Health

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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.

Yealands Winery

Sticky back beliefs


ResearchBlogging.org
I get excited when I can write about New Zealand research! Especially when it’s done by a nice guy like Ben Darlow.
Ben’s just completed his PhD looking at the effect of what we say on people’s beliefs and behaviours when they have low back pain. And believe me, it’s not pretty! I think it’s David Butler from NOI who described the concept of “sticky” words, or words that have great power to influence beliefs about pain, and Ben’s research absolutely supports this.

What Ben and his colleagues did was survey 1000 New Zealanders using a postal survey. He used the Back Pain Attitudes Questionnaire (Back-PAQ), and, with a response rate of 602 (pretty good Ben!), worked to establish the relationship between attitudes and beliefs and (1) back pain experience and (2) health professional exposure. Respondents were from the New Zealand electoral roll, so were 18 years of age and older.

Unsurprisingly, Ben found that 87% (95% CI 84% to 90%) of people had experienced low back pain – yes, it’s very common – and that 27% (95% CI 24% to 31%) were experiencing back pain at the time of the survey.

Now, here’s the tough stuff: While 76% of people responding to this survey thought that their back was “one of the strongest parts of their body” and 78% thought that their back was “well designed”, and enormous 89% thought that their back was easy to injure and 95% believed that they could injure their back if they were not careful.

No wonder people rush off to see a health care provider when their backs hurt! And no wonder many people are too scared to move when they’re sore.

Worse than this, however, were the findings that 99% thought that good posture was important to protect the back, and 97% believed that they needed strong muscles. 94% of respondents believed that it was not safe to lift without bending the knees.  Thank YOU Mr Precious McKenzie and the ACC “Don’t use your back like a crane” messages from the 1980’s and 90’s!

Of course, just because people believe this does not mean they actually try to keep “good posture” or “strengthen muscles” or even lift with bent knees – but it goes to show how pervasive these erroneous beliefs can be in the general population.

One interesting finding that I think gives us a bit of hope: people who had been to see a health professional were more likely to believe it’s OK to remain active despite pain. Praise be!

What worries me is that public health interventions to promote remaining active despite back pain are few and far between. People still believe their backs need protecting, yet they can look at pictures of people doing amazingly strenuous activities with flexible and strong backs without reflecting that their own backs could be just as strong and flexible. Please oh please can we begin to recognise that backs were meant to be flexible, move and bend and twist and give us an enormous range of positions from which we can do things! And please, can we stop telling people they need to “lift properly”??!

Darlow, B., Perry, M., Stanley, J., Mathieson, F., Melloh, M., Baxter, G., & Dowell, A. (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand BMJ Open, 4 (5) DOI: 10.1136/bmjopen-2013-004725

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Don’t worry, be happy: Could optimism counteract negative effects of pain?


ResearchBlogging.org

Warning: there is an earworm contained in this post!

How on earth could anyone be happy when they have pain, huh? Well, more about that in a minute, first let’s look at this interesting study from Maastricht University by Jantine Boselie, Linda Vancleef, Tom Smeets and Madelon Peters.

We know that having chronic pain reduces a person’s ability to undertake complex cognitive tasks, particularly those that involve making decisions or problem solving. People become overwhelmed, fatigued and then perform poorly when they need to maintain concentration when they’re experiencing pain, and researchers have found that this is, at least in part, because pain demands attention. More than this, self regulation, or the ability to modify thoughts and behaviours in order to achieve what is important, can become depleted over time, compounding the original loss of capacity. It’s enough to make you feel just a bit unhappy!

These researchers investigated whether optimism might (a) be able to be induced in people who are currently experiencing pain, and (b) might be able to reduce some of the fatiguing effects of self-regulation depletion. This is based on the notion that people who remain optimistic keep persisting with tasks even when the going is tough. They also investigated whether experimental pain has a direct effect on self-regulation (well, actually, executive task performance which is in turn affected by self-regulation status).

Once again, healthy undergraduates were the participants in this study, so for what it’s worth, these are people who are warped enough to participate in a pain study, and who are generally well. It’s also an experimental pain, so probably doesn’t have the same effect on people as chronic pain, but then again, it’s probably one of the few ways to carry out this kind of research.

