The complex world of identifying nociplastic pains


Towards the end of 2017, IASP put forward a new mechanistic classification: nociplastic pain. The definition is: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

Note: Patients can have a combination of nociceptive and nociplastic pain”.

This was great news! Prior to this, the term “central sensitisation” was used and abused to describe processes involved in ongoing pain that wasn’t inflammatory or neuropathic. Problem with that term is that it’s apparent in nociceptive mechanisms, as well as both inflammatory and neuropathic…. When the way people used the term was more akin to “well, the pain hasn’t settled down, so ‘something weird’ is going on and it must be in the central nervous system so we’ll adopt this term seeing as Clifford Woolf described it in the spinal cord” (Woolf, 1996, 2007).

In other words, any pain that seemed to radiate, hang around, and no respond to treatment was “centrally sensitised”. Perhaps so. Perhaps not. Suffice to say, people got confused because most of the typical central sensitisation from nociceptive/inflammatory processes subsides over time, but these “centrally sensitised” pains did not.

I, for one, am glad there’s a group in which weird pains that don’t appear to involve typical nociceptive, inflammatory or neuropathic mechanisms can be put.

Problem is: how do we know what fits into this group? We can be pretty certain when it comes to neuropathic pain, because the definition is very clear (though not so clear in the clinic) – “Pain caused by a lesion or disease of the somatosensory nervous system.” The notes go on to say that “neuropathic pain is a description, not a diagnosis” and I’d say the same about nociplastic pains (which is why I use the plural…). I also step out to say that I don’t think ALL nociplastic pains will be found to have the same biological mechanisms, especially given how widely variable neuropathic pains are.

Nevertheless, we need some way to decide which pains are in, and which are out of this group.

This table comes from Kosek et al., (2021) and summarises the findings from a consensus process within an expert group. They make the point that acute pain isn’t helpfully included in this group, and instead it should be used for pains that persist for 3 months or longer. They also point out that regional pain is included while discrete pain is typically not because of the central sensitisation processes involved (note: this is the correct use of the term! Confused? CS is a neurophysiological phenomenon, associated with more than nociplastic pain).

Looking at the above criteria, possible nociplastic pain is present if the person has criteria 1, and criteria 4. Probable nociplastic is present if the person has all the above.

There are some notes, of course: regional means the musculoskeletal pain is deep, regional or in several places or even widespread (not localised to one place), and each condition eg frozen shoulder and OA knee needs to be assessed separately. If there is an identifiable nociceptive source (or neuropathic source) then the pain needs to be more widespread than “usual” for that pathology. Finally, because nociplastic pain unlike neuropathic pain, has no definitive test currently, there is no “definite nociplastic” category – but once there is, this will be added.

What does this mean for us as clinicians?

Firstly it ought to stop people being thought as faking, malingering or otherwise not being believed. That should be a given but unsurprisingly because of legal and health systems and our own frustration at not being able to “fix” people, people with pain get that impression more often than they should. It also ought to stop psychopathologising people who have this kind of pain: we can’t distinguish between people with nociplastic pain and the DSM5 “Somatic Disorder” – so let’s just not add another unhelpful mental health label to what is already a stigmatised situation.

Then it ought to stop clinicians using treatments that simply don’t help – such as opioids for fibromyalgia. It might help clinicians pause before prescribing movement therapies at a level that is too intense for the person, because this only revs the nervous system up even more making the whole process unpleasant. Beginning at the level the person can manage and gradually increasing is crucial to success. And it ought to stop clinicians from administering “explanations” or “education” and expecting that alone to reduce pain. Because while cortical processes are part and parcel of every pain there is, it’s in this group of pains that some people think “top down” by thinking yourself out of pain is a thing. FWIW pain reduction is lovely and part of treatment, but shouldn’t ever be the only outcome (Ballantyne, 2015), and many times in this group of pains, may not even be an outcome.

Finally, it should stimulate helpful discussion about what “whole person” approaches to managing these pains looks like. The authors say “patients with nociplastic pain are likely to respond better to centrally than peripherally targeted therapies” and this does not mean talk therapy alone, or exercise alone, or indeed medications such as gabapentin or nortriptyline alone. To me, it means individualised, tailored, and integrated strategies to moving, managing daily life, restoring sleep, enjoying an intimate relationship, managing mood and memory, and these might best be offered by pain coaches rather than siloed “therapies” of physical, psychological or whatever other stripe there is.

Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of Chronic Pain — The Wrong Metric? New England Journal of Medicine, 373(22), 2098-2099. https://doi.org/10.1056/NEJMp1507136

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Woolf, C. J. (1996). Windup and central sensitization are not equivalent. Pain, 66(2), 105-108.

Woolf, C. J. (2007). Central sensitization: uncovering the relation between pain and plasticity. The Journal of the American Society of Anesthesiologists, 106(4), 864-867.

Women, partner violence and pain


As the potential for greater repression of women’s autonomy grows (Afghanistan, United States, Mexico), along with racist and misogynist statements from business leaders (DGL CEO Simon Henry) it’s timely to look at pain in women. We already know that more women than men present with persistent pain (Blyth, n.d.), while women who are seen for their pain are more often misdiagnosed, offered psychiatric medication or psychological intervention only and have their experiences dismissed as “hysterical, fabricated, or nonexistent” (Samulowitz, et al., 2018). My daughter, when attending Emergency Department was offered a paracetamol and told “there’s no cure for being a woman” when seeking help for an ovarian cyst. Period pain is considered “normal” (Drabble et al., 2021). Pain in women is not a sexy topic.

Intimate partner violence is common among women. 27% of women who have had a partner report violence perpetrated against them. 24% of young women aged between 15 – 19 years report violence. Low-income countries reporting higher levels of intimate partner violence, and while data was not available for the past two years of covid-19 disruption, it’s expected that higher levels of violence are probable (Sardinha et al., 2022).

