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:

masculinity

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


ResearchBlogging.org
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.

pink

How does chronic pain management work? A self concept hypothesis


In my previous post looking at how chronic pain management works, I put forward the hypothesis that

“What DOES change is [people's] self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.”

Later in the comments I mentioned the idea of renegotiating self concept – that part of learning to live well with chronic pain is the process of integrating the reality of on-going pain and associated limitations within their “understanding of how he or she responds in situations and the roles he or she expects to fulfil” (Baumeister, 1997; Christiansen, 1999).  Self-concept is a predictive process where the knowledge a person has about his or her personality traits, roles, and relationships guides their actions so that they present consistently across social and private contexts.

So self concept is “the person I am”. Several authors have described chronic pain as a “biographical disruption” that forces individuals to reconsider their past, present and future, often creating a discrepancy between the self-concept before pain and the current self (Asbring, 2001; Richardson, Ong, & Sim, 2006; Wilson, 2007). To accommodate chronic pain within the self concept means people need to incorporate an understanding of the new current self in a way that can retain as much of the past self as possible, without placing unsustainable demands on the future self. People who cope well with pain develop a self-concept in which the effect of pain is assimilated without compromising critical values in their lives, even though it may influence how these are enacted.

What this means is that people who cope well with pain identify the important values they hold (parts of self), let go of old parts of themselves they can’t continue to achieve, and find ways of ensuring the parts of themselves that they do value very highly can still be done.

John Quintner suggested that programmes that help people cope with their pain provide people with hope. I agree. I think that by helping people see that they can still retain essential parts of their concept of who they are, they can begin to see that life CAN continue to have some of the good things they really value.

Some of the mechanisms that I think might be involved in helping people renegotiate their self concept are:

  • engaging in occupations (activities, roles that are individual and unique to them) as part of learning to make sense of their pain
  • this helps to make their pain less threatening, more predictable
  • and thus they’re more able to account for the effects of pain on what they want to do

People don’t only learn by doing things themselves, they also learn by seeing other people do things. This means that when people see a famous athlete or actor identifying with something like depression, for example, people with depression can gain hope that they too can still achieve despite their depression. In chronic pain management, people attending a group programme watch one another do things that they have also struggled with – and this provides both a model as to how this can be done, but also something to aspire to. This increases self efficacy because instead of seeing how “experts” (ie professionals) suggest they do things, they see people “like me” doing things.

If learning to live well with pain is partly about developing a new sense of self, then acceptance also involves letting go of things that can no longer be sustained (the past self) while holding onto important aspects of this self that can continue in a sustainable way into the future. This is something we all need to learn to do as we grow older. Usually it’s a gradual process, and most of us are sad to recognise that we’re aging, but also positive in that we’re moving towards new things that continue to add to our self concept. For people who develop chronic pain, it can be a profound change.

Letting go of the desire to “go back to normal” is incredibly hard. It won’t happen if a new opportunity to “go back to normal” keeps on being offered. And this is the tragedy of repeated attempts to find a complete cure, because it stops people being able to let go of things that may be unsustainable, keeps them in a sort of stasis while their life is focused on pain. And for many types of pain, there is no complete cure – even very successful interventions rarely completely abolish pain.

Hope, for people with chronic pain, involves more than taking all the pain away. It needs also to restore their confidence that they can be the person they want to be, to fit their self concept.  This is why return to work for people with chronic pain needs to address issues of the person feeling unreliable (“how can I go to work if I can’t go every day because of my pain?” “who would employ me when I can’t work the way I used to?”), of being able to present themselves as an asset to an employer, where chronic pain isn’t a liability but can be an asset. Because most people want to be seen as competent, reliable, and contributing within a work environment – and until they can see how these things can be achieved despite their pain, it’s going to be hard for them to convince an employer.

I think that learning to be flexible in terms of how to go about achieving something important might be the biggest factor in how chronic pain management programmes work. And I think the process is about renegotiating a self concept that allows this flexibility to occur, and maybe by helping people identify the values that underpin important occupations we might be able to support them to find new ways to express those values.

Asbring, Pia. (2001). Chronic illness – a disruption in life: identity-transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing, 34(3), 312-319. doi: 10.1046/j.1365-2648.2001.01767.x

Baumeister, Roy F. (1997). Identity, self-concept, and self-esteem: The self lost and found. Hogan, Robert [Ed], 681-710.

Christiansen, C. H. (1999). Defining lives: occupation as identity: an essay on competence, coherence, and the creation of meaning. British Journal of Occupational Therapy, 53(6), 547-558.

Richardson, Jane C., Ong, Bie Nio, & Sim, Julius. (2006). Is chronic widespread pain biographically disruptive? Social Science & Medicine, 63(6), 1573-1585. doi: http://dx.doi.org/10.1016/j.socscimed.2006.03.040

Wilson, S. (2007). ‘When you have children, you’re obliged to live’1: motherhood, chronic illness and biographical disruption Sociology of Health & Illness, 29 (4), 610-626 DOI: 10.1111/j.1467-9566.2007.01008.x

sugar coating

How does chronic pain management work? A hypothesis to ponder


There have been increasing calls for clinicians and researchers to move away from using grouped results from randomised controlled studies because these fail to distinguish between those people who do really well and those who do not. Eminent researchers like Amanda Williams, Chris Eccleston and Steven Morley have said it’s time to move away from “black box” RCTs in chronic pain, and begin to use more sophisticated methodologies to examine not only outcomes but processes during therapy (Williams, Eccleston & Morley, 2012).  While early studies comparing CBT-approaches to chronic pain vs waiting list controls demonstrated moderate to large effects, over time the results have shown smaller effects as these approaches are compared with other active treatments.

The magic ingredients in an effective CBT-approach to self managing chronic pain are not all that clear. There are some people suggesting that it’s all about providing good neurophysiology information about pain mechanisms to people with chronic pain (Moseley, Nicholas & Hodges, 2004; Louw, Diener, Butler & Puentedura, 2013) and this does seem to be part of the picture – but is it enough? Education doesn’t have the greatest of effects on behaviour in any other area of health (think of diets, smoking, exercise, immunisation), and while there’s no doubt we need to reduce the threat value of pain by helping people understand the old message “hurt does not equal harm” (a message I know has been around since the early days of Fordyce and Sternbach), this doesn’t always produce results.

