Not a day for hanging out the washing

Education or a cognitive behavioural approach?


ResearchBlogging.orgThere is a reasonable amount of evidence suggesting that self management of chronic pain is only moderately effective.  Some of the factors thought to influence outcomes include the “one size fits all” approach – people with chronic pain may not all equally benefit from the same aspects of a programme; that programmes are usually delivered within a university-based, middle-class, North American setting and that there may be moderating or mediating factors that influence the who and what actually works within a programme.

I was interested to read about an RCT of “education” and “cognitive behavioural approach” conducted by Day, Thorn and Kapoor.   Dr Bev Thorn has written many books and research papers on a structured cognitive behavioural approach for pain that specifically addresses the appraisals people make of their pain.   In this approach, people are taken through a process of firstly identifying their appraisals, then learning how to challenge and restructure their thoughts about pain, while at the same time learning to do activities that they may have avoided for some time.  One feature of a CBT approach is using  “home learning” activities to bridge between sessions and help generalise the learning.

By comparison, an educational approach provides accurate information on aspects of pain and coping strategies, but doesn’t include the “home learning” and doesn’t directly address ways to identify and restructure thinking about pain.

One of the problems with many cognitive behavioural programmes for pain management is that they demand a lot from their participants – and particularly, they require literacy.  There can be, if not carefully structured, a lot of writing.  For people who don’t do writing or pen and paper activities, this can be really off-putting.  The sessions are also somewhat “talky” – again, this can be off-putting for people who prefer action and doing.

In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8.  Both groups received a group-based programme of 10 sessions of 90 minutes.  They both received a workbook and additional reading material.  The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not.

Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced.  Instead it presents thematic analysis from in-depth interviews of the participants.

What this analysis found was that while the CBT group participants initially found it difficult to “get into” the process, they spontaneously identified many of the CBT elements that were meaningful to them such as intermediate beliefs, the ability to “redirect” thinking, and integrating activity management strategies such as pacing and task perseverance.

Fewer of these themes emerged from the education group, although group process factors similar to that identified in the CBT group were found.  Both groups identified that it was good to know they weren’t alone and that they learned from other members in the group.  Both groups also identified that they felt more confident and in control of their situation, that they could “rise above” their pain.

Where the groups also differed was in their engagement in preferred life activities (occupations).  Participants in the CBT group indicated that they were returning to preferred social activities, sports and leisure activities and that they believed they were able to persist with these despite an increase in pain.  This didn’t occur in participants involved in the education group.

What does this tell me?

Well, a couple of really important things.  While we don’t know which parts of the self management programmes do the hard work for people with chronic pain, it seems that a group approach has some unique benefits irrespective of the type of programme offered.  People with chronic pain often feel isolated and very alone, as if they are the only people with their specific problems.  A group approach provides an opportunity to normalise these experiences.

I also take the idea that information alone doesn’t necessarily initiate change – structured goals seem to help, setting an expectation that learning and engaging in activities between sessions may help, the feedback and problem-solving may help too.  It could also be the process of cognitive therapy – learning to identify thoughts and beliefs, and restructure these may be helpful.

We can’t, from this study at least, determine which of these ‘active ingredients’ is doing the trick.  I rather fancy that although the cognitive aspects certainly play a part, it could be these other aspects – setting expectations, supporting change, problem solving – these could actually be the parts that get people started on doing things differently in their own environment.

Is it time for a different take on self management? Maybe it’s time to embark on a less educational, more occupation-focused approach that incorporates cognitive restructuring in an active and “doing” way as part of problem solving – what do you think?

Day, M., Thorn, B., & Kapoor, S. (2011). A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education The Journal of Pain DOI: 10.1016/j.jpain.2011.02.354
Miles, C., Pincus, T., Carnes, D., Homer, K., Taylor, S., Bremner, S., Rahman, A., & Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs European Journal of Pain DOI: 10.1016/j.ejpain.2011.01.016