What about the intersection between partner violence and persistent pain? (BTW violence is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship and includes stalking, psychological aggression such as coercion, as well as physical and sexual violence).

Persistent pain is one of the most commonly reported health consequences of intimate partner violence (Walker, 2022), and women are more likely to be the recipients of partner abuse than men. Yet – open conversations about violence and persistent pain in women, recognising the signs and symptoms of partner violence in people seeking help for persistent pain, and adequate approaches to treatment are rare. Women may not disclose their situation for fear of being stigmatised, labelled unfairly, or having their pain – and their situation – trivialised.

Walker and colleagues (2022) carried out a systematic review of studies exploring the types of pain women experienced in association with partner violence, the severity of that pain, and the impact of pain on the person. They found that while pelvic pain was common amongst women who had been sexually abused, women also reported chest pain, back pain, neck pain, arthritis, and stiffness in joint or muscles, more frequent headaches, and more back pain – furthermore, women who had experienced partner violence reports higher pain severity, with 75% of women indicating moderate to severe pain, and the longer a women had been in an abusive relationship, the more likely they were to report higher intensity pain.

Interestingly, disability from persistent pain wasn’t measured often – only two studies from 12 included in the final review – but women with persistent pain from partner violence reported higher pain-related disability. They also reported worse impact on their mental health – more PTSD, anxiety and depression, with depression being one of the key mediator between a history of partner violence and ongoing pain.

The authors of this study (Walker et al., 2022) point out that it’s likely that women who have sustained partner violence and experience persistent pain are “not being adequately identified and responded to in clinical settings” – and that the fear of not being believed and the stigma of being on the receiving end of partner violence likely limits how many women openly discuss their situation.

Isn’t it time to get women’s pain prioritised? To get political about systems and processes that fail women? Isn’t it time to shift the narrative around women’s menstrual pain? To acknowledge that women are not mini men?

Finally, when we consider pain rehabilitation, we need to not only recognise that women have different priorities and goals for their lives than men, we also need to understand that doing rehabilitation is more complex for women than men – women report more difficulty prioritising their own rehabilitation over other responsibilities in their life (Côté & Coutu, 2010). Women may not even be referred for rehabilitation as often as men (Stålnacke et al., 2015). It’s time to prioritise understanding the lived experience of women as they pursue help for their persistent painand then do something different.

Blyth, F. (n.d.). Chronic pain in Australia: A prevalence study. Retrieved May 12, 2019, from http://www.ncbi.nlm.nih.gov/ pubmed/11166468

Daniel Côté & Marie-France Coutu(2010)A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?,Disability and Rehabilitation,32:2,87-102,DOI: 10.3109/09638280903026572

Drabble, S. J., Long, J., Alele, B., & O’Cathain, A. (2021). Constellations of pain: a qualitative study of the complexity of women’s endometriosis-related pain. British Journal of Pain, 15(3), 345-356.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018. https://doi.org/10.1155/2018/6358624

Sardinha, L., Maheu-Giroux, M., Stöckl, H., Meyer, S. R., & García-Moreno, C. (2022). Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. The Lancet, 399(10327), 803-813.

Stålnacke, B., Haukenes, I., Lehti, A., Wiklund, A., Wiklund, M. et al. (2015)
Is there a gender bias in recommendations for further rehabilitation in primary care of patients
with chronic pain after an interdisciplinary team assessment?.
Journal of Rehabilitation Medicine, 47(4): 365-371
http://dx.doi.org/10.2340/16501977-1936

Walker, N., Beek, K., Chen, H., Shang, J., Stevenson, S., Williams, K., Herzog, H., Ahmed, J., & Cullen, P. (2022). The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review. Trauma Violence Abuse, 23(2), 490-505. https://doi.org/10.1177/1524838020957989

Rehab Fails: What goes wrong in rehab 4


It’s not hard to choose rehab fails, the problem is more about when to stop! I tell a lie, it’s more about how to make changes so these things don’t happen.

Today’s #rehabfail is all about attempting to carve bits of a person off so each profession gets “their” bit to do with what they will. Oh boy, this is a doozy, and it comes to me off the back of seeing the return of the age-old argument about whether pain is “all about the bio” or whether the person gets a look-in. Cuz if it’s all bio then we just treat that bio and be done with it, right? It’s a question that also arises when we begin to ask questions about what the person understands about their pain and disability, when they <gasp!> show that they’re frustrated, demoralised, maybe sad or grieving for what they can’t do….

If I had a dollar for every time I’ve heard someone say “oh but I’m stepping out of scope” – usually in response to a suggestion that they incorporate cognitive behavioural principles in their work, or when someone says it might be a good idea to look into psychosocial factors – I would be wealthy and retired. I cannot believe how often therapists with a primarily physical orientation seem to think that asking someone how they’re feeling about their situation, what they understand might be going on, what they prefer, how they’re sleeping, how they’re getting on with their family… ALL these things is “out of scope!”

Seriously folks. Since when did being a human communicating to another human about how they are in the face of pain and disability turn into a “OOooh but I’m not a psychologist” kind of fear? Who else is going to be able to guide someone to a psychologist unless it’s the insightful clinician who is sensitive to when someone is feeling pretty rotten?

Another part of this chasm between “mind” and “body” is the idea that psychosocial factors are only relevant if or when the person “fails” therapy. Who failed, huh? And where did the idea that psychosocial factors are all negative come from? We all have psychosocial factors in our lives: our temperament, memories, assumptions, relationships, goals, routines, job, choices are all psychosocial, and some of them are even pretty positive!