There are other people who argue that it’s all about exercise and that exercise is not only good for people with chronic pain, but also as a “preventative” for those with acute pain who are at risk of develop chronic pain (for example in early whiplash) but this has recently been challenged by the findings from PROMISE, a study by Michaleff, Maher, Lin, Rebbeck, Jull, Latimer et al, (2014).  Nevertheless, exercise does seem to be a common ingredient in most self management programmes.

Pacing, as I indicated a couple of posts ago, has been included in many pain management programmes, but has not been examined in-depth – and even defining pacing has been pretty difficult.

Similarly for most of the approaches included in chronic pain self management: lots of “logical” reasons to include components, but when we take a closer look at them, there’s either very little information on the coping strategy itself, or the effect sizes are equivocal.

Nevertheless, for people with chronic pain who haven’t responded to any other form of treatment, these programmes are a life-line. Remember, that for many people it has taken 4 years to get referred to a pain management programme, and the chances of finding good medication options (or interventional procedures) that abolish pain are pretty slim.

“ Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients … do not always occur with concurrent improvement in function … These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain & to have a major effect on physical & emotional function in most patients with chronic pain.”Turk DC, Wilson HD, Cahana A: “Treatment of Chronic Non-Cancer Pain”, The Lancet 2011; 377: 2226–35 (25.6.11)

So, we have programmes that are offered to people who have reached the end of their treatment line, but we don’t really know much about what works and for whom. Yet there is an effect on people, small though it may be, and there’s some evidence that people who do what the programmes suggest do better than those who don’t (Nicholas, Asghari, Corbett, Smeets, Wood, Overton et al, 2012).

Two things occur to me:

  1. We need to use more sophisticated ways to study process and subgroup analysis of people in chronic pain self management programmes. I think this might include using single subject experimental design. This design was used in some of the early work by Vlaeyen and colleagues looking at response to graded exposure for pain-related fear and avoidance (Vlaeyen, de Jong, Geilen, Heuts and van Breukelen, (2001), and Asenlof, Denison & Lindberg (2005). It allows clinicians and patients to really monitor the effect of various parts of treatment, and can be a very sophisticated way for “real life” clinical work to be evaluated.  Another option is the kind of analysis conducted by Burns, Nielson, Jensen, Heapy et al (2014) where subgroups were evaluated over the course of a pain management programme to identify the programme elements that might be most effective. Their findings suggest that there are two mechanisms: one directly relevant to the components of the programme such as relaxation or exercise, and another that they call “general mechanisms”. It’s this latter one that interests me.
  2. The way in which a programme might work may not be associated with the components. Like Burns and colleagues, I’ve thought that perhaps there is something within group process, or therapeutic process that is the “active ingredient” for change. Let me quickly unpack this.

Some people do quickly adopt what a programme suggests is useful – or at least they complete recording sheets to suggest they have. Others might still use the strategies, but perhaps in a different way from that originally intended (think of pacing as a good example: lots of patients I’ve seen who have been through a chronic pain management programme think that it’s all about “stopping before your pain gets out of control”, and rather than maintaining a consistent level of activity over time, their function gradually reduces as they do less and less. Their interpretation of pacing is that it’s about using your pain as a guide.

And still others pick and choose elements of what is covered in a programme – and use the strategies flexibly within the context of their daily lives. So on one day they may boom and bust, while on other days they chunk their activities into smaller bits. One day they’ll arrange their environment to suit them, another day they’ll ask other people to give them a hand. Their coping skill use depends on their goals and priorities at the time.

What DOES change is their self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.

 

Asenlof, P., Denison, E., & Lindberg, P. (2005 ). Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single-case studies of patients with recurrent and persistent musculoskeletal pain in primary health care. Physical Therapy, 85(10), 1061-1077.

Burns, J., Nielson, W., Jensen, M., Heapy, A., Czlapinski, R., & Kerns, R. (2014). Does Change Occur for the Reasons We Think It Does? A Test of Specific Therapeutic Operations During Cognitive-Behavioral Treatment of Chronic Pain The Clinical Journal of Pain DOI: 10.1097/ajp.0000000000000141

Louw, Adriaan, Diener, Ina, Butler, David S, & Puentedura, Emilio J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy theory and practice, 29(3), 175-194.

Moseley, G., Nicholas, Michael K., & Hodges, Paul W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi: http://dx.doi.org/10.1097/00002508-200409000-00007

Michaleff, Zoe A., Maher, Chris G., Lin, Chung-Wei Christine, Rebbeck, Trudy, Jull, Gwendolen, Latimer, Jane, . . . Sterling, Michele. (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet, 384(9938), 133-141.

Nicholas, M., Asghari, A., Corbett, M., Smeets, R., Wood, B., Overton, S., . . . Beeston, L. (2012). Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16(1), 93-104.

Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research & Therapy., 39(2), 151-166.

Williams, Amanda C. de C., Eccleston, Christopher, & Morley, Stephen. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, (11). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007407.pub3/abstract doi:10.1002/14651858.CD007407.pub3

Tauhou "New arrival"

Pain management and the political


There are only a few more weeks before a general election in New Zealand. This means the usual rounds of promises, muck-racking, hoardings and defaced hoardings. As I browse the research into chronic pain, and bemoan the lack of attention to the SOCIAL of the biopsychosocial model, I find myself looking at factors that almost entirely depend on a political solution. Let me explain.

Social. What is meant to fit into this part of Engel’s model? Drawing from one of his earlier works, Engel stated in his Cartwright Lecture at Columbia University College of Physicians and Surgeons (1977), that

“Health restored is not the former state of health but represents a different intersystemic harmony than existed before the illness, with characteristics based on all the system changes incurred during the illness. By virtue of the illness not only is the individual changed as a person, but so too may be changed others in relationship to him, in the family as well as the community…”

I interpret this segments of Engel’s work, and in particular the diagram he included in the published version of this speech, as a clear indication that while a biomedical model looks at the levels from quarks to systems, a biopsychosocial systems approach looks beyond this and into the person right up to society and nation.

biopsychosocialAnd this is where it gets political. While individuals reappraise their self worth, learn new skills, develop new living patterns (well within the contributions of most allied health including occupational therapists), Governments and economic policy have a direct influence on what occurs in the interaction between what the individual does and the effect on the family, community, culture and subculture (however you define this), and ultimately society-nation.

Here’s some recent research illustrating how these factors interact.