There were four conditions: (1) pain plus optimism induction; (2) no pain plus optimism induction; (3) pain without optimism induction; and (4) no pain and no optimism induction. The pain induction was a cold pressor test cold pressor test

Yes, that’s ice. 2 degrees C. For a maximum of 3 minutes. Ouch.  This is what participants were told: ‘‘The aim of the task is to submerge your right hand in this cold water tank for as long as possible until you cannot
take it anymore. When you cannot take it any longer, you are allowed to remove your hand from the water. Try, however, to hold on as long as possible.” They weren’t told of the maximum time limit.The optimism induction was taken from the “Best Possible Self” technique developed by King, while the neutral or control condition was simply writing about a typical day.

All the participants were asked to complete a working memory test (the operation-span task).

As with most studies of this type, every participant also completed a set of questionnaires, to help determine some of the characteristics that might be associated with their ability to do the task, or influence the outcome.

What did they find?

Firstly, they found that the optimism induction did have an effect. That’s good – people can indeed feel more positive and optimistic if they imagine themselves succeeding.

Secondly, they found that people who went through the cold pressor test did, in fact, report more pain. Whew! That’s good.

They also found that irrespective of whether the participants went through the optimism induction, or the neutral writing task, they reported the same pain intensity. So – it’s not possible to “think yourself pain free”, at least, not in this study.

Now for the good stuff: using ANOVA (Yay! ANOVA is awesome! Read the link if you want to know more about the maths), the researchers found that there is an interaction between optimism and performance on the executive task, in the presence of pain. In other words, when a person experiences pain and has not participated in an optimism induction, their performance on the executive task is poor. If they’ve participated in an optimism induction, their task performance did not suffer.

What this means

Well, bearing in mind that this is an experimental study, so we can’t translate directly to clinical practice for people who have chronic pain, what it shows is that pain degrades performance, particularly complex executive functioning. IT also shows that people who can become optimistic don’t show this kind of performance degradation.

Optimism is a complicated construct. Some people appear to be more cheerful, happier, more likely to think they’re doing well, and this seems to be their normal state. I’m not one of these people! However – it’s been shown that people CAN increase their sense of optimism by doing certain things, such as imagining themselves succeeding and doing well, feeling grateful for what they have in life, “counting blessings” and so on  (Meevissen, Peters, & Alberts, 2011).

The authors of this research suggest that these findings might be important for people who have chronic pain. We know that chronic pain depletes self-regulatory functioning. We also know that people with chronic pain can become more optimistic if they use something like the Best Possible Selves induction on a daily basis. The argument is that perhaps, by using an optimism induction, people with chronic pain might be able to mitigate their self-regulatory depletion.

I’m a little less optimistic (heh! heh!), but I do think there’s some merit in looking at this further.

I wonder what would happen if we focused on helping people identify some of the positive aspects of having chronic pain. And yes, there ARE some positives.

When people with chronic pain successfully manage their pain, demonstrate courage, personal strengths, planning and problem solving ability. In bucketloads. They become capable of navigating through healthcare systems. They learn more about themselves. They become skilled at stress management, relaxation, exercising and delegating. They develop greater awareness of what is a priority in life. They recognise that energy is a precious resource – and they get good at allocating that energy where it matters the most to them.

More than this, we as health professionals can help people be more optimistic by focusing on what they want to achieve despite pain. We can help people recognise that they are making progress, developing skills, becoming their own pain experts. We can guide them to appreciate what they have, rather than what they do not have. This reminds me of coach John Wooden’s quote: “Do not let what you cannot do get in the way of what you can.”

Could we do more to show how a life with chronic pain CAN be good?

Meevissen YMC, Peters ML, Alberts HJEM. (2011). Become more optimistic by imagining a best possible self: effects of a two week intervention. Journal of Behavioral Therapy and Experimental Psychiatry, 42: 371-8

 

 
Jantine J.L.M. Boselie, Linda M.G. Vancleef, Tom Smeets, Madelon L. Peters (2014). Increasing optimism abolishes pain-induced impairments in executive task performance Pain, 155 (2) DOI: 10.1016/j.pain.2013.10.014

fencing

Trust, teamwork and transparency


ResearchBlogging.org
Teams are a feature of healthcare, and nowhere more so than in pain management.  This is because, at least for chronic pain, no single profession can claim to have all the answers.  Many of us know we need to rely on one another to address patient/client concerns and to provide a consistent approach for the person to have some confidence in.

