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

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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.

 

An apology to the Australasian Faculty of Musculoskeletal Medicine


Some months ago I wrote a blog post about fibromyalgia, and mentioned that a group of clinicians seem to believe that psychosocial issues are not important when nociception can be abolished.  A commentator took issue with my comment, and I very quickly amended the post. You can read the amended version here.

I also offered an invitation to the people who were offended by my statement that : if you’re able to demonstrate HOW you integrate biopsychosocial approaches in your practice, I’ll publish it. 

Today, however, I found out that the AFMM has written to the University and wishes me to be censured, and that I should apologise for that blog post.

I wrote that post pointing the finger at a specific group of clinicians, and I apologise for causing them offence.  I sincerely do not want to point the finger at any clinician who integrates biopsychosocial aspects of pain and pain management into their practice.

As I stated in my amendment to that post, it’s simplistic to suggest a single discipline is at fault, but any profession that does not address the person as a whole (person-in-context) and particularly the psychosocial factors (because they’re so strongly associated with longterm disability associated with pain), needs to take a good look at the broad pain literature.

The AFMM is aware that the post was immediately amended. The invitation to publish a post showing how the psychosocial factors are addressed by this group of clinicians remains open – I welcome open discussion because the practicalities of HOW to incorporate all three elements of the model needs to be discussed widely to help reduce the risk to people with pain, especially those who are at risk of developing ongoing disability associated with their pain.

That’s the beauty of social media – we can ALL contribute to the discussions, clinicians, academics and patients alike.  I’ve had a wonderful response to posts I’ve written over the years I’ve been blogging (since 2007). Over 1 million hits from all around the world in that time, many from patients but even more from clinicians.  I see blogging as a really useful way to extend the conversations beyond the closed doors of the clinic, and the offices in the ivory towers, and the associations and faculties and other regulatory bodies.  Some people don’t like what I post, others welcome what I write – whatever reaction in response to a blog post means people are thinking about chronic pain. And that is a good thing.

 

through the heavens

Complex regional pain syndrome: yes, it’s complex


ResearchBlogging.orgComplex regional pain sydrome or “CRPS” (pronounced CRIPS) is an enigma. It’s complex. It involves different body systems. It’s very, very painful, and it can be incredibly disabling. It has had lots of different names over the years – in 1982 when I trained it was called “causalgia” or “Sudeck’s atrophy”, but in 1993 the International Association for the Study of Pain developed guidelines for diagnosing and managing this complex pain problem.

Since then we’ve heard a lot about CRPS, at least those of us working in the pain management field have. I am not so sure that the general public, or even healthcare professionals who don’t deal primarily in pain will have heard nearly so much.

What is it?

CRPS is a pain problem that may develop spontaneously (roughly 10%), but more often develops after what seems to be a trivial kind of injury. I’ve seen people develop CRPS after a cat bite, an abrasion to an ankle, an undisplaced metatarsal fracture, and a rose bush scratch. It can also develop when a limb is immobilised (for example after a fracture or sprain), after surgery, and stroke. What people will experience is very high pain intensity (more than normally expected with a minor injury), changes in skin colour (either pale, blue, or red or mottled), swelling, hyperalgesia (increased pain with usually painful stimulus), allodynia (pain with usually nonpainful stimulus), and changes to movement. Pain doesn’t conform to a dermatomal or myotomal pattern, but might be like a glove, or a sock, it may spread far from the original insult, can even go to the other side of the body, and can lead to skin ulceration and tissue breakdown.

That’s in the worst case, of course. Many CRPS begin with fairly vague symptoms that can quickly become severe, while others will begin with very severe symptoms but rapidly resolve. It usually begins, however, with a burning, tingling, electric shock type of pain (neuropathic type pain).

It’s hard to identify the number of people who develop CRPS partly because it can resolve very quickly in some people, and partly because it’s a complex problem to diagnose – not the least because it can occur in acute treatment settings where perhaps clinicians are not fully aware of the potential for a chronic pain problem to develop. The open source paper I’ve cited indicates that two studies show an incidence of 5.4 – 26 per 100,000 people, and a prevalence of 20.57 in 100,000, with a female:male ratio of 3.4-4.0:1. Two more recent studies found 3.8% of 1549 people with wrist fracture developed CRPS within four months, while another 7% of 596 people with wrist, scaphoid, ankle, or metatarsal fracture.