When a person develops chronic pain, clinicians are likely to ask “How did it begin? What happened?” The person will probably talk about an event in the last few months or years that may have triggered the most relevant experience of pain. What clinicians may not think to ask about, and the person with pain may not even consider, is what happened in early life.

Goosby (2013) looked at socioeconomic disadvantage and maternal depression in individuals during their teenaged years, and found that the probability of chronic pain increases in magnitude over life in those adults who had parents with less education, and in those who had mothers who were depressed. She points out that mothers who live in low-income households (e.g. single mothers on a benefit?) are “especially vulnerable to psychological distress and disorders such as depression” (p. 77). She calls this “intergenerational transmission”, and goes on to describe “risk amplification” that occurs for children with low socioeconomic status who continue to experience deprivation as they become adults, while those who are not disadvantaged continue to maintain their health and wellbeing at least in part because of economic stability.

She continues by describing that childhood disadvantage increases the risk of depression and pain in adulthood and that adult socioeconomic status is a key factor through which adult health and wellbeing emerge. Interestingly, she found that adult depression is influenced by fewer factors than adult chronic pain – in fact, she found that all indicators of childhood socioeconomic status had significant interactions with the RR of adult chronic pain relative to no conditions, and particularly for those who had mothers who were depressed.

A similar finding was made by Lacey, Belcher, & Croft (2013) in a study looking at life-course socioeconomic position influencing chronic pain in older adults.

It doesn’t take a rocket scientist to see that this is political. In a climate where single parents (most often women) are told they are “welfare dependent”, receive a tiny sum of money or are asked to return to work when the child is 5 years old, often to work that is poorly paid (because more senior and well-paid positions rarely allow workers time to attend to children’s needs, mind you neither are poorly paid jobs), life is stressful and anyone vulnerable to depression and/or chronic pain is at high risk.

A sense of injustice can exist where individuals feel that circumstances are not fair, and that they are the victims of an injustice. In New Zealand there is a mitigating factor in that all accidental injuries are covered by the state-owned and tax-payer funded Accident Compensation Corporation. BUT, and this is a big one, there are incentives for those case managers to encourage and support people to return to work, while those who are injured while not working may receive far fewer entitlements and will not receive rehabilitation to return to work. This shouldn’t matter because access to rehabilitation is available to all – but in practice, does it?

McParland & Eccleston (2013) found that a sense of injustice can affect emotions, cognitions and behaviours. A particular point they raise is that when there is inequality between two people in a relationship, ie where one has money but the other does not (one is working, while the other is unwell with chronic pain) there may be adverse responses between the individuals. In New Zealand, if one person in a longterm relationship becomes unwell, while the other person is employed there is very little if any financial support for the couple. If the earner is only receiving a minimum wage, this presents a huge obstacle even to attending treatment.

My final review today (and believe me, there are SO many more than I’ve touched on!) comes from Antao, Shaw, Ollson, Reen and colleagues (2013).  They looked at intermittent work incapacity and how this influenced the way we can support people to sustainably remain working despite having times where their chronic pain interferes with this ability.  They draw on Bronfenbrenners Ecological Systems Theory which views child development within a context of social and interpersonal environments. Antao and colleagues used the environmental framework to analyse the workplace: .Micro level issues are defined as issues within the individual and personal realm and include factors such as cognitive deficits. Meso level issues are related to the workplace, such as workplace policies and accommodations. Finally,macro level issues are related to socio-cultural or political issues, such as benefits and insurances. (p. 13).

What these researchers found was there is considerable literature discussing micro-level support for people with pain. These are things like the individual learning about his or her condition, maintaining physical fitness, working on routines that can maintain or support work. Education, for example, focused on giving individuals information about worker’s rights, how to maintain quality of life through coping changes.

Meso-level strategies were rather more scarce in the literature, but they were present – things like educating employers and supervisors, modifying tasks or workstations, ensuring people are aware of the benefits of working on the individual and so on. I guess some of these fit into the “ergonomics” category.

Macro-level strategies were even less often presented, but included using flexible work practices (shifts, glide time, sharing tasks), providing timely financial support during times when an individual is unable to work, anti-discrimination laws and similar.

Meso- and Macro-level strategies are about social change and political will.

Where does this leave me?

When I consider the influence socioeconomic deprivation has on people, right from childhood through to the flow-on effects in adults, I worry about the effects of policy on people in New Zealand. There is an increasing disparity between those earning above $100,000 per annum, and those on the minimum wages of $14.50 or so. Worse for those on a benefit who are also labelled “benefit dependent”.

I’m worried that very often there is an outcry if a policy is introduced to support the situation of workers – employers complain that this is unsustainable, that they won’t remain in business and there will be economic fall-out because of this. I’m concerned at labelling that occurs if a person is on a benefit. Being on a benefit is not a life of luxury, yet benefit fraud is pursued more vigorously than so-called “white collar” crime, and in research conducted by Victoria University in 2011 “22 per cent of tax offenders received a custodial sentence” while “approximately 60 per cent of welfare fraud offenders received a custodial sentence.” Sophie Rule, Report Writer, Youth Parliament 2013, Ministry of Youth Development.

I am unhappy that the “trickle down” of economic growth hasn’t trickled, and that people who have few resources in so many ways are in a very real situation of social injustice. It’s a brave person who challenges an employer who decides to fire a worker who, having been in the same job for 20 years, has a heart attack and needs three months time off work. True story. Or a woman who, since the business she works for has moved from town to Rolleston, now has to travel by bus for an hour, then cycle for another 30 minutes to work in a job that pays minimum wage. And do the same again in the evening, despite her chronic obstructive pulmonary disease. In Christchurch. In winter. Oh and she lives with the man who had the heart attack. She doesn’t get paid when she needs a week or two off work because of her COPD as happened recently.

The social is largely, I think, a political matter. And chronic pain affects one in six New Zealanders. And they all vote.

 

Antao, Lilian, Shaw, Lynn, Ollson, Kaitlyn, Reen, Kavleen, To, Flora, Bossers, Ann, & Cooper, Lynn. (2013). Chronic pain in episodic illness and its influence on work occupations: A scoping review. Work: Journal of Prevention, Assessment & Rehabilitation, 44(1), 11-36.

Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91. Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91.

Lacey, Rosie J., Belcher, John, & Croft, Peter R. (2013). Does life course socio-economic position influence chronic disabling pain in older adults? A general population study. European Journal of Public Health, 23(4), 534-540.