The siloing of professions particularly in musculoskeletal pain rehabilitation is one of the least helpful things I’ve seen in health. The second is to have a “team on paper” where the “team” members do exactly the same things they do when working as a solo practitioner. Serial monotherapy does nothing for people living with pain. What I mean by this is every doing their therapy concurrently but failing to talk to one another, failing to modify what they do to suit the overall needs of the person, failing to have a common understanding of what one another do, and failing to support one another. How confusing is that for the person getting treatment?

Now I am not suggesting that psychologists should become physiotherapists, or occupational therapists become pharmacists, or even a full transprofessional approach (though this is something our NZ health ministry is aiming for over time). I am simply suggesting these things:

  1. Know that whole people are seeking help, not a knee or a belly pain or a back. Pains are experienced by people.
  2. Be human and listen to (and ask about) human things like: how is your job going? what’s your sleep like at the moment? what do you think is going on with your pain, what is your theory? how are you feeling in yourself at the moment? Open-ended questions about human experiences and habits – and follow up with more open-ended questions, and lots of reflective statements. Do this from day one. For everyone.
  3. Take some time to sit in with someone from a different profession. Make friends with them. Go have a coffee with them. See how they work with someone in common. Let them know this isn’t so you can be them, but so you can help your patients/clients understand a bit more about what seeing them might look like.
  4. Read about “whole person rehabilitation.” Matt Erb and Arlene Schmid’s book is awesome (and not just because I wrote a chapter in it! So did a heap of people! – click.)
  5. Dip your toe into understanding your patient’s life. Ask questions that help you understand how they’ve made the decisions they have. Nobody gets up in the morning to do dumb things that might hurt them: there are logical reasons – to them – for why they do what they do. We just need to get our heads around their reasons to begin to tease out the assumptions they hold (and we hold) that have influenced their choices. Remember we all do this.
  6. Never, ever think that you’re treating a back, or a knee, or a headache or a belly pain. You are always working with a person who is experiencing pain in a part of their body, and that pain has enough meaning for them to decide to ask for help. That’s what we’re actually working with.

Here are some readings discussing how we might build teamwork and whole person rehabilitation:

Bashir, U., & Siddiqui, A. S. (2021). Teamwork in chronic pain management and the way forward in low and middle-income countries. Anaesthesia, Pain & Intensive Care, 25(2). https://doi.org/10.35975/apic.v25i2.1477

Cartmill, C., Soklaridis, S., & David Cassidy, J. (2011, Mar). Transdisciplinary teamwork: the experience of clinicians at a functional restoration program. J Occup Rehabil, 21(1), 1-8. https://doi.org/10.1007/s10926-010-9247-3

Cassell, E. J. (2011). Suffering, whole person care, and the goals of medicine. In T. A. E. Hutchinson (Ed.), Whole person care: A new paradigm for the 21st century (pp. 9-22). Springer. https://doi.org/10.1007/978-1-4419-9440-0

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3), e663. https://doi.org/10.1097/PR9.0000000000000663

Griffin, H., & Hay-Smith, E. J. C. (2019). Characteristics of a well-functioning chronic pain team: A systematic review. New Zealand Journal of Physiotherapy, 47(1). https://doi.org/https://doi.org/10.15619/NZJP/47.1.02

Maynard, M. T., & Gilson, L. L. (2021). Getting to know you: The importance of familiarity in virtual teams. Organizational Dynamics, 50(1). https://doi.org/10.1016/j.orgdyn.2021.100844

Mallick-Searle, T., Sharma, K., Toal, P., & Gutman, A. (2021). Pain and Function in Chronic Musculoskeletal Pain-Treating the Whole Person. J Multidiscip Healthc, 14, 335-347. https://doi.org/10.2147/JMDH.S288401

Rehab Fails: What goes wrong in pain rehabilitation 3


I’m beginning to think this series could grow into a monster – so many #rehabfails to pick from!

Today’s post is about rehabilitation that doesn’t fit into the person’s life. Or that the person hasn’t been supported to fit the rehabilitation into their life. THEIR life, not ours!

You know what I mean: for six to twelve weeks, this person has been coming along to their treatment sessions, doing the things the therapist suggests. They make progress and it’s time to end the programme. “Good bye patient” the therapist says. And the patient skips off into the sunset, fixed for life.

Yeah right.

Roll that movie right back to the start.

At the first consultation, therapists often ask the person about what they’d like to achieve. Often the person doesn’t really know, after all most people don’t routinely set goals – and particularly if someone is experiencing the disruption of dealing with a painful problem that doesn’t go away like it should. It’s not for nothing that people describe this time as being in “zombie land” and dealing only with “the essentials” (Lennox Thompson, et al, 2019). Nevertheless, therapists ask and people are expected to come up with something that can then form the focus of subsequent therapy. A recent systematic review, however, found that many studies describing goal setting practices fail to implement all the components of effective goal setting – in particular, omitting “formulation of coping plan” and “follow up” (Kang, et al, 2022).

Now these two components are crucial for long-term adherence to rehabilitation, and especially in persisting pain where it’s probable the person will need to follow therapeutic practices for a very long time. The “coping plan” consists of identifying barriers and facilitators to doing the actions that lead to achieving goals, and also involves assessing confidence to do so, along with generating a plan to deal with unexpected situations. “Follow up” involves self-evaluating progress, evaluation, and adjusting the plan to suit. (Kang et al., 2022).

Why are these two components so important?

Well, think of one of your recent patients. Think about the things you (and others in your clinical team) asked that person to do. Are any of these things typical for this person? Are they habits, built into daily routines? Are they familiar? What is this person’s daily routine like? What does their family need to do and what does this person need to do for them? If the person usually works, and is still trying to maintain that on top of their usual home and family activities, how much are you and your colleagues asking the person to do on top of these? When they’re already struggling with the debilitating effects of their pain problem?

