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:
- 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.
- 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
HealthSkills Blog 
Bronnie, it would not surprise me to learn that the most important element that people gain from these programmes is restoration of hope. In fact we coined the acronym wHOPE – whole person engagement – to encompass this approach to pain management. It meshes well with your hypothesis.
I think it’s an element of the picture John. I will add in some more pondering I’ve been doing in my next post – I think there’s a large element in these programmes of helping people reconceptualise their self identity. It’s not often discussed, but formed a large part of my findings in my PhD thesis. Hope + self efficacy + adjusting self-concept = acceptance – allows future plans to be made, maybe?
Bronnie, making sense of one’s biological predicament could be the first step in the process.
P.S. I confess that I do not understand the concept of self-identity.
“making sense of pain” is part of the first phase of learning to live well with pain, according to my theory. That includes finding out what the diagnosis is, accepting that it won’t go away, learning that hurt doesn’t equal harm, understanding the patterns of symptoms etc. Self concept and self-identity are complicated but I’ll do my best to explain it in my next post.
Is it correct to say, “nothing works for everyone, but everything has potential to work for someone at some time, but we don’t know how to tell you which or when?”.Thus the process is the important thing, regardless of what tool you use in the process. The outcome is improved self efficacy in the context of what is important to the person with pain, and it doesn’t really matter what process or tool was used to get there. And my first statement says we don’t have the evidence to guide us what tool or process to use in any one individual at any point in time. But the context of what the person wants to do is most important. Am i correctly paraphrasing you? This would be my experience as well. To me its more like coaching than anything else, except we are using specialized tools to help coach them to a better place – one where they want to go themselves.
I think there are things to guide us towards more useful rather than less useful approaches – so it’s more useful to support people to engage in things they enjoy than to tell them to let pain be their guide. It’s more useful to help people have access to a wide range of tools to use rather than determine those that we “think” might be useful. It’s helpful to support flexibility in how to go about doing things than to narrow down the options and argue that “only” pacing or “only” graded exposure “should” be used. The individual’s own motivation can many times need defining – what is it that they’re wanting to do, how dissonant are their beliefs about what they need to do to get there. So yes, coaching is exactly what I see chronic pain management being about.
I have had my own journey through direct experiences of excessive amount of pain. The sensitivity to pain came from a painful experience as an infant. There of course are other factors. Some examples were neuralgia, migraine, endometriosis, lower back pain, etc. I have healed myself from this over many years, and have developed models, and methods, working with pain and perception which have a positive affect. For me personally I am now pain free and very healthy. If anyone out there is interested in exploring this further please be in touch. I should very much like to bring the scientific research into the work that I am doing, though it is quite esoteric and a little artistic. You can find out a bit more through my website at embodytruth.com
You raise (re-appraise) a valid point regarding the ‘active ingredient’. Not even medicine can be reduced to an active component – just consider the placebo-effects. As you point out the most potent focus could be new methodologies. But to what extend do we have valid theories regarding perception (‘the hard problem’) and is it possible to move any closer to an understanding of perception (including pain) without these?
Great blog!
Good point – I think one part of self management that differs from a biomedical approach is that it incorporates the “meaning response” or “placebo” components like expectancy, conditioning, interpersonal meaning and ritual and so on. I guess one question I have is whether it’s necessary to understand pain as an experience in order to offer management approaches. In medicine there are many things, as you’ve alluded to, that we don’t understand the mechanisms of action, but we use (and have done for decades). Lithium salts for bipolar disorder, the action of tricycle antidepressants for depression – and now for pain – just to identify two. I think that knowing more about mechanisms is vital, but I don’t think we need to stop trying things out until we get a better understanding.
I used your article as a reference or “pressed” it, or whatever you call it on my latest entry about pain medication and how it effects chronic and cancer pain patients. Hope that’s alright. Keep doing what you’re doing.
Thanks so much for sharing!