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7 comments

  1. HI Bronnie
    It looks like you are setting people up to make an either-or decision – CBT OR education. Why would anyone provide education (new cognitions) without then using this to change behaviour?
    Also, even though you started with a comment about cookey-cutter approaches, this either-or sets the tone that we should be looking at what helps the greatest number of people and then give everyone that intervention.
    Could you define self-management? how much guidance/coaching/cheerleading are they receiving?
    Would the outcomes be different if the subjects and the clinicians had high expectations of effectiveness, if the subjects were given enough time to create significant neuroplastic changes (we don’t know how long this is, but often research suggests At Least 90 minutes five days a week for 4-6 weeks), and if the people providing the education had a high skill and experience with providing pain education ( I have seen many people providing pain education with all the right info, but leaving the learners uninspired and believing that the teacher thinks ‘it is all in the head’?
    To the final point about occupation-focused approaches…. I am totally with this idea, and believe that changing physical behaviour should be the whole point of cognitive behavioural interventions. We need to change the nervous systems, and this can be done in many ways. Cognitions are one way. Changing input from the body is another, and it doesn’t require literacy, though it requires a good understanding of the patient’s culture, at the same time as excellent rapport skills.
    Our job should be to know how to positively impact neuroplasticity in order to change how the person moves and functions. Using occupational tasks is an excellent intervention when this in itself is not a major source of conscious or ANS wind-up.

    As always, thanks for the post – got me thinking!
    neil

    1. Hi Neil
      I believe the facilitators of both groups were experienced clinicians, or supervised psychology masters students. I’m not sure, on reflection, that the “education” sessions were as passive as I may have initially construed – I think the main distinction was between specific home-based activities that people were guided through alongside the cognitive “work” people were exposed to, and the information sessions that gave the ideas but not necessarily guided people into integrating them, along with no cognitive restructuring.
      I agree, sometimes people are given the impression that “it’s all in my head” when they participate in a programme based on cognitive behavioural therapy alone, equally with information alone – I don’t think this was the case here, but it’s a problem that can occur if not carefully managed.
      I actually don’t think there is a GOOD definition of self management – it’s a real bogey because without a clear and generally accepted definition there are all sorts of problems establishing whether the approach “works”. I’ll blog about it I think, because it is such a vexed question.
      I’m sorry I have the impression that I was suggesting “either-or” CBT vs education – I think this is something we have yet to grapple with effectively. At this point, I think we will need to continue with the “one size fits all” until we have a better handle on sub-groups. The moderator/mediator variables mentioned in the second paper in my reference list (forgot to draw attention to it in the post itself!) didn’t find any particular variables that made a difference. However, the old Westhaven-Yale Multidimensional Pain Inventory has been used to establish three main subgroups, and these groups have been used to provide targeted interventions – three week intensive pain management (five days a week, three weeks) for people who were identified as in the “dysfunctional” group, communication and relationship input alongside pain management for the “interpersonally distressed” group, and a basic outpatient group programme for people who were in the “adaptive coper” group – I’d say the participants in this study by Day, Thorn and Kapoor would have been in this last category.
      Establishing subgroups is incredibly difficult – not only do we need consistent methods to identify risk factors and other characteristics, we also need much better and more targeted interventions.
      And I still believe that group programmes provide a more helpful approach than individual sessions, although the studies are equivocal. There are certainly advantages and disadvantages to both – and maybe a combination approach would be a way through this minefield!
      Thanks for your thought-provoking comments as ever – you make me think!
      Bronnie

  2. Thanks for the response Bronnie
    Amazing how similarly we view many things.
    I know that in research we cannot change intervention based on the subject’s response, yet in clinical practice this I believe is where the best results come. When we can be committed to giving a technique a good try and then watching for when it is not working, we can change paths and interventions.

    As much as I find the science of many to be helpful in directing clinical practice, I think people do best clinically with the science of one – apply what is expected to work based on science, then reassess and modify to get the best results.

    To the point about psychology people educating about the science of pain, to date I have not experienced one who can talk physiology convincingly (without relating it back to psychology). Even most PTs I know struggle with truly understanding that pain is about physiology and biology – let alone translating that effectively to people in pain. Sure there is the body and the mind, but it is the activity of the cells and the systems we are trying to change, by using our body, mind and spirit.
    …a pet soap-box of mine…