See why we might have trouble with adherence? Let alone ensuring that the person feels it’s worthwhile doing what it is we’re asking them to do!

I’ve seen this problem time and time again. Little, if any, consideration of this person’s usual daily life context. Little thought to the burden of trying to manage normal life and what the therapists is asking the person to do. No discussion about what might get in the way of fitting these therapy things into their life – and then I’ve heard clinicians have the audacity to suggest the person isn’t motivated!

So much for person centred rehabilitation. So much for helping the person work out how they might fit these things in, and how they might develop a routine or habit that they can continue once they leave the therapist’s care.

While I’ve looked at goal setting and therapy for persistent pain, what I notice is that even in acute musculoskeletal management, studies have shown that therapists don’t really understand goal setting. Alexanders and colleagues (2021) found that physiotherapists undertaking goal setting for anterior cruciate ligament rehabilitation might employ SMART goals – but didn’t understand the theory behind goal setting, didn’t know that expectations were important, and didn’t use feedback sufficiently. And this is for SMART goals that have already been found wanting (see Swann et al., 2022).

What do I suggest?

  1. Start by understanding the person’s current responsibilities in life, and the impact their pain problem is having. Recognise that those impacts will also have an impact on their capability for adding to their daily routine.
  2. With the person, establish the best time of day for them to do whatever it is you think they should do. Work through what might get in the way – and what might support them.
  3. You may need to help them develop some additional skills to deal with what might get in the way of undertaking your activities – maybe skills to communicate with family, or the boss, so they can take 10 minutes out to do the breathing practice you’ve suggested, maybe some work with thoughts to help them be OK with guilt for “not doing things as normal.”
  4. Assess their confidence to engage in this additional task. Use motivational interviewing to boost their confidence (and it probably would help you to consider the importance of what you’re asking them to do in the context of their values and activities).
  5. Check how much you’re asking the person to do – is it achievable in this person’s life? A certain intensity might be theoretically important for physiology, but if the person doesn’t do it because he or she can’t fit it in, it just won’t get done.
  6. Check in with the person in between appointments. If you see them once a week – send a text 3 days in to that week to see how they’re getting on. Or ask the person if they’ll send you a text to let you know. Give feedback, alter your plan, encourage, celebrate.
  7. And once the person is nearly ready for discharge, make sure you have a set-back or relapse prevention plan in place. What should this person do if things begin to go pear-shaped? Do they need to keep going at the same intensity as they have during your therapy? What are their warning signs for things beginning to fall apart? (clue: it’s often not when people are beginning to hurt again, it’s often because the person is feeling good and starts to drop the things that have helped!)

Don’t do #rehabfails

Kang, E., Kim, M. Y., Lipsey, K. L., & Foster, E. R. (2022). Person-Centered Goal Setting: A Systematic Review of Intervention Components and Level of Active Engagement in Rehabilitation Goal-Setting Interventions. Archives of Physical Medicine and Rehabiltation, 103(1), 121-130 e123. https://doi.org/10.1016/j.apmr.2021.06.025

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

Lenzen SA, Daniels R, van Bokhoven MA, van der Weijden T, Beurskens A. (2017). Disentangling self-management goal setting and action planning: a scoping review. PloS One,12:e0188822.

Swann, C., Jackman, P. C., Lawrence, A., Hawkins, R. M., Goddard, S. G., Williamson, O., Schweickle, M. J., Vella, S. A., Rosenbaum, S., & Ekkekakis, P. (2022, Jan 31). The (over)use of SMART goals for physical activity promotion: A narrative review and critique. Health Psychology Review, 1-16. https://doi.org/10.1080/17437199.2021.2023608

What goes wrong in pain rehabilitation (2)


One size does not fit all. Cookie cutter treatments fail to take into account the huge variability each person brings into a clinical encounter, particularly when the person is living with persisting pain. Not really earth shattering news, is it?!

Let me unpack this one.

When we’re treating a person with an acute musculoskeletal injury, let’s say a lateral ankle sprain, I’m going to hazard a guess that most of the recovery occurs without our assistance (don’t shoot the messenger – go read Chen et al, 2019). In essence, we’re creating an environment that supports tissues to do what they do well – get on with healing. Because of this, there’s good reason to follow a basic treatment algorithm that will work for most people. That is, unless or until recovery stops for some reason.

It’s here that algorithms begin to lose utility, because the factors that are implicated in delayed recovery are many and varied – and it’s important to narrow down the particular factors involved for this person with their ankle.

So, IMHO, cookie cutter treatments begin to fall apart when recovery is slower than expected because there are a heap of variables involved. And yet what do I see? “Oh it failed but let’s do the same thing again but harder!” or “the person wasn’t doing their exercises” or “it must be psychosocial factors.”

Well, no, actually, perhaps psychosocial factors are involved, but they were there from the outset (just ignored because the tissue-based factors capture our attention). And no, doing the same thing again but harder leads to the same outcome, only more disappointing. And we have no idea whether the person was, or wasn’t doing their exercises – or whether the prescribed exercises were useful, or whether they even make much of a difference anyway! (again, don’t shoot the messenger, go read Wagemans, et al 2022).

But probably the most heartbreaking thing about using “one size fits all” is that this doesn’t take into account this person’s goals, lifestyle, current priorities, other contextual factors like workplace, family and friendship obligations that are integral to being a person, not just a lateral ankle sprain.

I once worked at a chronic pain centre where every person was assessed by three clinicians: a medical practitioner for diagnosis and medication management; a psychosocial clinician to understand life stressors and the person’s understanding of their pain and their current coping strategies; and a person who assessed how he or she was managing with daily life and functional activities. What I couldn’t understand was how almost every patient was given the same management plan: to try some drugs, see a psychologist, and do a home exercise programme. Come to the centre to see each clinician on a different day of the week. Irrespective of the unique presentation, the same recipe was given. The ingredients might have been a little different when the person was seen for treatment, but without fail, the basic elements were exactly the same.

