on progress – and successfully achieving what was planned, no matter how low the level of activity, provides a sense of accomplishment and becomes reinforcing.

More on this tomorrow!

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

Self regulation – what it is and what to do

So, if self regulation is about exerting control over thoughts, feelings, actions and physiology, how does it work?
When I skipped through some Google references last night (o font of all knowledge!) I found a good number of sites referring to self regulation and children – but not nearly as many relating to adults, or the long-term results of limited self regulation. Curious in our world where kids get to ‘express themselves’ and are protected from disappointment, have few challenges set (especially those where they have to persist with difficult tasks), and don’t need to think about consequences for themselves because parents and teachers do it for them… Hmmmm

When I got to reading though, self regulation really is what much of pain management is all about. It is all about learning to manage emotions, thoughts, social relationships, coping, behaviour and physical activity – and managing sleep and fatigue. As Solberg Nes, Roach & Segerstrom state ’self regulation is important for good functioning … and pain is associated with deficits in self regulation and executive functions…’ The real challenge in chronic pain is because pain reduces the ‘coping reserve’, these things are harder to do, and maybe require more replenishment than before the pain started – or maybe because there were deficits in coping, the chronic pain becomes problematic.

Emotion regulation – chronic pain is linked with feeling bad, it’s part of the definition of chronic pain! To moderate both joy and sadness and express them appropriately for any given situation requires both upregulation (to ‘look happy’ when things are feeling not so good, or to focus on the good in the face of not so good), and downregulation (calming down when irritable or using that energy in a positive way).
Solberg Nes, Roach & Segerstrom record that Functional MRI studies have linked activity in the prefrontal cortex to emotional regulation, and that the activity of self regulating emotions is linked also with executive functions – they affect each other. One study cited in this paper suggests that suppressing anger can increase sensitivity to pain – giving further support to the ‘mindfulness’ and ‘acceptance’ approach to allowing emotions to flow past rather than actively suppressing or focusing on them.

Thought regulation – in order to regulate emotions, it’s necessary to regulate thoughts. Chronic pain, especially pain that lacks a specific diagnosis, or pain that is then perceived to be ‘forever’ (you know the words ‘you’ll need to learn to live with this, there’s nothing we can do…’) generates worry, and worry is essentially perseverating on negative thoughts. Being able to switch attention from one thing to another is an executive function that can be affected by negative rumination, and it’s thought that ‘deficits in executive functions may make an individual more prone to rumination’. Helping people with chronic pain allow their thoughts to pass by (again a concept of mindfulness and acceptance) may help reduce the fatiguing effects of rumination and alter the emotional impact.

Social regulation – if there is one thing that people with chronic pain fail to recognise, it’s the impact of their non-verbal behaviour on others. To interact effectively, we need to not only regulate our actual emotions and thoughts, but we also need to regulate how we present. People with chronic pain often report difficulty dealing with the effects of pain on relationships, feeling misunderstood, having trouble negotiating changing roles, and coping with the effect of ‘looking well’ while feeling wretched. I do wonder whether we give nearly enough attention to the ways in which social interactions are affected in people with chronic pain, and whether we give them tools to manage this more effectively, especially attending to non-verbal pain behaviours.

Coping - active coping is about remaining engaged in living despite pain, while passive coping often involves avoiding, disengaging from and reducing the level of activity despite pain. Active coping is almost entirely about regulating despite ‘not feeling like it’ or being fatigued. In order to develop more active approaches to living life with pain, therapists are faced with helping people develop skills like setting goals, persisting despite delayed gratification, remaining engaged ‘when we don’t feel like it’, and recognising both thoughts and emotions and that they can be influenced.

Physical activity - Keeping on doing things despite pain has been consistently shown to improve not only physical condition but also emotional, social and general quality of life. Therapist intervention to establish goals for physical activity that are within reach, and that provide some positive feedback, along with developing the self regulatory ‘muscle’ in gradual increments is one way to create change that becomes self-generating.

If chronic pain involves central nervous system dysfunction, and from most accounts the majority of chronic pain does, it’s entirely feasible for physiological deficits due to reduced ability to self-regulate to also be present. There are not too many patients I’ve seen who don’t report breath-holding, or at least limited use of diaphragmatic breathing, have trouble regulating their breathing rate or their heart rate, and indeed, heart rate variability, which is an ‘index of the fluctuation in the time interval between normal heartbeats’, controlled by the central autonomic network and thought to be an indicator of self-regulation. The central autonomic network consists of several brain structures such as the ventromedial prefrontal cortices, anterior cingulate, hypothalamus, amygdala, insula and the periaqueductal gray. This set of structures regulates many of the aspects of homeostasis, including the rhythm of the heart. People with chronic pain often present with lower HRV, suggesting again that self regulatory deficits are present.

I was really interested in this next section on neuroendocrine abnormalities that are present in people with chronic pain – mainly because of the effect of these abnormalities on cognition, and particularly executive function. I was aware of dysregulation of the HPA and HPG axes, leading to changes in the release of various hormones including cortisol. The importance of this is in terms of regulating levels of blood glucose and metabolism of blood glucose. The brain relies on effective availability of glucose for adequate functioning – if this is impaired, even slightly, it could affect sensitive functions such as those required for executive functioning, making it difficult for people with chronic pain to access and persist with tasks that demand high level executive functioning.