    thanks for “listening”
    neil

    1. Neil, how much do people “need” to hear the physiology? Really? In the end, the effect of knowing that info is to help the person reconceptualise – and typically I think people think in broad brush strokes – “this pain isn’t bad for me” “this pain is unknown and therefore scary” “this pain hasn’t done what I think it should, therefore it’s scary”.
      I know it’s possible to teach basic neurophysiology to people, I’ve done it myself, but I’m not yet convinced that it’s necessary. I also know I’ll probably need to duck for cover saying that! Personally I like using Woolf’s classification of types of pain, neuromatrix and the CNS being “too sensitive” to input as my starting point – but despite this, it’s not what a person knows or the names they call things, it’s what those things might imply (or how the person appraises that information or sensation or situation) that is important. Because no matter what we currently know about pain, it’s the person who has to make up his or her mind to approach or avoid the sensations they experience, and in turn begin to reconceptualise their expectations. And for some people, all the information about what is going on is less helpful than simply doing things differently. Influencing the cells and systems requires the person to trust the practitioner sufficiently to try something out (ie appraise the situation in terms that make it OK for them to have a go) – and then allowing the results to speak for themselves. In pain, however, this can mean a lot of unlearning and anxiety when doing things differently can often lead to increased (mainly temporary) pain.
      I prefer to work from a case formulation that is generated with the person – a set of working hypotheses that are systematically and collaboratively tested by the person and me to establish whether the hypothesis is supported, or not. The risk of “changing tack” is that it can feel unpredictable to the person, it can be interpreted as blaming the patient for the intervention not working out, and it can be a case of the therapist simply trying anything/everything at random (or from some sort of recipe book method) as opposed to clear clinical reasoning. This is one reason a manualised approach doesn’t really work well – but in a group-based CBT approach, the individualising comes when the person is integrating skills in his or her own environment. The skills of identifying thoughts, generating alternatives and then using those alternatives are pretty generic, while the actual situations, thoughts etc may be quite individual. They can also learn by watching and hearing what other people do, and this can enhance learning by exposing them to alternative solutions that they may not identify themselves.
      BTW, “occupation” in this instance isn’t just work, but all those goal-directed activities that characterize daily human life as well as the characteristics and patterns of purposeful activity that occur over lifetimes as these affect health and well-being. The “occupational therapy” term “occupation”.
      cheers
      Bronnie

  3. Hi Bronnie
    I hear what you are saying, and I believe it is a totally excellent way to approach people.
    Language and internet are issues here – I think we are agreeing on a number of things but do not use the same words to express ideas.
    I do not believe there is one way to educate people in pain – but since their attitudes towards pain and recovery are massive barriers to recovery, we better do something that changes these, and measuring these beliefs in some way should always be an outcome measure.

    Here are related questions to the one about needing to know pain physiology. Do yoga teachers need to know anatomy to teach yoga? We need a case of wine to talk through that one. Or how about, do yoga practitioners need to know anatomy to be successful with the physical practices of yoga? This one might be a bit easier, and both are intended as rhetorical.

    I also believe that the best way for one person to treat an individual is not necessarily the best way for another to do so. Human experience is different from a chemistry experiment.

    I would never suggest a mindless changing tack in treatment, but as you state, start with hypotheses and work together with the person based on these – use scientific process as best as we can with this one person. When the hypothesis is not supported by observations in this person, I am suggesting that the clinician allows for mistakes and alters treatment rather than sticking with what is not working. The vast majority of clinicians I teach do not get this part. They have learned that they are not allowed to make mistakes or to be wrong, so they rigidly stick to treatments that are obviously not working – this protects their ego, and keeps them trapped in old paradigms.
    I like how your posts provide information to help people challenge their paradigms.

    Around pain education I htink about it this way – maybe treatment success is poorer when the clinician is not skilled in educating the patient based on neurobiology, regardless of what they teach. Otherwise they will be more likely to educate based on pathophysiology (cannot change that), or based on psychology(it is your fault, it is not real, …), or totally ignoring what science says about neuroplasticity (pain cannot be changed).

    neil

    1. We are most definitely saying the same thing! Whew!! I was worried for a moment there… No, I agree – so few clinicians do move beyond the simplistic explanations and metaphors they learn in training, and often if the person doesn’t “get it”, the person gets blamed, rather than clinicians thinking again about what they’re saying and doing, and how they’re saying and doing it.
      Glad to swap notes on this topic!!
      cheers
      Bronnie

  4. Awesome – I am feeling relieved too!
    great post on what the heck this self-management thing is, and I loved the way you tackled the passive=bad baloney. It is amazing how we get stuck in black/white, either/or,… thought processes, and sad that this is often taught as the predominat wya of consider information in our professional education – guess it is easier to test what is right/wrong rather than grading ability to listen, process and consider alternatives. Then again I think I just described a situation more typical of the PT curriculums than OT.
    enjoy the day
    neil

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