How is this person-centred care? What if this person was a 4 wheeldrive off-roading enthusiast who loved to go fishing? What if this person was a traveling sales rep with a well-developed meditation practice? What if this person had five kids and couldn’t get to the pain centre for the twice weekly appointments? What if this person was hankering after spending some time with other people who were also living with pain so she could hear that she wasn’t alone, and could pick up tips from people who knew what it was like?

Today I still hear of people being given a copy of “Explain Pain”, get to do the “Protectometer” and then told to go see the physio and psychologist. Nothing about the person’s desire to work out the impact pain has on their daily life, nothing about the understanding the person already has about their own pain fluctuations, and nothing that’s tailored to what this person needs and wants to do.

Seriously folks, pain rehabilitation and management is all about tailored, bespoke, clever therapy based on what the person needs and wants to do, what they already know and bring to their own recovery, and it probably needs to include connection with other people who are in the same situation. Why? Because while “other people” might not give the advice the journal articles recommend, they offer advice from their own experience. And mostly, people with persisting pain need affirmation that they’re resilient, capable, knowledgeable and can work a way through this.

Maybe what we need to do is include people who live with pain in service design (Sandvin Olsson, et al., 2020) – and pain management delivery (Farr, et al., 2021). It seems to work.

Chen, E. , McInnis, K. & Borg-Stein, J. (2019). Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports, 18 (6), 217-223. doi: 10.1249/JSR.0000000000000603.

Farr, M., Brant, H., Patel, R., Linton, M. J., Ambler, N., Vyas, S., Wedge, H., Watkins, S., & Horwood, J. (2021, Dec 11). Experiences of Patient-Led Chronic Pain Peer Support Groups After Pain Management Programs: A Qualitative Study. Pain Med, 22(12), 2884-2895. https://doi.org/10.1093/pm/pnab189

Sandvin Olsson, A. B., Strom, A., Haaland-Overby, M., Fredriksen, K., & Stenberg, U. (2020, Aug). How can we describe impact of adult patient participation in health-service development? A scoping review. Patient Educ Couns, 103(8), 1453-1466. https://doi.org/10.1016/j.pec.2020.02.028

Wagemans, J., Bleakley, C., Taeymans, J., Schurz, A. P., Kuppens, K., Baur, H., & Vissers, D. (2022). Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis. PLoS One, 17(2)http://dx.doi.org/10.1371/journal.pone.0262023

Rehab fails: What goes wrong in pain rehabilitation (1)


Well obviously I’m not going to cover everything that goes wrong – and certainly not in one post! But inspired by some conversations I’ve had recently, I thought I’d discuss some of the common #fails we do in rehabilitation. Things that might explain why people with pain are thought to be “unmotivated” or “noncompliant” – because if the rehab doesn’t ‘work’ of course it’s the person with pain who’s at fault, right? So for today, here goes.

Starting at the wrong intensity

One of the main things that happens when someone’s in pain is to reduce overall activity level. Pain has been called “activity intolerance” and it’s common for people to stop doing. So naturally when a clinician is developing an activity or exercise programme, the aim is often to simply increase how much movement a person does in a day. So far, so good. Muscles and cardiovascular systems improve when we use them.

But guess what? There’s a person inside that body! And people have minds. Minds with opinions about everything and in particular, anything to do with doing. There’s often a “should” about how much movement or activity to do. This rule might be based on “pain is a sign of tissue damage” so anything that increases pain clearly “should not be done”. There may equally be a “should” about how much exercise this person used to do, or wants to do, and often mental comments about “what kind of a person does this amount of exercise.”

I’ve heard good clinicians say that their patients “have unrealistic goals” – this is probably because the person’s mind has an opinion about what he or she “should” be able to do!

What can good therapists do about this? Well, firstly to ignore the person who inhabits the body is plain wrong. Secondly, flashy gadgets like coloured tapes or special elastics or foam thingies probably won’t do much for the person’s opinionated mind except to temporarily distract — oooh! shiny!!

Something I might do would be to ask the person what level they think they can begin at – beginning where the person is at, and moving at his or her pace is a solid foundation for developing a relationship where experimenting with movement becomes about the person and his or her relationship with their body. I think one of the aims of movement rehabilitation is to help the person develop trust in their own body and how it moves, so enhancing playfulness and experimentation can be a good start.

I might ask the person “what shows up when we begin doing this set of movements/exercises”? By “showing up” I’m talking about thoughts, images, sensations in the body that pop into a person’s mind (minds are soooo opinionated!). We might need to guide the person to notice quick thoughts or images, to put words to emotions and feelings, and to get in touch with fleeting sensations in the body.

Some of the things I’ve heard people say include: “only weak losers would call this exercise”, “I used to be able to lift 40kg sacks of cement and now all I can move is this pathetic 5kg dumbbell”, “he wants me to do what?! I hate boring exercises”, “but what am I going to feel like tomorrow?”

What do we do with these thoughts?

First: make room for them to be present. Don’t quickly deny them “Oh of course you’re not weak”, “5kg isn’t pathetic”, “exercise is great fun”, “you’ll be fine, you can do this”. Saying these sorts of things dismisses the validity of the person’s fears and won’t win you any friends.

Second: empathic reflection. Indicate that you’ve heard what the person has said, validate that this is their experience, their thoughts. Something like “it’s a long way from what you used to lift, and that’s hard”, “it’s tough beginning to build up again”, “you’re worried that this is going to be unrewarding”, “you’ve had pain flare-ups before, and it’s hard to deal with”.