What do we do about this?
Once again, I’m struck by how this information simply reinforces the basic pain management strategies that have been used for a long time. Goal setting, working with thoughts and emotions, developing skills to upregulate and downregulate physiology, exercising and basically ‘living well’ all play a part in normalising input to the brain – and allowing executive functions to be supported. At the same time I’m aware that the information coming from neurophysiology supports the notion that the central nervous sysem is not only always involved in the experience of chronic pain, but can be influenced through nonmedical means. The ‘dividing line’ between body and mind has never been slimmer – roll on the day when it no longer exists.

Solberg Nes, L., Roach, A., & Segerstrom, S. (2009). Executive Functions, Self-Regulation, and Chronic Pain: A Review Annals of Behavioral Medicine, 37 (2), 173-183 DOI: 10.1007/s12160-009-9096-5

I’m so tired of coping: Self regulation, executive functions and chronic pain

Changes take energy – that’s nothing new, I know, but perhaps something as clinicians we might forget when we work with people who have chronic pain. I was thinking about this as I’ve had a week away from regular blogging so I could focus on writing and some self care.  Things are busy and as we enter the run up to Christmas, not likely to slow down any time soon – and yes, this takes energy!

Adjusting to living with a chronic health problem is demanding, it’s complex and requires people to reflect on what is important to them, how to achieve important activities all the while maintaining a sense of self.  Self regulation is a term used to refer to the ability to alter thoughts, feelings, and behaviors.  In chronic pain ‘[the] demands cross biopsychosocial boundaries and include managing the pain itself (e.g., by redirecting attention or exercising), negotiating close relationships that can be affected by the limitations associated with chronic pain, suppressing ruminative thoughts about pain, and regulating moods such as depression and anxiety that are commonly comorbid
with pain.’ (Solberg, Roach & Segerstrom, 2009).

I’m not sure that we generally acknowledge the fatiguing aspects of all this adjustment – and I reflect myself on how I respond when someone says they’re tired, I usually start to think about whether the person might be depressed, what their sleep might be like and so on, but rarely ponder the extent to which adjustment and self regulation might be a finite resource that requires replenishment from time to time.

Solberg, Roach and Segerstrom state that ‘Executive functions, largely orchestrated by the prefrontal cortex (PFC), are “a collection of interrelated abilities that enables people to modify their thoughts and actions”’. Executive functions vary both in terms of general ability and specific ability to regulate thoughts and actions. Use of a portion of the brain to self regulate (eg suppress thoughts or emotions) reduces the ability to carry out other cognitive functions such as reasoning. ‘Acts of self-regulation (e.g., attention control, emotion control) led to poorer higher order intellectual performance on tasks involving logic and reasoning, cognitive exploration, and reading comprehension.’

It’s already recognised that some chronic pain conditions such as fibromyalgia and temporomandibular disorder not only present with pain, but also affect cognition, emotions and physiological functioning.  People commonly report being fatigued, having ‘fibro fog’, and present with a range of other problems including disruption to sleep.  The authors of this paper point out that many of the same brain regions that are affected in chronic pain are also associated with executive function such as cortical blood flow to thalamus, the caudate nucleus, and the anterior cingulate cortex and gyrus.  Whether these changes are cause or effect matters less than to recognise that they are present and functionally suggest that people with chronic pain may also have trouble with self regulation.

Importantly, self regulation can be developed.  Active coping in chronic pain is almost all about self regulation – setting goals, persisting in certain tasks, halting others, managing emotions and so on.  The ability to sustain these activities varies considerably and I’m sure we’ve all encountered people who have managed well for a time, but lapsed or had a major set-back due to another significant event.  Important to remember is that ‘if patients with chronic pain are already experiencing self-regulatory fatigue, they have little strength to initiate or maintain such activities, regardless of their potential benefits.’

Maybe one part of the success of graded reactivation is not so much the habituating to pain, nor even the ‘return to fitness’ that is now being challenged (just how fit are the therapists compared with the participants who have chronic pain?!), but because it doesn’t tax the already fatigued self-regulatory resources.

The paper I’ve been quoting from provides a helpful, albeit brief, review of self regulation, executive functions and chronic pain. Recommended reading if you haven’t considered the area before, and also because it summarises a good deal of the neurophysiological information and self regulatory literature and applies it directly to the areas we are concerned with in chronic pain management.

This week I’ll be focusing on self regulation – there’s much more to learn! I think it may well be a significant part of resilience, and therefore worth developing not simply in people with chronic pain, but maybe in ourselves as clinicians. Who knows, some of us might be both!

Solberg Nes, L., Roach, A., & Segerstrom, S. (2009). Executive Functions, Self-Regulation, and Chronic Pain: A Review Annals of Behavioral Medicine, 37 (2), 173-183 DOI: 10.1007/s12160-009-9096-5

…Someone doesn’t work on his birthday

I don’t blame anyone for making a policy to never work on your birthday, I think it would be a lovely gesture from an employer to give you one working day off for your birthday, but I can just see my employer ROTFL at that one! Anyway, someone I know isn’t working today – Happy birthday!

LOLs ‘cos i need ‘em

see more dog and puppy pictures

see more dog and puppy pictures

Needing to take a brief break!

Just for a couple of days while I finish a paper I’m writing on functional capacity evaluations. Apologies to all.