McParland, Joanna L., & Eccleston, Christopher. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.

old man willow

Should we take their word for it? Patient-reported vs observed functional outcomes


Pain is a subjective experience. There’s no direct means to measure what it is like to be in pain. Disability, or the impact of pain on what we do in daily life is, on the other hand, able to be observed as well as reported on by people with pain. A question that has always fascinated me is the relationship between what an individual says they can or can’t do, versus what they can be observed to do.

One of the more common ways to determine disability by observation is the “functional capacity evaluation” – and readers of my blog will know that I’m not especially fond of them when they’re used to determine “work fitness”. There are instances though, where they make sense – particularly if the individual with pain is able to gain confidence about what he or she can do. Just don’t use them to predict whether a person can carry out a full working week.

Alternatively, and for reasons of convenience and cost, self-report measures of disability are often used. These are thing like the Oswestry Disability Index (Fairbank & Pynsent, 2000), or the Oxford Scale for hip and knee function (Dawson, Fitzpatrick, Carr & Murray, 1996).  These pen and paper assessments are completed by patients, have excellent psychometric properties, and are often used for both assessment and outcome measurement.

The question is: do they represent the real world experience of the person with pain? How accurate are they, really?

In the Orthopaedic Surgery Department where I work, physiotherapists conduct a functional assessment of all people who have been referred for hip and knee joint replacement. The activities used are aligned with the Oxford hip and knee questionnaires. What’s interesting is how poorly the two are correlated. Physiotherapists recognise that many people report difficulty performing things like going up steps, kneeling and so on, but when they are asked to do those same movements in the clinic, they have excellent motor function and manage them well. Why? and which version of the “truth” do we use?

I don’t have the answer, because physical performance and self-reported disability are influenced by many different factors, but I am interested that in a recent study conducted by the IMPROvE Study Group in Denmark, researchers found that using AMPS (Assessment of Motor and Process Skills – an assessment approach developed and used by occupational therapists) and the SF-36 Mental Composite Score showed distinct differences in outcomes six months after a two-week interdisciplinary pain management programme for people who met the 1990 American College of Rheumatology classification for fibromyalgia.

What does this mean?

The first point is that the programme these people attended demonstrated good outcomes in the things that matter most: daily activities, self care and motor performance. Participants became more able to do the important occupations that you and I need to do each day.  Group content doesn’t look any different from the pain management programmes I’ve seen around the world. Lots of information, sharing experiences with one another, exercise including how to increase daily exercise, developing ways to return to usual activities of daily living, and some psychology sessions as well as an opportunity to meet with the rheumatologist. Interestingly, two weeks is not enough time to develop changes in muscle strength – yet function and activity levels increased. It’s not a “training” effect, at least not physical training. Two weeks, 35 hours a week, is not an enormous amount of time in which to deliver a programme of this type – but it’s clear it can and does make a difference for people who had fibromyalgia diagnosed roughly 1 – 3 years ago.

The second is that the two outcome measures are not measuring the same thing.  Using the SF-36, change was minimal, and not clinically significant, neither were changes at six months statistically significant. Using AMPS, however, individuals demonstrated a clinically relevant improvement in performance in both motor ability and process ability (ADL). Interestingly, the researchers report that there were large interindividual differences – something that grouped data cannot show.  Self-report measures show what the person believes he or she can do.  AMPS provides external validation of performance, or what the person will do, or does do when observed. And from this study, it looks like AMPS is more sensitive to change, and to individual differences, than the well-known SF-36. AMPS also provides information on the quality of performance, something that is missing from the SF-36.

In terms of the research design, the assessors, all occupational therapists trained in AMPS and who had just recently been recalibrated (checking to see how consistent and how closely they remain true to the original training) did not know which of the two groups individuals had come from (control or programme).

From this study, I draw a couple of conclusions:

  1. Using both observed performance and self-report gives a broader picture of the impact of pain on daily life. That the two measures don’t correlate well is fine – they’re measuring different things. It’s good to be reminded that what a person says they have trouble with doesn’t necessarily reflect what they can do in usual setting, nor the quality of the performance. Both measures are useful, and it might be worthwhile using both. An unanswered question, of course, is what the participants thought. How did they view their performance? It would have been nice to see something like the Canadian Occupational Performance Measure included in the outcome measures.
  2. While group analyses may not show much difference, within the group, some individuals responded very well. It’s worthwhile considering some different analyses that can show the variation within a group – and then start the search to find out the characteristics of those people who responded well, and this is another reason I like the single subject experimental design approach to clinical outcome measurement.
  3. Occupational therapists, trained to understand occupation made a significant and unique contribution to this study. Many disciplines fail to recognise the specialist expertise of occupational therapy: this study shows that by assessing and focusing on activities that matter to individuals, and directly measuring the impact of interventions on occupation, a more detailed analysis of progress is achieved. Time to wave the occupational therapy flag I feel!

In answer to my question, should we take their word for it? I think the answer is – not exactly. We need to spend time understanding the differences between self-report and observed performance, not as a way to ‘catch a person out’, but as a way to more adequately assess what matters to people who experience chronic pain.

Amris, Kirstine, Wæhrens, Eva E., Christensen, Robin, Bliddal, Henning, & Danneskiold-Samsøe, Bente. (2014). Interdisciplinary rehabilitation of patients with chronic widespread pain: Primary endpoint of the randomized, nonblinded, parallel-group IMPROvE trial. PAIN®, 155(7), 1356-1364. doi: http://dx.doi.org/10.1016/j.pain.2014.04.012

 

Dawson J., Fitzpatrick R., Carr A., Murray D. (1996). Questionnaire on the perceptions of patients about total hip replacement surgery. Journal of Bone and Joint Surgery, 78:185-90

Fairbank JCT & Pynsent, PB (2000) The Oswestry Disability Index. Spine, 25(22):2940-2953

crossing paths

Pacing – Activity management concepts (a longer than usual post)


In the literature recently there’s been a flurry of activity around pacing as a concept. When I first wrote about pacing I couldn’t find very much that had been published, and I ended up writing something that made sense to me at the time. Today I hope to add to that by summarising a few of these recent papers, and discussing some findings from my PhD research.

Firstly, what is pacing?