Third: Ask the person where they’d like to begin, put them in control of the intensity. Then ask them “how do you think that’s going to pan out” – in other words, will their option get them to where they want to be? What’s good about it? What’s not so good about it? from their perspective not yours! The idea is to establish how workable the person’s starting point might be. It might be perfectly fine, even if it’s not your choice!

Fourth: Affirm that the choice is the person’s – and that this is an experiment that will be reviewed at the next session. You might say something like “So you’d like to try doing 5 minutes of walking instead of the treadmill that I suggested, because you think this shouldn’t flare your pain up as much. What’s your choice now that we’ve talked about the good and not so good? We can review it next time.”

Fifth: Review how it went at the next session! Note down the rationale the person had for the level of intensity they chose, and then review how well that intensity worked from this perspective. For example “you wanted to do 5 minutes of walking because it wouldn’t flare you pain up as much, what did you notice? What showed up? How well did it work?” Notice all the open-ended questions, the reminder that the person thought this intensity wouldn’t flare their pain as much, and the focus on workability. Because at the beginning of a movement or exercise programme, what you’re looking for is adherence, sticking to the level of intensity chosen. Habits take time to make, and often adhering to a programme is because the opinionated mind is having a go at the person, interfering with their willingness to stick with it. If we avoid that roadblock, we have at least one point on the board.

Your opinionated mind might now be telling you that “oh they’ll never make progress at that pace”, “they’ll do themselves an injury if they lift that much”, “this is just pandering to their lack of motivation”

Be careful! At this point you could reflect on what’s showing up for you. Are you worried their outcomes will reflect badly on you? Do you only have a few sessions with the person and need them to get somewhere or you’ll have failed? Make room for those uncomfortable feelings. Let them be present and listen to what your opinionated mind is telling you. Maybe remind yourself that outcomes don’t depend on you – they depend on the person sticking to the programme, and a programme that doesn’t start because the person’s mind tells them it’s not worth it is a #rehabfail Remember also that you’re aiming for the person to gain confidence in their body, learn to listen to what happens when they try something out – the repeated progress reviews you do with the person are the actual active ingredients in therapy, they’re the bits that help the person to reflect on what works, and what doesn’t. That’s gold.

ps The technique I’ve described above is – gasp! – a psychological approach, based on ACT and motivational interviewing. You won’t find a specific study examining this approach in journals (at least not in a cursory search like I did!), but it’s an application of well-studied approaches into a movement or exercise context. It’s the same approach I use in contextually-relevant occupational therapy. Reading Bailey et al, 2020, affirms to me that we have a way to go to define and measure adherence, so I feel justified in using these strategies!

Bailey, D. L., Holden, M. A., Foster, N. E., Quicke, J. G., Haywood, K. L., & Bishop, A. (2020, Mar). Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review. Br J Sports Med, 54(6), 326-331. https://doi.org/10.1136/bjsports-2017-098742

Eynon, M., Foad, J., Downey, J., Bowmer, Y., & Mills, H. (2019). Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 29(5), 638-650. https://doi.org/10.1111/sms.13403

Levi, Y., Gottlieb, U., Shavit, R., & Springer, S. (2021). A matter of choice: Should students self-select exercise for their nonspecific chronic low back pain? A controlled study. Journal of American College Health, 1-7. https://doi.org/10.1080/07448481.2021.1960845

Making sense of pain


It’s been said many times, so many times I can’t locate the originator of the saying “humans are meaning-making machines” – no more so than when a person experiences pain. Whether it’s a stubbed toe, sprained ankle, thundering headache – or, in my case, weird and ongoing widespread body pain AKA fibromyalgia – we would like to make sense of what’s going on. And mostly we tell simple stories about what we were doing, what happened to the body and that’s that.

In the case of weird or persistent pains the challenge becomes harder. The original story might not fit any more, or because of that story, we limit what we do in case we do damage.

Now philosophers and other commentators have taken up the matter of what this experience really is: sensation or perception? Frankly, I don’t think this matters a jot to the people I see who are trying hard to make sense of what their pain means to them. One person I’ve seen recently said “I feel adrift, like a pingpong ball bobbing on the sea” – life is what isn’t making sense any more. And life, dear readers, is not as simple as sensation or perception.

One of the concepts used to understand what constitutes health is the construct “meaning in life.” Meaning in life is associated with resilience, better health outcomes, and very importantly, recovery from Covid and dealing with the stress of how Covid and other world events have played out over the past few years (Arlsan & Allen, 2021; King & Hicks, 2021; Lin, 2021). But where meaning in life has been extensively studied is….chronic pain.

This makes sense to me! Chronic pain is known to disrupt “normal” life for the person experiencing it. Movements that used to be done without thinking are now etched into memory. Sleep isn’t the respite from world cares it was – now it’s endless hours of aching. Assumptions about how quickly a person should recover from injury are smashed. Chronic, persisting, ongoing pain can disrupt life as we know it.

Meaning in life is thought to comprise three facets: coherence, purpose, and mattering. Coherence is about comprehending or “making sense of the past, present and imagined future aspects of life, being able to integrate their life story into a coherent whole (King & Hicks, 2021).” Purpose is “a central, self-organizing life aim that organizes and stimulates goals, manages behaviors, and provides a sense of meaning (McKnight & Kashdan, 2009).” Mattering is about how a person believes their life counts – a sort of transcendence beyond self to a bigger world.

All three of these constructs contribute to an overall belief that life makes sense, and that we are effective agents that contribute over and above our lifetime. You can see how this can erode when living with a meaningless pain like neuropathic pain, or ongoing migraines, or low back pain that just doesn’t settle.