However (you knew this was coming!), teamwork isn’t easy and some groups of professionals appear to have a good deal of difficulty overcoming implicit attitudes and assumptions about other disciplines.  Now before I’m annihilated, I acknowledge that the attitudes and behaviours within every group of practitioners varies in a bell-shaped curve!

I had occasion, recently, to address a group of health practitioners who shall remain nameless.  This group were discussing sharing of health information, and an approach to inviting patients to be part of a programme of self management in which health information sharing is a component.  To my perplexion, I found that there were two major concerns about this approach. 

  1. That “all” health information would be shared by all team members rather than being selected by this group of clinicians (the risk being identified was that mental health and sexual health information would be shared along with cardiology, musculoskeletal, immunological and so on)
  2. That inclusion on this programme would not be “controlled” by this group of clinicians. 

In other words, that patients would be able to decide for themselves whether they wanted to participate, and that all their health information would be available to other clinicians was viewed with anxiety. I’m venturing to suggest that this reflects a lack of trust in both other health professionals, and in their patients, with the latter being a somewhat outdated paternalistic view, IMHO.

I took it upon myself to have a quick flick through the literature on health professionals attitudes towards one another, and there is a wealth of it! Unsurprisingly, studies about biomedical attitudes towards professionals of other persuasion dominate, so I’ll summarise just a couple and let you draw your own conclusions about how widely the findings might apply.

Moret, Rochedreux and colleagues (2008) found that while physicians delivered diagnosis and prognosis (and nurses agreed), nurses thought they provided additional explanations about diagnosis, information on investigations, and benefits and risks of treatment to what physicians provided, while physicians appeared unaware of the contribution of nurses.  Concerningly, more than 20% of patients were not satisfied with information on benefits and risks of investigations and treatments, and wanted more.  This report suggested that lack of physician-nurse collaboration affects the quality of patient care, and that both professions should recognise the contributions of each other.

Gaboury, Bujold et al (2009) examined the collaboration between medical doctors and “complementary and alternative medicine practitioners”.  (For the skeptics amongst us, these are the practitioners included: naturopathy, massage therapy, chiropractic, and traditional Chinese medicine, including acupuncture. Other practitioners coming from a biomedical healthcare background, such as nurse practitioners, physiotherapists or pharmacists were also eligible participants. I make no comment on whether these practitioners provide useful/helpful input, kthx).  They found that “awareness of one’s own limitations related to one’s healthcare paradigm and similarly limitations in colleagues’ abilities … affect[ed] the level of collaboration among the clinic staff.”; and that “capacity to acknowledge one’s own limits was identified as a major personality characteristic [my emphasis] that stimulates appropriate patient referral and safer care for the patient.”  They also state that  “comprehensive understanding and knowledge of colleagues’ healthcare abilities, and perspectives based on their healthcare paradigm appeared to be vital to the team cohesion.”   Sharing patient records was found to enhance collaboration, and patients were asked to agree to this.

However, relating directly to my experience regarding power relationships, this study identified that “…even though patients could self-refer and specifically request to see a CAM specialist in all of the five clinics visited, the designated entry practitioner for two clinics was the medical doctor. One manager interviewed depicted his clinic’s referral system as if the medical doctors were the orchestra conductors responsible for ensuring continuity of care and integrative care.”

There appears to me to be an easy assumption by the medical profession that they are at the top of a decision-making hierarchy in a healthcare team.  I’m not sure this is justified in all situations (I don’t mind if a doc decides for me if I have acute appendicitis!) – but it’s an attitude adopted very early in medical training.  A study of medical students by Weaver and Peters (2011) looked at factors contributing to medical students developing sense of professional identity.  They found two main elements could be identified : professional inclusivity and social exclusivity.  By professional inclusivity, they meant that as students participated in clinical placements and were treated as “members of the team”, and social exclusivity, they meant medical students tended to socialise with one another.  A commentary by Bleakley in the same journal suggests that “as medical students are drawn further into associating with those in medical culture, so other associations are denied or lost”, “as trainee doctors, medical students become ‘clinical reasoners’ and this, traditionally, identifies them and distinguishes them from others.” Bleakley says “Medicine has claimed a degree of autonomy that has progressively provoked its consumers – patients.” He goes on to say “When a student in the study … remarks that the medical profession is ‘something to look up to’, one wishes that this student had described it as ‘something to look forward to’. ‘Looking up to’ can so easily progress to ‘looking down on’, where meritocracy hardens into autocracy.