Pacing isn’t well-defined. In one of a few recent papers on pacing, Nielson, Jensen, Karsdorp, & Vlaeyen (2013) suggest that pacing should be defined as “…the regulation of activity level and/or rate in the service of an adaptive goal or goals” (p. 465).  Gill & Brown (2009) point out that because pacing is poorly defined, and despite the term being used widely and most especially in the mid 20th century (and related to the “3 P’s” of planning, positioning and pacing used for rheumatoid arthritis), there are a diverse range of articles mentioning pacing, but no consensus as to what it might include.

Jamieson-Lega, Berry and Brown (2013) scanned the literature and sought feedback from stakeholders from a range of disciplines, and developed a concept map for the term. Concept mapping involves identifying the use of the concept in the literature, defining the attributes of the concept and developing a model case (a “pure” example), and both borderline and contrary cases (incorporating none or only some of the concepts). Antecedent and consequent outcomes associated with the concept of pacing were also defined, and empirical referents, or phenomena that show how the concept has occurred.

Key criteria for pacing, drawn from the literature by Jamieson-Lega, Berry & Brown (2013) show that pacing has five consistent attributes:

  1. Action – pacing involves intentional behaviour
  2. Time – pacing occurs over time and involves attending to time
  3. Balance – weighting activity and rest in accordance with intended outcomes
  4. Learning – pacing needs to be learned, it requires an effort
  5. Self-management – the process of using pacing involves independently integrating the practice once the skill has been developed.

The definition proposed by this group is therefore slightly different from Neilson and colleagues:

“Pacing is an active self-management strategy whereby individuals develop self-efficacy through learning to balance time spent on activity and rest for the purpose of achieving increased function” (p. 209).

When would someone need to develop this skill and what might happen if they use it successfully?

Janieson-Lega, Berry and Brown (2013) suggest that there are prerequisites for the need to develop pacing.  These involve activity disruption secondary to pain, imbalance between activity and rest, patient’s lack of pain self-management knowledge and having pain. When an individual successfully uses pacing, the expected outcomes are pain management, self-direction and improved self-efficacy, avoidance of pain exacerbation, balanced activity/rest, increased functional ability, and increased knowledge and skills in activity planning and prioritising (p. 210).

Therefore, if a person with chronic pain isn’t able to engage in what they want to do, finds it difficult to have sufficient rest or activity, lacks self-management knowledge and has pain, they could expect that pacing would enable them to manage their pain more effectively, become self-directed and more confident, minimise flare-ups, have a balance between activity and rest, be able to do more, and know more about what is important and how to achieve what is valued.

What does the literature suggest?

Despite the problems with defining pacing, and consequently having no real measure of pacing, there have been several studies examining the relationship between pacing and other important variables. The first study I saw of pacing was McCracken and Samuel’s 2007 paper looking at the relationship between avoidance, pacing and other activity patterns.  Surprisingly, these authors found that pacing was associated with both activity avoidance and disability. From this study, the authors suggested that avoidance activity may resemble healthy coping (and from this I deduced that pacing is considered “healthy”).

Murphy, Smith & Alexander (2008) conducted a small pilot study of activity pacing in women with lower limb osteoarthritis. This study used actigraphy to monitor movements, and correlated this data with self-reported pain and fatigue. This study found that “high pacers” had more severe, escalating symptoms, and activity pacing was related to lower physical activity. Karsdorp & Vlaeyen (2009) found that activity avoidance but not activity pacing was associated with disability, and challenged the notion that pacing as an intervention is essential in pain management.  van Huet, Innes, & Whiteford (2009) on the other hand, found that “graduates” from a pain  management programme continued to use pacing strategies years after completing a programme, but made no comments as to the effect on outcomes although they did comment that “the application of pacing tended to be individualised, with the use of self-selected time increments and novel strategies providing structure to limit over-activity” (p. 2036).

Andrews, Strong & Meredith (2012) completed a systematic review of activity pacing in relation to avoidance, endurance and functioning.  This study found that pacing was linked to better psychological functioning but more pain and disability, but couldn’t comment on the direction of this relationship.

What about people with chronic pain, what do they think?

People with chronic pain indicate that they use pacing in studies within the qualitative literature. The problem is that these describes rarely include definitions of pacing.  van Huet, Innes and Whiteford’s study from 2009 provides quotes from graduates of pain management programmes who describe pacing as “doing things in bursts of 20 minutes and half an hour, then changing what I’m doing, then go back”; “you don’t have to do the whole lawn at once”.

From my study of people who cope well with pain, participants were selective about their use of pacing. Many of them indicated that pacing was not used when they had an important goal to achieve, while using “chunking” or breaking activities into smaller units was used from time to time – what was interesting is that pain intensity wasn’t used as an indicator for when to stop. Patients I’ve worked with in the past have described using pain intensity or fatigue as the indicator – they always stopped before their pain or fatigue “got out of hand”.

Where does this leave us?

My take in pacing as it currently stands is that there is a great deal of confusion on the matter. My personal opinion, and from both the literature and my own experience with my fibromyalgia, is that pacing can be useful in several ways – but can also be unhelpful.

Here’s how I think it can be useful:

  • When beginning to work towards an increased activity level – by setting a baseline level of activity, then titrating this level up by time or “chunk” increments rather than using pain or fatigue as a guide
  • When individuals are finding it hard to maintain activity levels over a day/week/month, pacing using time or quota as the guide can help extend activity levels over a longer period
  • When people are not sure of their symptoms and find it difficult to know what triggers an exacerbation, usually during the “making sense of pain” phase of adjusting to chronic pain
  • When engaging in routine activities that don’t need to be carried out all at once, such as mowing the lawn, doing the laundry, vacuuming the house. Things that need to be done, but might be carried out over a longer period of time than a single session. I used this approach to write my PhD using Pomodoro Technique.  I also use it when doing housework.

When might it be unhelpful?

  • When individuals continue to use pain as a guide to stopping activity, and “stop before it flares up”
  • When individuals monitor their pain intensity and seek to avoid fluctuations in pain
  • When working to a quota doesn’t help them reach goals and isn’t used to reduce distress, disability and isn’t progressed. A good example of this is the “5 minute break” I saw instituted in a data entry workplace. It was a computerised system that stopped the keyboard for five minutes with no over-ride. The “5 minute break” was obligatory for everyone every 45 minutes, there was no rationale for using it, it interrupted flow, and people HATED it. I’ve seen similar things used when people are returning to work – “work for 15 minutes then stop for 5″, maintained for weeks without being reviewed and without establishing effect.

Next steps?