What this means is there are a lot of people who experience CRPS after what usually looks like a simple fracture. And of course, many of these cases resolves spontaneously, and it’s not yet known why some fail to resolve and can turn particularly nasty.

What are the mechanisms?

Here the contenders: ” disturbances involving abnormal response to tissue injury, peripheral and central pain sensitisation processes, neurogenic inflammation, endothelial dysfunction, disturbed sympathetic-afferent coupling, hyperalgesic priming, somatosensory cortical reorganisation, genetic predisposition, and even some degree of autoimmunity”.

That’s quite a few! No wonder it’s called “complex”!

What do we do about it?

Unfortunately, even though there have been many studies looking at ways to treat CRPS in a recent Cochrane review the conclusion was that most approaches are not very strongly indicated. In other words, the field is wide open.

Moseley and associates in Adelaide have certainly made waves about using “brain training” to address cortical reorganisation with CRPS, but an overview of recent meta-analysis found that graded motor imagery (asking an individual to imagine progressively more complex movements of their affected limb), laterality training (asking an individual to identify left or right hands/feet or other body parts amongst more and more complex settings) and mirror training (using a mirror to reflect the unaffected limb, to “fool” the brain into seeing it as the affected limb but not experiencing pain), were somewhat useful when compared with “usual care” (whatever that is!), that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo, and low quality evidence that physiotherapy and occupational therapy have positive effects but after one year, have limited effect when compared with social work support (O’Connell, Wand, McAuley, Martson & Moseley, 2013).

What does this mean? Well, we don’t have very much to go on.

Here’s my take on managing CRPS based on my clinical experience and reading this literature.

All treatment is a balance of risks and benefits. The risks associated with having substances put into a body are well-known, and the findings from O’Connell’s review suggest that there are adverse affects with all of the pharmaceutical approaches, along with some benefits. The studies weren’t methodologically strong on the whole, and many of them didn’t use patient-oriented outcomes, particularly quality of life measures (remember this!). I think if I had CRPS I’d be happy to try some of the infusions – but I’d want to have an end-point in mind. If it didn’t change my pain so I could engage in using my body part I’d be likely to stop within a month.

Because graded motor imagery, laterality and mirror therapy are all non-invasive, I’d be happy to try these. I would need to be prepared for some weird effects – having put my hand into a mirror box already and experiencing some odd perceptual effects I’d be prepared for these to be far greater if I had CRPS. I’m also pretty slow at laterality identification. Once again I’d be keen on establishing, from the outset, a time frame for response – but these approaches appear relatively safe. I have to say that patients I’ve worked with have reported increased pain at times, and “feeling weird” or slightly disoriented.

I would also be ready to try a treatment that wasn’t included in this review – and I think it didn’t feature because it was a very, very small sample size, a repeated measures “N = 1″ trial using single subject experimental design. This was a graded exposure in vivo (not graded imagery) following Vlaeyen’s fear-avoidance approach. In contrast with GMI and mirror therapy, this approach addresses avoidance rather than pain intensity (deJong, Vlaeyen, Onghena, Cuypers, den Hollander & Ruijgrok, 2005) .  In the study, people were asked to develop a hierarchy of feared and avoided tasks, and were introduced to those tasks beginning with the least feared. The aim wasn’t to reduce pain but instead to reduce avoidance and increase use of the affected limb.

Why would I try this? Because the thing I’m most worried about is being confident about doing things. Pain is often not able to be reduced – it happens in many chronic pain conditions. Pretty much all the other interventions are aimed at reducing pain, and my experience with working with people who have pain reduction as the focus is that this can (not always) lead to a delay in “getting on with life as it is now”. Instead, people invest a lot of energy and time into trying to “get back to normal”.

Of course it’s a personal question: how long do you wait before deciding it’s more useful to get on with life as it is, or stay looking for a chance to go back to “normal”. I can’t answer that for anyone else except myself – but I wonder if people are given a fair chance to think about the possibility that a person CAN live well with their pain?

 

de Jong, Jeroen R, Vlaeyen, Johan WS, Onghena, Patrick, Cuypers, Corine, Hollander, Marlies den, & Ruijgrok, Joop. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain, 116(3), 264-275.