Bleakley writes strongly about the need to challenge medical students’ social exclusivity saying “The excluded ‘other’ (health care colleagues, patients, cultures other than medicine) should be a major focus for inclusion in medical education; otherwise students will continue to progress habits of exclusivity in their work as doctors, indicated by relatively poor communication with patients and colleagues”.

Really, I couldn’t say it better myself, so I’ll leave the last word to Bleakley:

Belonging to the medical team is an issue of professional identity, whereas belonging to the wider health care team is an issue of interprofessional identity.

 Applies to all of us, doesn’t it?

Bleakley, A. (2011). Professing medical identities in the liquid world of teams. Medical Education 45(12): 1167–1173

Gaboury, I., M. Bujold, et al. (2009). “Interprofessional collaboration within Canadian integrative healthcare clinics: Key components.” Social Science & Medicine 69(5): 707-715.

Moret, L., A. Rochedreux, et al. (2008). “Medical information delivered to patients: Discrepancies concerning roles as perceived by physicians and nurses set against patient satisfaction.” Patient Education and Counseling 70(1): 94-101.

 
Weaver R, Peters K, Koch J, & Wilson I (2011). ‘Part of the team': professional identity and social exclusivity in medical students. Medical education, 45 (12), 1220-9 PMID: 21999250

fencing

Living well with persistent pain – a problem solving model


Regions of the cerebral cortex associated with...

Regions of the cerebral cortex associated with pain. (Photo credit: Wikipedia)

ResearchBlogging.org

Chronic pain is abnormal. Living well with chronic pain seems a myth, a bit of an impossibility. After all, chronic pain starts with the kind of pain that most people would expect to go away – acute pain.  Acute pain is normal and most of us will experience some painful episode today.  Acute pain goes away – either by itself, or because we’ve done something to remove the stimulus that triggered the cascade of neurological events that eventually reached the brain that produced the experience of pain.

Because chronic pain begins just like any other pain, and because acute pain generates our attention and stimulates some sort of problem solving process so we can take appropriate action, it makes sense that we apply the same problem solving strategy to the problem of chronic pain.  Eccleston and Crombez (2007) proposed that one of the ways we can view the distress, loss of function and reduced quality of life is through a model of “misdirected” problem solving.

Problem solving is often discussed as if the problem exists outside of a context. “Here’s the problem, go solve it” fails to establish the frame of reference – why is it a problem? who has the problem? what contributed to the problem? what resources are available to fix the problem?

One of the major contributions of psychology in the field of pain, particularly a cognitive behavioural model, is helping people view their problem differently. If a situation is viewed differently, the “problem” may go away, or at least be seen as manageable.

BUT, in the case of pain, mostly people start by thinking that pain is something to be cured or fixed, the pain should go away, and life should return to normal.  In the case of chronic pain, when the pain persists, the same problem solving strategies that work so well for acute pain begin to get in the way of living. Life becomes a merry-go-round of searching for relief (maybe an explanation, diagnosis, medication, surgery, new treatment), hope being raised, then very often being dashed because nothing has changed.

Eccleston and Crombez describe this cycle in terms of the function of worry.  “Where such problem solving leads to success, pain and worry abate. However, when the problem solving attempts fail to find a solution, worry is fueled. A ‘perseverance loop’ is established in which the failure of a solution to the problem of pain amplifies worry. In this loop increased worry functions to strengthen motivation to persevere in solving the problem. Problem formulation becomes narrowed and inflexible, whilst greater effort is employed repeating the same solutions. If on repeated attempts a solution is achieved, again pain and worry will stop. “

Over the past 20 years or so, cognitive behavioural approaches for helping people cope with their ongoing pain have focused on reducing distress and disability by helping people reframe the problem of persistent pain as something that can be managed.  This takes the focus off trying to remove the pain, and broadens problem solving so that people begin to look at what else can help them live well.