Having arrived at a reasonable definition, I think it’s time to see how people use pacing in daily life, within the context of the ebb and flow of normal activities. I’d like to see an ecological momentary assessment approach to see what triggers use of pacing, how well do people return to their activities, how long is a break, and whether there is an impact on both disability and distress.

 

Andrews, Nicole E., Strong, Jenny, & Meredith, Pamela J. (2012). Activity Pacing, Avoidance, Endurance, and Associations With Patient Functioning in Chronic Pain: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation, 93(11), 2109-2121.e2107.

Gill, Joanna R., & Brown, Cary A. (2009). A structured review of the evidence for pacing as a chronic pain intervention. European Journal of Pain, 13(2), 214-216. doi: 10.1016/j.ejpain.2008.03.011

Jamieson-Lega, K., Berry, R., & Brown, C. A. (2013). Pacing: a concept analysis of the chronic pain intervention. Pain Research and Management, 18(4), 207-213.

McCracken, Lance, & Samuel, Victoria. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain, 130(1), 119 – 125.

Murphy, S. L., Smith, D. M., & Alexander, N. B. (2008). Measuring activity pacing in women with lower-extremity osteoarthritis: a pilot study. American Journal of Occupational Therapy, 62(3), 329-334.

Nielson, Warren R. PhD, Jensen, Mark P. PhD, Karsdorp, Petra A. PhD, & Vlaeyen, Johannes W. S. PhD. (2013). Activity Pacing in Chronic Pain: Concepts, Evidence, and Future Directions. Clinical Journal of Pain, 29(5), 461-468.

van Huet, Helen, Innes, Ev, & Whiteford, Gail. (2009). Living and doing with chronic pain: Narratives of pain program participants. Disability and Rehabilitation: An International, Multidisciplinary Journal, 31(24), 2031-2040. doi: 10.3109/09638280902887784

middle earth

Coalface conversations


Knowing about something doesn’t hit the heart or mind nearly as well as doing it. As regular readers of my blog will know, I teach various aspects of pain management to postgraduate health professionals who come from a wide range of disciplines. Hopefully I can guide people towards thinking about the range of factors that can influence what goes on between delivering a treatment and the eventual outcome. It’s difficult, though, because much of what I need to do is based on giving access to information rather than opportunities to practice and then integrate this material.

I thought about this the other day when I met with a new patient. He comes to me with a history of seeing lots of health professionals, and learning lots of skills, but still essentially having the same struggle as he’s had throughout his lifetime. What can I possibly add to his ability to cope when he’s already had such a lot?

One of the conversations I often have with new patients is the relevance of psychosocial factors in their situation. It’s a conversation many health professionals fear – and then avoid. I’ve heard people say that they’re worried that their patient will think they’re saying “it’s all in your head”, or that their problem isn’t taken seriously. That comment is certainly something I’ve heard from patients as well.

So, when I met with this patient I decided to use what he had already learned to find out what he thought was going on, and to help us both discover more about what I could offer. This is essentially Socratic Questioning. Socratic questioning is styled after the teaching approach of Socrates and written about mainly by Plato.  It’s an approach where questions are asked after each answer, and through doing this, people discover the underlying beliefs or “truths” for themselves, rather than being told what to think. It’s a process of discovery – and when I use it with a patient or client, I use it so we can BOTH discover something.

It’s not easy to describe how to use Socratic questioning without coming up with a pat series of responses, but I’ll have a go. In reality, Socratic questioning is a subtle series of responses that can summarise, clarify and then probe behind the superficial to access deeper insights for both parties. If the clinician “knows” what the answers are, and uses this line of questioning to simply show the client something, it can end up being a process to show off how brilliant he or she is, subsequently missing the point of this approach.

Here’s an excerpt (as far as I can remember it):

B:       Tell me what’s been going on since we last caught up.

P:       Well, I’ve had a few flare-ups and I’m struggling a lot with the effort it takes to keep going even on a bad day.

B:       You look defeated when you say that. Do you feel defeated?

P:       Yes. I’m no good. I haven’t got what it takes.

B:      What do you mean “I haven’t got what it takes?”

P:       I haven’t got the strength, or the commitment to keep going. I’m just not good enough.

B:       Has something happened to lead you to this conclusion, or have you felt this way for a long time?

P:        It’s just got clear to me this last week.

B:        So this is a change in your thinking?

P:         Yes. I spent the weekend with my family and saw how happy they all are, and here am I doing nothing and sitting on the sidelines. If my kids were with my brother, they’d be so much better off.

B:        So…because you care about your kids, you decided you’ve let them down, you haven’t got what it takes.

P:        That’s it. If I didn’t have this pain, if I could fight it more, I wouldn’t let them down and they’d be happier.

B:        You said this was a change in your thinking. You’ve had your back pain for quite a while now, and you’ve been around your family lots of times. What did you think about yourself in the past?

P:        I think I was feeling better about myself because at least I was trying and my pain wasn’t in the way as much. Trying hard isn’t enough.

B:        I don’t think I quite follow. Why is trying not enough?

P:       Because no matter how hard I try, I can’t get around my back pain and my kids aren’t getting what they should from me.

B:       Is that what they say to you?

P:       No, but I can see my brother’s kids are so happy.

B:       And you’d like your kids to be happier.

P:       Yes.

B:        What things would you do differently if your pain wasn’t such a problem?

P:       I’d talk with them more, I’d encourage them, I’d play ball with them, I’d be there more for them.

B:       Are these things you could do even though your back pain is more than normal?

P:        Well… I couldn’t play ball with them.

B:       What about talking, encouraging them?

P:       Well, I suppose I could, but I’m scared I’ll just get angry with them.

B:       How would it feel just to try some new things anyway, even if you get irritable by the end?

P:       I suppose it would be a start, and they would at least see I tried. But I am still worried I’ll let them down.

B:      If you did let them down, would it negate having tried encouraging them at first?

P:      No, I guess it would give them a bit of the old me for a while.

There are roughly three steps in this exchange: (1) collecting information together; (2) examining this information together; (3)  inviting the patient to develop his own plans for doing something with that information. You’ll see that I didn’t attend to his pain, but instead focused on what he was afraid of – that his pain would make him grumpy, and that this would make his kids sad.  The conversation is all about discovering together, being curious and trying to learn about his experience from his perspective. By doing this together, we make long term changes because our clients learn how to discover what they’re thinking and doing, explore their thoughts and actions from a variety of perspectives, and generate their own answers.