Fukushima, F.B., Bezerra, D.M., Villas Boas, P.J.F., Valle, A.P., & Vidal, E.I.O. (2014). Complex regional pain syndrome BMJ, 348 (g3683 )

O’Connell Neil, E., Wand Benedict, M., McAuley, James, Marston, Louise, & Moseley, G. Lorimer. (2013). Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database of Systematic Reviews, (4). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009416.pub2/abstract doi:10.1002/14651858.CD009416.pub2

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Managing pain is an experiment


I’ve been thinking a lot about clinical reasoning recently.  There’s been a lot written about clinical reasoning, but not as often applied to pain management, which is a shame.  One definition of clinical reasoning is that it is a “complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyse patient information, evaluate its significance, and weigh alternative actions” (Simmons, 2009).  It’s often used synonymously with with decision-making and clinical judgment. It’s not diagnosis alone, although it includes diagnostic reasoning, and it includes decisions made how to assemble the information collected into a form that can be used to make decisions. Got that?!

OK, so why do I think that managing pain is an experiment? Is it just trial and error?

Let me unpack some of this for you.

For something to be an experiment, we need to “perform a series of actions and carefully observe their effects in order to learn about something”, according to the Merriam Dictionary. It usually involves manipulating one or more variables, with the intention of influencing another dependent variable. There are often a number of unknowns, and other variables that need to be controlled to ensure that only the one variable is influencing the outcome. Of course, in people and in the real world, this is nigh on impossible. But the principles apply.

In chronic pain management, there are many factors involved – this is why we often work in interdisciplinary teams, because no single discipline can possibly attend to all the factors that may be present. Some of the variables are known. We know, for instance, that women are more often affected by chronic pain than men. Some of these are less well-known: we may not realise that some clinicians treat women with chronic pain differently from men with the same problems (Hirsh, Hollingshead, Bair, Matthias, Wu & Kroenke, 2013).

We arrive at a problem with ideas in our heads based on our training, our knowledge base, recent patients we’ve seen, new information from journals or conferences or blogs, striking experiences such as a person who reacted badly to a treatment, or someone who responded really well. We also bring our ideas of what matters in a clinical presentation in the form of a model. Models are simply representations of the relationships between variables thought to be important. We all carry them, whether we’re aware of them or not. This means that some variables are therefore thought to be less important, and are perhaps disregarded.

There are some certainties when working in acute pain management: we know, for example, that if we remove nociceptive or inflammatory input as soon as possible, most of the experience of pain reduces, leaving the person with memories and beliefs about what should happen if they ever have that kind of pain again. So, if a bone is broken, we know that if it’s aligned and stabilised, most of the pain disappears. If there’s an infection in a finger, we remove the splinter, get rid of the pus and the finger heals with pain subsiding. And person experiencing pain processes what has happened and assembles information about what should go on if a similar event happens again. People around that person also understand basically what is going on, and what to expect. And their idea of what they should do is also developed.

But chronic pain is different. Chronic pain doesn’t follow the rules of acute pain, and although there have been some strides forward in understanding it, we don’t have a simple mechanism-based approach to get rid of the pain and allow the person to get on with life, in most instances.

Instead we have a person who is experiencing something mysterious, something that doesn’t make sense, and doesn’t follow the rules. Additional variables become far more important than they are in acute pain, while some variables that are vital in acute pain become less significant.

What’s different and why does it matter?

Apart from the less clear-cut underlying neurobiological mechanisms involved in the pain experience, chronic pain affects people as they engage in normal occupation (see this wikipedia entry for more information about why occupation is important). Occupation, or the normal daily activities we do within the context of our lives, informs and is informed by our sense of self identity. When we can’t do the things we need or want to do in daily life, we become aware of losing something important: our sense of self. People experiencing chronic pain encounter challenges and threats to self identity as they do the normal things of daily life. They may find it hard to sit to read or watch TV, they find it hard to clean their teeth, they may have trouble attending work, they can have difficulty sleeping, or going out socially – all those things that people do that reinforce a sense of self and purpose in life.

While “taking the pain away” may help a person return to many of their usual occupations, it fails to address the underlying problem of loss of identity. Can this person trust that this threat to identity has really gone? How has this person changed as a result of this experience? What meaning has this person made of their experience?

This is far more complex than simply abolishing nociception and inflammation. It’s much more about considering the factors that help a person make sense of their pain, weave that meaning into their sense of self identity, abandon aspects of self that can no longer be sustained, generate new understanding of capabilities and purpose and go on to engage in what is important in their lives.

Because (a) there are so many variables, (b) each individual’s past learning is different, (c) each person’s sense-making is unique and (d) each person’s future and the way they express their sense of self is distinctive and particular to them, we as clinicians can never just apply the same reasoning as we have to another person.