My research is examining how people who do live well with their pain manage to do so.  While the people I’m talking with don’t say no to new treatments, they don’t seem invested in it so that their whole lives are focused on solving the problem of pain.  Instead, they seem to view pain as “just another thing” that they deal with while they get on with the real business of living life. Some have found that having chronic pain has enthused them with a new direction in life. Others have a focus on family, or community, or work.

The context of chronic pain matters.  It’s the way that the problem of chronic pain is framed that situates and generates the range of problem solving options that are considered.  If we ask a person “what’s important in your life”, and see if they’re willing to make room for having pain present while they engage in occupations or activities that allow them to live their values, we offer people a chance to live well with their persistent pain.

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model PAIN, 132 (3), 233-236 DOI: 10.1016/j.pain.2007.09.014

Eccleston, C (2011). A normal psychology of chronic pain The Psychologist, 24 (6), 422-425

little schoolhouse

The Graded Motor Imagery Handbook – a review


I love getting presents, and I love books, so what could be better than getting a book to review as a present!

Graded motor imagery (GMI) has become incredibly popular in pain management, especially for people with unilateral pain.  It’s a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence.  For those who don’t know – level B1 evidence means there are several RCT’s, and at least one meta-analysis showing support for this approach.

Back to the book.  Like all the NOI books it’s an unusual size, has groovy graphics and an easy-to-use layout. It’s a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes.  The illustrations and photographs are clear and provide excellent guidance for clinicians.  Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler’s favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment.   Each chapter can stand alone, and it’s not necessary to read from beginning to end – but of course, it does help!

This book isn’t for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain – and the translation into the “real world” – are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.

Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment.  GMI has best application in people with unilateral pain such as CRPS and phantom limb pain – although it has been extended to other pains.  These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.

Back to the book again!   I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI.  His writing is clear and provides an excellent scientific basis for the approach.  He doesn’t extend his writing into psychological aspects of pain beyond the concepts of what he calls “neurotags”, or “interconnected neurones … that produce an output”.  Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action).  I have learned these associations as just that – associations between various aspects of learning and anticipation, and have called them the neuromatrix – but NOI have used the term neurotag, and I guess it’s as good a name as any.

The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written.  While it’s possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer’s neuroscience, and Butler’s metaphors, it becomes far more flexible.  I like this.  It is a chapter that I think many clinicians will turn to regularly – but as is emphasised throughout this handbook, patients/participants should read this stuff too.

Worth getting? Yes, I think so. 

My caution lies in over-interpreting the application of GMI beyond the evidence-base.  If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her.  Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain.  Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world.  After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport – where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment.

Where to get it? Go here – and let ‘em know I sent you.

slowdown

Gratitude when you’re in pain? You’ve got to be kidding!


ResearchBlogging.orgOr – introducing the “parent of all virtues” (Wood, Joseph & Linley, 2007).

For some time now I’ve been exploring the contribution of positive psychology on wellbeing in people with chronic pain.  Positive psychology is the ” scientific study of the strengths and virtues that enable individuals and communities to thrive”. (Seligman, ND). It strikes me that in chronic pain management, we’ve responded to the issues raised by people who don’t “live well” with their pain, leaving the group of people who do cope well largely ignored. We have much to learn, I believe, from those who have faced their situation and either been stoic – or in a surprising number, grown from their experiences.  Some excellent resources in the field of positive psychology in general can be found at The Positive Psychology Center and Authentic Happiness, and for Kiwi’s, the New Zealand Association of Positive Psychology.

Gratitude is an emotion that most people feel frequently and strongly (McCullough et al., 2002).  Most people say that feeling grateful makes them feel happy. And oddly enough, gratitude seems to emerge despite difficult circumstances – with some research suggesting that it is in times of intense personal challenge that gratitude is most prominent (Peterson & Seligman, 2003). Immediately after the earthquakes in Christchurch nearly a year ago, people frequently expressed gratitude for one another, for the workers who kept the city running, and for the simple things in life like water, shelter and social support.