Simply giving my patient/client the task to “do things differently” with his kids might have given him some homework, but it doesn’t help him learn about himself, nor about his main concern which is the effect of his back pain on his relationship with his children. This is definitely a psychosocial issue, but my patient didn’t reject what I had to say because we discovered it together and he gave me the information himself. It’s a very rewarding way to collaborate with someone.

Here’s a handout swiped from www.thebeckinitiative.org

A more in-depth web page of info on Socractic questioning and cognitive therapy is here

pastorale

Better ways to meet the needs of people with chronic pain


I’ve worked in chronic pain management in New Zealand for about 20 years. In that time I have never, ever heard of a chronic pain management centre without a waiting list. There are always more people than places for them to go. This situation hasn’t changed one iota, and it’s the same everywhere in the developed world. It’s also going to get worse because of the aging population with chronic health problems. Somehow, though, the urgency with which we need to address this problem just hasn’t reached health policy-makers and budget-holders. Chronic pain is still pretty invisible.

If tertiary care waiting lists are enormous, then who ends up taking on the majority of care? By and large it’s General Practitioners, who by their own admission don’t feel confident, and neither do they have sufficient time, to deal with the needs of people with chronic pain. There is conflict between the focus of a GP and that of the patient, and implementing back pain guidelines for example, has not been entirely successful (Breen, Austin, Campion-Smith, Carr & Mann, 2007; Coudeyre, Rannou, Tubach, Baron, Coriat, Brin et al, 2006; Williams, Maher, Hancokc, McAuley, McLachlan, Britt et al, 2010).

What can be done?

The strategy most commonly recommended is some form of stepped care approach. This begins with simple advice and simple analgesia. It’s usually carried out by a GP, or in some cases (such as accident patients in New Zealand), other primary care clinicians such as physiotherapists, osteopaths and chiropractors can also provide this – although not usually involved in prescribing.

When this approach fails, or after a certain length of time, the next step adds in  some sort of reactivation, involving a physiotherapist or similar, and perhaps a screening questionnaire to establish the presence or absence of risk factors.

When this fails, the person may then be seen by an interdisciplinary team or at a chronic pain management centre.

But someone this approach hasn’t worked – because, at least in Christchurch, people will have had their pain for roughly four years before finally being referred to the pain management centre. This delay might be because of limited chances of getting in to the service, or it might be because patients haven’t been to see their GP about their pain, or it might be because they’re still wending their way through the acute services in pursuit of a cure or cause for the pain. Whatever the case, it’s not good for people.

Some ideas rely on using technology to provide greater collaboration and communication between both the person with pain and his or her virtual team (Kroenke, Krebs, Wu, Yu, Chumbler & Bair, 2014). I think this idea has a good deal of merit, although in the article I’ve cited I think some opportunities were missed. In this study, participants were randomised into two groups – one group received usual care, while the other received automated symptom monitoring via voice-recorded phone calls or the internet, along with one face-to-face meeting with a nurse care management, who discussed medications with a pain physician, followed by a phone call to discuss the care plan, and two other calls, one at one month and one at three months. Additional calls were provided on the basis of symptom records.  Patients in the intervention group benefited, with reduced scores on pain severity and interference as recorded by the Brief Pain Inventory.

What this study missed doing was use clinicians to support increased functioning and manage emotional distress. While there would have been an increase in cost, the outcomes would have, I feel, justified this expense.

Who should deliver this kind of intervention? Well, for my money, I’d go for occupational therapists, physiotherapists, perhaps nurses, social workers and counsellors. People working at the limits of their scope of practice.

You’ll note I don’t think psychologists should be involved, and not because I don’t think psychologists are very good people – but in a stepped care approach, I think their skills should be reserved for people who also present with psychopathology, things like depression, anxiety, and so on. Let’s instead use clinicians who have skills specifically aimed at increasing engagement with normal activity (or occupation, if you want to be pedantic).

I think there are other ways allied health can be used, reducing the demand on medical time.

What about group clinics where people from two or three medical practices can meet together once a week with an occupational therapist and physiotherapist? A time when people can learn new skills, be encouraged to set goals, have social support and also have a chance to learn about their pain and how to live despite it. Combine this with the prescribing practices described in the Kroenke et al (2014) study, and I think you have a great beginning for a primary care approach for people with chronic pain. If you included the local pharmacist in the mix, you’d have a very effective approach that maximises the use of clinical skills amongst a group of people who sorely need help.

If individual patients needed extra help, they could arrange appointments at the group clinic, and be seen by clinicians who already know them, and who are in contact with the primary care GP.

Because, while its the person with pain we want to help, there are other goals as well – relieving the burden of care of GP’s, reducing the use of emergency departments for what is a chronic health problem, limiting the number of health professionals the person needs to see, and using what already exists in the community.

Another alternative is to regularly provide “education” sessions to people with chronic pain. Combine this with giving people a clear indication of what to expect from seeing each health professional, and leaving the responsibility to make an appointment with those professionals, and we have the beginnings of a system based on patient’s readiness. This has already been implemented in Western Australia.

The reason I focus on supporting GP’s and using allied health instead of medication management is that we know medication has a limited effect in many forms of chronic pain (Turk, Wilson & Cahana, 2011). We also know that even when pain is reduced, without addressing underlying fears and specific concerns, people may not return to normal activity. The majority of predictive factors for ongoing disability associated with chronic pain are psychosocial – pills don’t fix beliefs, entrenched behaviours, family situations and not having a job. And a seven minute consultation with a GP cannot possibly address these things either. What does help is skilled, effective and specialised help from clinicians who understand “doing”. People with chronic pain don’t need pills, nor do they always need mental health management – what they DO need is a focus on practical ways to get on with life. I think that’s a better way to meet the needs of people with chronic pain.

 

Breen, A., Austin, H., Campion-Smith, C., Carr, E., & Mann, E. (2007). “You feel so hopeless”: a qualitative study of GP management of acute back pain. European Journal of Pain: Ejp, 11(1), 21-29.

Coudeyre, Emmanuel, Rannou, Francois, Tubach, Florence, Baron, Gabriel, Coriat, Fernand, Brin, Sylvie, . . . Poiraudeau, Serge. (2006). General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain Vol 124(3) Oct 2006, 330-337.