This means we need to generate models that allow us to gather information across many different domains that may influence why this person is presenting in this way at this time, and then carefully tease out the relevant factors that will allow us to collaborate with that person to become less distressed and less disabled – and much more themselves. We need to carefully monitor “what happens” when we suggest an intervention. We can’t assume that the end point achieved for one person is the same as the end point for another. We need to travel from information collection right through to culmination of the experiment which isn’t just when we stop treating the person.

Managing pain is an experiment for everyone. We, clinicians and patients alike, DO NOT KNOW what will “work”. Being honest and transparent about this might help both to collaborate and avoid dogmatism.

 

Some interesting readings on gender, ethnicity, and depression on clinical judgement:

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.

Parsons, S., Harding, G., Breen, A., Foster, N., Pincus, T., Vogel, S., & Underwood, M. (2012). Will shared decision making between patients with chronic musculoskeletal pain and physiotherapists, osteopaths and chiropractors improve patient care? Family Practice, 29(2), 203-212.

Hirsh, A., Hollingshead, N., Bair, M., Matthias, M., Wu, J., & Kroenke, K. (2013). The influence of patient’s sex, race and depression on clinician pain treatment decisions. European Journal of Pain, 17(10), 1569-1579.

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.

Scott, N., Moga, Carmen, & Harstall, Christa. (2010). Managing low back pain in the primary care setting: The know-do gap. Pain Research & Management, 15(6), 392-400.

pooling

Gaps, and answering gritty questions


Research journals are full of really interesting studies, but some of the studies I’ve been reading lately seem to lack something. While they’re interesting, they don’t seem to approach some of the gritty questions clinicians need answers to. There are enormous gaps in our understanding of processes of healthcare delivery.

I like to get practical when I want to ponder things. I’ll weed the garden, prune the roses, take some photographs, and recently I’ve even taken to getting out in the garage to carve and sand wood, rip pallets apart – and while I do, I let my mind wander over things that puzzle me. I don’t have answers.

So where has my mind been wandering recently?

One question I have is why there is so little information on the long-term relationship between primary care clinicians and people with chronic pain.

There’s a little on how people get the label/diagnosis of chronic pain, like this paper from Allegretti, Borkan, Reis & Griffiths (2010), where interviews between patients and their doctors were analysed, finding that many times doctors and patients talk past one another, and that doctors may hold a more biopsychosocial model than their patients. Another paper (Dow, Roche & Ziebland, 2012) points out the frustration that patients with chronic pain often express, and their keen desire to have their pain acknowledged, recognised and validated. There’s even a paper exploring patient’s experiences when attending a pain management specialist service (Harding, Parsons, Rahman & Underwood, 2005), but the real passionate cry was for those wanting medical practitioners to give a consistent message that also validated their experience. But these studies look only at short-term relationships, rather than what it’s like to have a long-term relationship with a provider.

There’s also information available on how doctors break bad news to their patients – diagnoses like cancer, or other life-limiting illness. But as Karen Schaepe (2011) says, mostly these diagnostic discussions are presented as a single event where the person is “given the bad news” – but for most people, getting to a definitive diagnosis is a process involving investigations, telling and re-telling the story, experiencing all the things that make up our health service delivery before “that day” when they finally hear about what is going on. And these prior experiences are embedded in the way the diagnosis is made and then experienced.

So I’m interested in how medical practitioners, particularly those working in primary care, respond to the ongoing needs of those with chronic pain.

I’m also curious about how medical practitioners tell people that they have chronic pain, or a chronic health condition that is painful.

This area is relatively unexplored. It seems particularly important given recent recommendations for diagnosing fibromyalgia. Rather than intensive investigations, the 2012 Canadian Guidelines for Diagnosing and Managing Fibromyalgia (here), recommends primary care clinicians make the diagnosis after firstly excluding the nasties, then a clinical evaluation which includes a history of current complaints, attention to past health status and a physical examination, without any confirmatory diagnostic test. The Fibromyalgia Impact Questionnaire is suggested as a useful tool in this endeavour.

But, as people with fibromyalgia know, it often takes a long time before this happens. Why? Because fibromyalgia, like many other chronic pain problems, can present insidiously, symptoms may differ depending on the individual, people can be passed from specialist to specialist, all looking at their own special body system while failing to appreciate the whole presentation.

Doctors do what doctors are used to doing, much like every health professional there is! Typically, a GP with limited time within a consultation, is processing all the various presenting features while simultaneously sifting through the possible diagnoses – and tending towards a conservative mindset, probably because of medico-legal concerns, look for ways to refer the person on for investigations or management from someone who can give a definitive answer.