The question then arises – is experiencing gratitude empirically related to psychological wellbeing? And the answer is, not unexpectedly, yes! One study showed that gratitude was associated with wellbeing more than the “big five” personality model (Wood, Joseph and Maltby, 2009). It appears that gratitude influences wellbeing in two ways: “directly, as a causal agent of well-being; and indirectly, as a means of buffering against negative states and emotions.” (Nelson, 2009).

The next question is – can we influence wellbeing by increasing gratitude? And so far, research seems to support it.  For instance, in Catherine Nelson’s 2009 review of gratitude interventions, she cites studies in which one group of participants were asked to write down five things they were grateful for each week over 10 weeks, while two other groups were asked to carry this out daily either for two weeks or three weeks. At the completion of the study, it was found that positive affect was increased, and that there appeared to be a dose-response effect. In other words, the more often gratitude was expressed, and the longer this was carried out, the more positively people felt (Emmons & McCullough,
2003).

Interestingly, although we think of gratitude as having an effect on emotion, expressing gratitude can have a direct influence on “physiological coherence”.  This is “increased synchronization between the two branches of the ANS, a shift in autonomic balance toward increased parasympathetic activity, increased heart-brain synchronization, increased vascular resonance, and entrainment between diverse physiological oscillatory systems. The coherent mode is reflected by a smooth, sine wave-like pattern in the heart rhythms (heart rhythm coherence) and a narrow-band, high-amplitude peak in the low frequency range of the HRV power spectrum, at a frequency of about 0.1 hertz.”(McCraty & Atkinson, 2003). What this means is that by expressing gratitude, we may be improving our physiological response to life events.

How do we introduce the idea of expressing gratitude when life is difficult? – for this part of my post today, I’m using my approach, because I haven’t yet found research that identifies “the best way” to do it!

My way is to begin with some mindfulness. Sitting with the person and asking them to be present with what is happening right now. This can be done through focusing the mind on breathing, really experiencing the sensations that occur while breathing – the rise and fall of the abdomen, the cool air in the nostrils when breathing in, the warmer air when breathing out, the heart beat, the weight of the body pressing against the surface of the chair or support, the warmth of hands on lap.

I then ask the person to think of something that they appreciate right then and there. I might say “What comes to mind when you think of something you’re grateful for right now.” If they seem stumped, I might suggest that they express appreciation for being able to breathe; or being able to hear – and I might guide them to sounds of nature; or having a chair to sit on – and I might guide them to experience the sensation of being supported by the chair.

I try to guide the person to identify at least four or five things they appreciate then and there, so they can experience what it feels like to mindfully notice the good that is around them, and to notice the emotions that arise from doing so.

Ongoing practice I then give people is to write down three things they appreciate or are grateful for at the end of each day just before going to sleep.  Research has shown that doing this can influence sleep quality (Wood, Joseph, Lloyd & Atkins, 2009).

So, here’s a thought: what about trying this strategy out for yourself? It’s easy, quick and has some surprising results. Let me know how it works for you.

Emmons, R.A. & McCullough, M.E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389.

McCraty, R. & Atkinson, M. (2003). Psychophysiological coherence. Boulder Creek, CA: HeartMath Research Center, Institude of HeartMath, Publication No. 03-016.

Nelson, C. (2009). Appreciating gratitude: Can gratitude be used as a psychological intervention to improve individual well-being? Counselling Psychology Review, 24(3-4), 38-50.

Wood, A., Joseph, S., & Linley, A. (2007). Gratitude – Parent of all virtues. The Psychologist, 20(1), 18-21.

Wood, A. M., Joseph, S., Lloyd, J., & Atkins, S. (2009). Gratitude influences sleep through the mechanism of pre-sleep cognitions. Journal of Psychosomatic Research, 66(1), 43-48.

Wood, A. M., Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological well-being above the Big Five facets. Personality and Individual Differences, 46(4), 443-447.
A Wood,, S Joseph, & A. Linley (2007). Gratitude – Parent of all virtues The Psychologist, 20 (1), 18-21

Strength

What to do when a patient is “inconsistent”


I’m a practical person, despite occasional flights of fancy dreaming of a health service that really integrates a biopsychosocial approach for pain management, sigh… Anyway, my intention with this short series of posts about “faking” and “inconsistency” is to:

  • point out that pain is personal and subjective and because of this, we can’t know what it’s like to have another’s pain
  • make it clear that pain and impairment and nociception and disability are not equivalent, so we shouldn’t be surprised when inconsistencies are present across various measures
  • move detection of fraud (malingering or faking for financial gain) out of the health arena
  • help clinicians know what to do when a patient is “inconsistent” – in a way that might help guide treatment

And it’s this last point that is the focus of today’s post – and might even be featured in more than one post.