Where does that leave us, if we’re clinicians working with someone experiencing weird pain? I think one of the most important parts of our work is to help people achieve a sense of coherence – that despite pain, it’s possible to still be “me” and that while the future may be different from what was previously imagined, it can still fit into a coherent whole. What this means is helping the person to establish what matters in their life, then figuring out ways for the person to resume those things, whether pain is present or not. This might look like helping the person come up with a story about their pain – a narrative that moves from damage to perhaps recognising that we don’t know why they hurt, but that they know of various factors that influence the severity, frequency and interference of their pain (Hadley & Novitch, 2021).

I also think we need to recognise that people living with pain may also find their purpose is challenged – and some of our work is helping people recognise their purpose in life and find ways to keep moving towards what matters to them. This is the part where we recognise values and life direction – perhaps “occupational drive” or the things that people want and need to do.

Finally, throughout our work with people, we need to remember that mattering matters. That the person we’re working with isn’t “the wonky knee” or “the shoulder” or “the bad back.” Being willing to see the person behind the eyes, the talk, and the pained body. This takes time, and most of all – listening with heart and curiosity.

Arslan, G., & Allen, K. A. (2021, Jan 25). Exploring the association between coronavirus stress, meaning in life, psychological flexibility, and subjective well-being. Psychology, Health and Medicine, 27(1), 1-12. https://doi.org/10.1080/13548506.2021.1876892

Hadley, G., & Novitch, M. B. (2021, Apr 1). CBT and CFT for Chronic Pain. Current Pain and Headache Reports, 25(5), 35. https://doi.org/10.1007/s11916-021-00948-1

King, L. A., & Hicks, J. A. (2021). The science of meaning in life. Annual Review of Psychology, 72, 561-584.

Lin, L. (2021, May). Longitudinal associations of meaning in life and psychosocial adjustment to the COVID-19 outbreak in China. British Journal of Health Psychology, 26(2), 525-534. https://doi.org/10.1111/bjhp.12492

Reflective practice


In occupational therapy and some other health professions, reflective practice is a vital part of professional clinical activity. In others – not so much. And the term reflective practice has a heap of assumptions attached to it, so it may mean different things to different people.

I thought I’d unpack a bit about reflective practice today because I think it needs to be part of working with people experiencing pain. It helps us get out of our own mindset (when it’s done well), and opens a space for questioning what we do and why we do it – and as you probably all know, questioning is part of who I am!

According to Wikipedia (NO! Not an academic source – but kinda handy in this instance) “Reflective practice is the ability to reflect on one’s actions so as to take a critical stance or attitude towards one’s own practice and that of one’s peers, engaging in a process of continuous adaptation and learning” (Schon, D, 1983). In other words, we take an action then step back from what we’ve done to critically appraise it. The appraisal might be simply asking “what worked, what didn’t work, what would I do differently?” or it might be a more complex process in which someone else helps us to ask these questions or compare what we’ve done against a theory or another way of working.

I will admit that I hold some skepticism about how well we do reflective practice (the “we” being us human beings in general). This is because we’re incredibly prone to cognitive errors such as anchoring, commission and omission biases, framing effects, availability bias, vested interest bias and groupthink (see Scott, et al., 2017). The sneaky thing about these biases is that they’re implicit: that is, we often are oblivious that we do them. To combat them we need to take deliberate steps, and most of us haven’t been taught how to do this. Even when we have another person to work with as a prompt, we can get caught up in biases and fail to be critical about what we think of as “normal”.

Lilienfeld & Basterfield (2020) agree with me, pointing out that reflective practice theory and practice doesn’t draw on an understanding of the difficulties using introspection to become aware of biases (because we’re not aware of these intrinsic biases), that self-assessment often omits areas in which we either feel highly confident or we’re afraid we don’t know and don’t want to admit we’re struggling, and that we often don’t learn from experience. Ooops.

Yet, there’s enough evidence to show that by employing reflective practice, people can develop meta-cognitive skills in which they check their own assumptions, identify gaps in their knowledge, seek new information to fill those gaps, then try that knowledge out in practice (Ziebart & MacDermid, 2019).

BUT how do we do it, and does it make for better outcomes for the people we hope we help?

Lilienfeld and Basterfield (2020) offer some ideas – and caution us not to accept clinician satisfaction with the process of reflective practice with evidence of effectiveness. They propose drawing on research understanding debiasing: things like “consider the opposite” or “consider the alternative” as deliberate questions clinicians can ask themselves. Asking clinicians “how might I test out an alternative hunch?” could be a useful approach. Suggesting clinicians and their supervisors/mentors take an “outsider perspective” to step back from their decision-making as ‘disinterested third-party observers’ might help break through our tendency to overlook habitual practices just because they’re familiar (and perhaps help us remain willing to be vulnerable and compassionate towards ourselves instead of defensive).

I suspect clinicians working in pain management could do well with an ongoing relationship with a supervisor. Not someone who holds themselves as the “font of all wisdom”, not a “mentor” who feels responsible for shaping therapists into something new, but more as a mirror lens on practice. A neutral but supportive partner who can ask questions like “I wonder if we could use this [novel theory] to explore what’s going on” or “what if we thought about this [opposite theory] for a while to see what we learn”.

In situations where we are utterly certain of a causal relationship between X and Y, and where this leads to treatment A being the only viable option, we possibly only need to reflect on whether we’ve done the right diagnostics. In pain coaching/rehabilitation/management we have little certainty, far less to guide us, and a person experiencing pain. This person is often in a very vulnerable position where they trust us to do the right thing by them. If we fail them by being too certain we’re right without being challenged, we can do them an enormous disservice.

Lilienfeld, S. O., & Basterfield, C. (2020). Reflective practice in clinical psychology: Reflections from basic psychological science. Clinical Psychology: Science and Practice, 27(4). https://doi.org/10.1111/cpsp.12352

Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books. ISBN978-0465068746. OCLC8709452.