While GP’s are there to work with the whole person-in-context, and they do (usually) see a person over years, they depend many times on other people to come up with a diagnosis and management plan. Then they will support that plan’s implementation – but perhaps only if it fits within a biomedical model. It’s rather more difficult for a GP to spend the time needed to understand how a person lives their life and could make changes.

So, when a person with chronic pain presents with a flare-up, which is common and part of having chronic pain, and if the GP hasn’t connected the dots and realised that this pain exacerbation is not a new problem, the person can be referred yet again to another specialist for another opinion and another management plan.

I’m curious as to why medical practitioners struggle to tell people that their pain is likely to remain, and that a pharmaceutical or procedural or even surgical option is not available. I can recognise that perhaps it’s because their model of pain is not well-developed. That it could be a way to manage a waiting room full to bursting with coughs and strains and osteoarthritic knees. I wonder if it’s a way to manage their own empathic response to another human in distress – by referring on, rather than giving the bad news and coming alongside the person to support finding management options. While there are many people who argue that it’s a calculated way to keep patients dependent on returning for treatment, I’m not so sure this happens as often as the cynics might think. I wonder if it’s another of those cognitive biases we all have – the tendency to look for confirmatory data rather than looking for information that disconfirms our suspicions.

For all the progress made in reconceptualising pain as a biopsychosocial emergent experience, I think helping medical practitioners shift from a “fix it” model to an interactive one, one where it’s OK to come alongside and sit with a person without wanting to DO something to take it all away, has a long way to go. Maybe it’s a woman thing – I often don’t want someone to fix it, to give me a solution, but I want someone to say “That’s really hard, that’s such a lot to deal with, no wonder you’re feeling overwhelmed”. I’m just not sure how we work our way towards this, particularly in light of a comment from a doctor saying “there’s too much attention paid to pain, I want to study medicine”.

 

Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. doi: http://dx.doi.org/10.1093/fampra/cmq063

Dow, Clare M, Roche, Patricia A, & Ziebland, Sue. (2012). Talk of frustration in the narratives of people with chronic pain. Chronic Illness, 8(3), 176-191. doi: 10.1177/1742395312443692

Harding, G., Parsons, S., Rahman, A., & Underwood, M. (2005). “It struck me that they didn’t understand pain”: the specialist pain clinic experience of patients with chronic musculoskeletal pain. Arthritis & Rheumatism: Arthritis Care & Research, 53(5), 691-696.

Schaepe, Karen Sue. (2011). Bad news and first impressions: Patient and family caregiver accounts of learning the cancer diagnosis. Social Science & Medicine, 73(6), 912-921. doi: http://dx.doi.org/10.1016/j.socscimed.2011.06.038

Please note: this is not my image!

Interrupted by Pain


If there’s one thing I loathe, it’s being interrupted when I’m in the middle of something. There I am, working away at something, in the flow, knowing where I’m going and what I’m doing then BANG! something gets in the way!

I wasn’t aware, but there is a science of interruptions – mainly studied within ergonomics or human factors research (the study of work and humans) – and this science has begun to unravel some of the issues associated with interruptions. Interruptions are not only annoying, they’re also a good way to provoke mistakes!

Pain is, as Geert Crombez and others have shown, a stimulus we find difficult to ignore. It interrupts what we have planned, and orients us towards finding ways to escape the stimulus. Of course, when pain doesn’t stop, as in chronic pain, people learn to deal with the interruptive effect of pain so they can get on and do things that are important – but at the same time, because part of our brains must deal with the pain in some way, our performance can be degraded.  Essentially, to continue doing something important when pain is also present requires us to deal with goal conflict. 

What happens when a person becomes aware of his or her pain while working on another goal?

Well, initially, the goal pursuit remains strong – our brains are very good at prioritising what we want to do, except when the new stimulus is salient (relevant), novel (new) and intense. Pain is (usually) relevant (it’s a threat!), is experienced as something new or different about our bodily status, and varies in intensity. So in the context of a task, people may remain focused on the task until the pain is intense enough, or meaningful enough, or new for it to capture the attention.

So, pain gets in the way, and we attend to the threat and the threat reduces.

After some time, we return to what we were doing – but the time that it takes to get back to what we were doing differs depending on a bunch of things.