Pain is a biopsychosocial phenomenon. Disability is also a biopsychosocial phenomenon – and it’s the disability that makes the difference between living well with pain or living as an invalid.  We could replace the word “disability” with the term “interference” because pain can interfere with anything a person wants to, or needs to do in life.  It doesn’t need to interfere completely, though, and that’s why I’m so passionate about working in pain management.  A life with chronic pain can be a very good life, but this seems to be a secret that so many health professionals don’t know, thus don’t share with the people they treat.

What should a clinician do if the person they’re seeing behaves “inconsistently”?

The first thing I’d advise is to be curious rather than suspicious – wondering rather than assuming.

I wonder why Alex is moving more comfortably when pruning the roses than when she’s hanging out the washing?”

I wonder why she says her pain is really bad today but seems relaxed and happy while chatting to the receptionist?”;

I wonder why Chris’s questionnaires show low pain anxiety and catastrophising, but he’s having such trouble returning to work?”

This opens up opportunities for exploring the sense a person is making of his or her situation.

  • Maybe it’s the effect of distraction
  • Maybe it’s about “faking good” with the receptionist
  • Maybe it’s “other factors” that are influencing return to work such as bullying or being socially excluded from the rest of the team

I think people generally do things for reasons that make sense at the time, also as a reflection of the information he or she has about their situation.  For this reason, it seems sensible to explore what the person thinks is going on, and in doing so, begin to generate some hypotheses about why the person is presenting in the way he or she is.  These hypotheses can be tested or verified, and resolution can be progressed.

It’s disability, or interference from pain, that is most profoundly influenced by psychological and social factors. 

By psychological, I’m referring not just to emotions as a response to experiencing pain, but the whole gamut from the attention the brain pays to the sensations that are eventually interpreted as “ouch, that hurt!”, through to the meaning of that “ouch!” as it influences future goals on the basis of what the person thinks the pain might mean – and so on.

And by social, I’m referring to responses from family (or lack of response because there are no family close by), from health professionals and their efforts to “find the cause” or believe/disbelieve the person, and ultimately to the societal attitudes towards people who have that kind of pain, and the legislative systems in which the person finds him or herself embroiled (not to mention the health systems).

For a health professional who notices that a person is not quite responding the way other people with the same impairment (ie injury, diagnosis, tissue damage, disease) responds, it’s only by working through all the above influences and generating a plausible and useful (ie testable) set of hypotheses that might explain why this person is presenting in this way at this time, that it’s possible to understand and address the next steps to help the person return to some of their important goals in life. Remember, as an observer, even the most astute clinician is filtering what they see through their own experiences, attitudes, beliefs and training.  And unfortunately, most of these influences occur without our knowledge (see here for some of the cognitive errors we all fall prey to).

For more on developing a case formulation, or set of working hypotheses, I’ve written several posts here, here , here and here – and yes, there are more, just follow the links.

My “take home” message today? Suspend judgement (it doesn’t help and usually hinders), be open to understanding the person’s reasoning for their so-called ‘inconsistency’, and work with the person to identify the hypotheses that can be tested to verify what is going on.

 

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Using the Chronic Pain Acceptance Questionnaire


ResearchBlogging.orgOver the past few months I’ve been using the Chronic Pain Acceptance Questionnaire (CPAQ-8) as part of a battery of questionnaires used at intake and outcome measures.  Along with the CPAQ-8, we use the Tampa Scale for Kinesiophobia, the Depression Anxiety Stress Scale, the Pain Anxiety Symptoms Scale, the Pain  Catastrophising Scale, Pain Self Efficacy Questionnaire, and Pain Disability Index.

The CPAQ-8 consists of two subscales: Pain Willingness and Activity Engagement.  Together they measure “acceptance” or psychological flexibility associated with chronic pain.