Kroenke, K., Krebs, E. E., Wu, J., Yu, Z., Chumbler, N. R., & Bair, M. J. (2014). Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. Jama, 312, 240-248. doi: 10.1001/jama.2014.7689
10.1001/jama.2014.7689.

MacNeela, Padraig, Gibbons, Andrea, McGuire, Brian, & Murphy, Andrew. (2010). “We need to get you focused”: General practitioners’ representations of chronic low back pain patients. Qualitative Health Research, 20(7), 977-986.

Turk, Dennis C., Wilson, Hilary D., & Cahana, Alex. (2011). Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226-2235. doi: 10.111/j.1468-1331.2010.02999.x

Williams, C. M., Maher, C. G., Hancock, M. J., McAuley, J. H., McLachlan, A. J., Britt, H., . . . Latimer, J. (2010). Low back pain and best practice care: A survey of general practice physicians. Archives of Internal Medicine, 170(3), 271-277.

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How much attention to psychosocial issues?


I’ve been asked, from time to time, to give some sort of screening questions or questionnaires that medical practitioners can use in their practice, so that I can avoid covering so much psychosocial material, especially in my teaching job. I’ve struggled with this for many reasons, and have had a hard time pinning down why I’m not all that keen to do it. Now I don’t want to stop medical practitioners from considering psychosocial factors when they’re assessing pain, far from it – quite the opposite in fact! But at the same time I worry about developing a “Dummies Guide”.

Psychosocial factors can seem incredibly complicated and difficult to understand. Some practitioners think it’s well outside their scope of practice – yet they’re working in pain management where the biopsychosocial model is widely accepted. Some practitioners think it’s way too woolly to come to grips with, all this “soft” stuff about beliefs and emotions, yet some of the crunchiest statistical and neurobiological mechanisms are used to understand it.  Some practitioners still see psychosocial factors as relevant only as reactions to the real stuff going on in the tissues, which is a particular concept developed in the 1890’s by Strong, one of the American Psychological Associations presidents.

He divided the experience of pain into two parts: the physical sensation and the psychic reaction to this sensation (Strong 1895). Researchers maintained this view until the 1940’s, thinking that pain could be separated into the perception of pain, and the reaction to pain. In this view of pain, perception of pain was a neurophysiologic process involving relatively simple and primitive neural mechanisms while the reaction to pain was a complex psychophysiological process involving cognitive, learned experience, culture and other psychological factors to produce a variable reaction pain threshold (Bonica and Loeser 2001). While psychosocial factors were incorporated into the model, neurophysiological processes involved in transmitting “pain signals”, or nociception were believed to be the primary mechanisms. Thankfully Melzack & Wall (1965) began the revolution showing that pain is intimately connected with our brain’s way of determining bodily threat. Nervous systems including the brain are needed for pain to be experienced, but it’s a judgement call that is considered amongst the other competing goals relevant to the individual in that context.

There are some very good reasons, IMHO, for maintaining the complexity of the psychosocial concepts as we understand them today. These are my thoughts:

  1. Without truly grasping the idea that pain is an emergent experience and the sum of biological, psychological and social factors, it can become only too easy to focus only on psychological risk factors. By this I mean that although clinicians may learn about psychosocial yellow flags (risk factors for chronic disability), they way they’re construed is that they’re the reason for physical treatments failing. So, if the person doesn’t respond to usual treatment using physical modalities (including pharmacology and needles and exercises) then clearly the issue is now psychosocial – and that means “I don’t have to deal with this”. (Thanks to a very good physiotherapist for telling me that this is how she learned it until she studied more). This viewpoint clearly reverts to the Cartesian dualist model.
  2. By only considering psychosocial factors as risk factors, clinicians are likely to forget that everything that is said, done and even the treatment context has an influence on outcome. Risk factors may be what the person with pain brings with them into a treatment setting, but if clinicians forget that treatment is an interaction between at least two people, they may forget that they too have beliefs, come from a particular culture, have developed a clinical/professional persona, and that all of these things and including what they say and how they say it affect the patient. These things matter – they affect what the person with pain understands about what is happening to them, and also what might happen to them in the future.
  3. Sometime when risk factors alone are considered, clinicians can fail to recognise individuals bring strengths with them as well. After all, people who come to see a clinician have got themselves up, traveled to an appointment, and carried out the tasks of everyday even though they have pain: they have coped at least to a degree. If we only attend to risk factors, we probably don’t think about how well a person is doing, or what they can do to enhance their wellbeing, or build on what’s already working for them.
  4. Psychosocial factors are definitely complex. That’s not necessarily a reason to try to dumb them down. After all, human body systems are also complex, and we don’t see attempts to simplify things like motor control, or bone remodeling or neurobiological systems and their response to pharmaceuticals. I’m sure that if I asked a medical practitioner to sum up the “things I need to know about prescribing” in a “dummies guide” I’d be shot down in flames, and rightly so. Frankly there just are some complicated things we need to learn if we’re going to work effectively with people who have pain, and particularly people who have chronic pain.
  5. Finally, I’m loathe to simplify psychosocial concepts because I don’t know where the clinicians I teach (or blog to) practice. I don’t know their contexts, and I don’t know what they already know. I don’t think it’s right to assume that everyone works in primary care, or secondary care. I don’t want to assume that everyone has a team to refer to. I don’t think I should decide what is and isn’t relevant to a clinician. And I think clinicians are smart enough to work out what they want to do with psychosocial material. I also know from learning theory that by processing and using information, we begin to integrate that knowledge rather than treating it as some sort of “add-on” to daily practice.

The fact is that for most health professionals, with the exception of those working primarily in mental health, psychosocial concepts are not taught nearly as thoroughly as biological ones. I can assume that most clinicians working in pain management know anatomy, physiology of normal healthy bodies, understand concepts like inflammation or bone remodeling or nerve transmission.

Unfortunately, I can’t say that most clinicians remember Psych 101 from first year, and so I need to go through basics like operant and classical conditioning. I need to review things like measurement concepts. I need to help people recall attention and social learning theory and become familiar with self efficacy as a concept, along with internal and external locus of control. And that’s before beginning to look at constructs like catastrophising.

Because if I don’t do a good job, the idea of catastrophising, for example, becomes yet another pejorative label to give to someone who doesn’t respond to “normal” treatment. Another way to place the blame on the individual with pain rather than thinking about what and how clinicians do their job. I’d rather that people became more familiar with the complexity of pain and began to attend to what they do.