Those things include

  • the threat value of the pain,
  • how readily it resolved,
  • how close to the end of the original activity we were,
  • how quickly we oriented towards the pain (the more quickly we do, the less easily we return to doing what we were originally doing, perhaps because we don’t have time to code the need to return to it into our memory before we move on to address the pain),
  • whether there are cues in the environment that help us remember to get back to the original activity

and a bunch of other things as well.

Some interesting facts have emerged about interruptions – if we have many interruptions, it’s easier to adapt to them and get back to the original task (which is possibly why mothers are known to be good at multi-tasking!); unpredictible interruptions are more difficult to recover from, they’re more disruptive; interruptions that last a long time make it more difficult to return to the original task.

In the case of chronic pain, pain is usually present to at least a certain degree all the time. It’s when it is intense, or the character changes, or it is particularly salient, or perhaps our overall coping is less, that pain interrupts more. So, for some people, it’s possible to delay being taken off task to attend to pain because these people might have learned that it’s “nothing unusual”, it isn’t a threat, it will subside of its own accord, or it’s just less important than the goal they’re working on.

For those of us who do deal with chronic pain, the aspect that may still trip us up is getting back to the activity we were working on before we needed to take a break because of our pain. If we need to take a long break, if we stop the original activity without having clearly planned to stop, if we don’t give ourselves cues to return to the activity, we might find it more difficult to remember (a) where we were in the activity, and (b) that we actually were working on something!

The relevance of interruptions becomes very important when, as therapists, we suggest to people that they consider using activity pacing.

While the definitions of pacing are not clear and still being debates, essentially it means interrupting what a person is doing to take a break, regain energy or maintain pain at a reasonable level. I’m sure many of you will remember the old-fashioned programmes on the computer that used to flash up a screen telling you to STOP! and do a break or stretch. You could “ignore” it a few times, but eventually it would lock your computer so you couldn’t use it until you’d taken the predetermined break. I LOATHED it! I’d be halfway through writing something and it would stop me and get in the way. So I deleted the programme.

That’s one of the problems of these kinds of approaches to activity management – they may stop you “overdoing” something, but they often stop you from completing a task, and completely disrupt your thinking!

My preferred way of helping people to use “pacing” was to suggest “activity chunking” where, at the completion of some chunk of an activity, the person could take a quick break to do a body scan or stretch or something. I found that people used this strategy more often, complained less often, and consequently relaxed a lot more!

After reading about pain and interruptions, I can now understand why this strategy was a little more effective – because at the end of a chunk of activity there are cues established in the memory to remind us that we’ve got a task to complete. These breaks were planned and expected, so they were easier to anticipate, and therefore accommodate.  Eventually, as people got good at them, they become habitual and no longer seem to get in the way of doing the original task.

Pacing, interruptions and pain. People with chronic pain are chronic multi-taskers. We know multi-tasking isn’t good for cognitive efficiency, accuracy or even energy (see the references below), so quite apart from the added burdens we as clinicians might give to people with chronic pain by suggesting “pacing”, people who have chronic pain are chronically stretched cognitively.

My suggestion for managing the demands of pacing and pain is to use planned breaks, preferably using chunks – or, as I’ve been doing recently, using Pomodoro technique to plan and schedule my activities and breaks. I also use mindfulness when my pain begins to get noticeable. By doing this I can remain “on task” rather than distracted.

Conard, M.A., & Marsh, R.F. (2014). Interest level improves learning but does not moderate the effects of interruptions: An experiment using simultaneous multitasking. Learning and Individual Differences, 30, 112-117.
Finley, J.R., Benjamin, A.S., & McCarley, J.S. (2014). Metacognition of multitasking: How well do we predict the costs of divided attention? Journal of Experimental Psychology: Applied, 20(2), 158-165.
Gatzounis, R., Schrooten, M. G. S., Crombez, G., & Vlaeyen, J. W. S. (2014). Interrupted by pain: An anatomy of pain-contingent activity interruptions. PAIN®, 155(7), 1192-1195. doi: http://dx.doi.org/10.1016/j.pain.2014.03.017

Katidioti, I., & Taatgen, N.A. (2014). Choice in multitasking: How delays in the primary task turn a rational into an irrational multitasker. Human Factors, 56(4), 728-736.
Munneke, J., Fait, E., & Mazza, V. (2013). Attentional processing of multiple targets and distractors. Psychophysiology, 50(11), 1104-1108.
Sanjram, P.K. (2013). Attention and intended action in multitasking: An understanding of cognitive workload. Displays, 34(4), 283-291.