Let me pull this apart a bit.  Pain Willingness refers to how prepared a person might be to experience an increase in pain so they can get something important done.  For example, I love to dance and I’m prepared to have an increase in pain when I dance (and afterwards) because of the buzz I get from the shimmy.  We probably all willingly experience pain to get a flu jab, or to stand in a queue to get tickets to a really great concert, or to carry a child who is too tired to walk.

Activity Engagement refers to how actively involved a person is in activities that are important – things like getting on with life, taking care of responsibilities, making plans for life that don’t include getting rid of pain.  I’m sure anyone who has worked with people who have chronic pain will have seen people who have put life on hold for sometimes years in their search for something to get rid of pain, who have turned the search for pain reduction into their reason for living.

I wanted to include this measure because of the mounting evidence that acceptance of pain has a strong relationship with things like mood, disability, confidence and so on, so it’s been really interesting to begin to use this tool clinically.

Before I proceed with the following example, please remember that case vignettes I share are based on real people with details changed to protect privacy!

Let’s call him Wayne.  Wayne has had a major mountain bike crash resulting in multiple fractures of his pelvis, lower leg as well as his right arm and shoulder.  He’s had his pain for four years, and has had several surgeries to firstly fixate his lower leg fractures, then to remove the pins and plate, then to remove the pins that were inadvertently left in place.  His main pain is his lower limb and he has been told it is complex regional pain syndrome – although technically it doesn’t have all the hallmarks of full-blown CRPS.  Whatever the diagnosis, he now has allodynia (pain on what is normally nonpainful stimuli – for him, it’s pain on the touch of fabric, when the breeze blows over his leg, water when showering etc), he has hyperalgesia (increased pain to what is normally painful input – when he bumps his leg, if he scrapes it), his leg aches at rest, and gets more painful when he walks for any further than a few meters, and he finds walking over rough ground is next to impossible.

Wayne has seen a lot of clinicians for his pain, including his surgeon, anaesthetists who have tried various infusions, physicians who have tried medications of all sorts, physiotherapists who have used TENS, mirrorbox, and functional restoration.  Wayne is not happy.  Nothing has helped.  He’d really like to have an amputation because he’s talked to other guys with similar injuries who have had an amputation who say they can now “get on with life”.

Wayne feels like his life has stopped since his accident.  He’s gone from being more than busy running his own business, involved in adventure sports, being in a good relationship, planning for children – to waiting, being dependent on compensation payments, and unemployed with no sporting outlets, and his relationship is foundering.

When I reviewed Wayne’s questionnaire responses, several things stood out: his DASS wasn’t elevated suggesting he doesn’t view himself as low in mood or stressed or anxious; his overall PCS was in the average range – but his Helplessness subscale in that questionnaire was very high, so while he may not feel that he catastrophises, he does acknowledge feeling there is little he can do about his pain.  His Pain Self Efficacy Questionnaire was slightly lower than average, so maybe he didn’t feel particularly confident about doing things despite pain; and on three of the subscales of the PASS his scores were below average, with only his Cognitive Anxiety subscale being elevated – but it was very high, so maybe he finds it difficult to “think straight” when his pain levels are intense.

On the CPAQ-8, his Pain Willingness was very low, in the 25th percentile.  At the same time, his Activity Engagement was in the average range at around 44th percentile.  These two measures combined tell me that Wayne’s not yet ready to accept living a different life from the one he’d pursued before his mountain bike smash.  His main focus is on not having pain while his activities are aimed at finding ways to avoid having pain.

Where do we go with this?  I’d like to start working on whether his current strategies are working to give him the life he really wants.  What he seemed to value before his crash was being outdoors, having a sporting lifestyle, getting into adrenaline-pumping high adventure living.  Is trying to avoid pain helping him live his values?  Is he willing to bring his pain with him while he does some of the things he loved? Can he make room for his pain to be present as he takes steps towards the life he used to have?  Can I, as a clinician, help him recognise how his old skills and bravery might help him live well despite his pain?
Fish, R., McGuire, B., Hogan, M., Morrison, T., & Stewart, I. (2010). Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8 Pain, 149 (3), 435-443 DOI: 10.1016/j.pain.2009.12.016