Scott, I. A., Soon, J., Elshaug, A. G., & Lindner, R. (2017, May 15). Countering cognitive biases in minimising low value care. Medical Journal of Australia, 206(9), 407-411. https://doi.org/10.5694/mja16.00999

Ziebart, C., & MacDermid, J. C. (2019). Reflective Practice in Physical Therapy: A Scoping Review. Physical Therapy, 99(8), 1056+.

Experiential avoidance – and persistent pain


Most of us will recognise that when we experience a pain, we firstly notice where it is, and the sensory qualities of it. We automatically make judgements about that pain – some of this judgement is about whether we recognise this pain (have we had it before?), some is about whether it’s important enough to interrupt what we’re doing (should I drop this hot cup of coffee, or can I hold onto it long enough to place the cup carefully on the bench), and some is about how we feel emotionally (yes, swearing is common when we smack our thumb with a hammer!).

In our response to acute pain, we often want to avoid or escape whatever we think gave us the pain – unless, of course, it’s something we choose to do even though it hurts. You know, things like lifting really heavy weights, running distances, taking rugby tackles, eating chilli! But in most cases where the pain is unexpected we’re inclined to want to make it stop, get away from the thing that probably caused it, and take a few minutes (or longer) to not do the things that make it worse. So we avoid walking on a newly sprained ankle and we don’t keep poking and prodding at a cut or a bruise.

Avoiding is quite common and even helpful when we experience the initial onset of a pain.

So why do we talk about “fear avoidance” as if it’s a bad thing?

Well, it’s because avoiding beyond a useful period of time often leads to ongoing problems. Some of these problems are possibly over-stated: things like “deconditioning” are probably not as much of a problem as we once thought (see Andrews, Strong & Meredith, 2021; Tagliaferri, Armbrecht, Miller, Owen et al, 2020). While other forms of avoidance may never even be considered.

What do I mean?

For a moment, think of a “weekend warrior”. The kind of person who heroically plays sport on a Saturday, trains once or twice during the week, and otherwise works hard and plays hard. Let’s think of this person as a male, perhaps in his late 30’s, thinks of himself as a hard worker and a family man. When he sprains his wrist after a particularly hard tackle in a weekend rugby game, he’s the kind who shrugs it off, and just keeps going. After a few weeks and his wrist doesn’t get much better, he heads off to see his local physio.

We wouldn’t usually think of him as an “avoider”. He’s not pain-avoidant, but sometimes because he doesn’t stop to take care of his wrist sprain, he ends up with a more troublesome injury. He might even develop a “boom and bust” pattern of activity: on a day he’s feeling good he’ll push through, but then his wrist starts playing up and he needs to take a day or two off.

I’m going to call it like I see it: this bloke is avoiding. What he’s avoiding is the experience of being vulnerable, of seeking help, of being advised to stop pushing himself for a day or so.

You see, experiential avoidance is what we do to avoid feelings (emotions) and actions that we don’t like or don’t want.

We see experiential avoidance most often described in pain research in the group of people who don’t resume their usual daily activities in part because they’re afraid of their pain. Or they’re afraid of what their pain might mean, or the effect of their pain on other things they need or want to do. For example, Angelina (see here) might be worried about the effect of pain on her sleep. And we’re reasonably OK with offering these people some information about what might be going on in their tissues, and that the relationship between pain and what’s going on in the tissues might not be as straightforward as it is when we hit our thumb with a hammer.

What we might be less aware of, and perhaps struggle to deal with is when a person appears to be doing the right things, like they’re remaining active and staying at work, but might be overdoing it. What might this person be avoiding? Perhaps, as I’ve suggested in the example above, it’s about avoiding feeling vulnerable, feeling like he’ll be told to slow down for a bit. Slowing down might be a sign, at least to our weekend warrior, that he’s not as young as he used to be. Perhaps he’s afraid of stopping because that means his busy mind can start to plague him with unhelpful thoughts about things he’s worrying about.

Experiential avoidance, like avoidance when a painful injury first happens, isn’t always a negative. When it’s used as the key strategy for life, indiscriminately and with an eye only to short-term benefits and not long-term consequences, then it’s not so good.

You see I hope we can help people to develop psychological flexibility: the ability to choose a response to any given situation that maintains moving towards what matters even if this means doing what feels odd or even a backwards step.

I also think we might benefit from developing psychological flexibility ourselves as clinicians. If we continue using the same old, same old strategy even if the results aren’t what we hoped for, we’re not helping anyone.

Andrews NE, Strong J, Meredith PJ. (2012). Activity pacing, avoidance, endurance, and associations with
patient functioning in chronic pain: a systematic review and meta-analysis. Archives of Physical Medicine & Rehabilitation. 93(11): 2109–21.e7, https://doi.org/10.1016/j.apmr.2012.05.029 PMID: 22728699

Tagliaferri, S., Armbrecht, G., Miller, C., Owen, P., Mundell, N., Felsenberg, D., Thomasius, F., & Belavy, D. (2020). Testing the deconditioning hypothesis of low back pain: A study in 1182 older women, European Journal of Sport Science, 20:1, 17-23, DOI: 10.1080/17461391.2019.1606942

Skyline

Your patient has psychosocial risk factors: what now?


Congratulations! You’re an insightful clinician who’s offered your patient a screening assessment to find out if she or he has psychosocial risk factors – and yes! they do! Well done. Now what?

Do you…

  • send your patient to the nearest psychologist?
  • spend at least one treatment session offering pain neurobiology education?
  • scramble to find a “psychologically informed physio” to send them to, because it takes really highly trained and special clinicians to work with these people
  • give your patient the same exercise prescription you were going to anyway because, after all, they still have things going on in their tissues (or is it their nervous system? I forget – whatever, they just need to move, dammit!)
  • throw your hands up in horror and say “I never wanted to deal with people in pain anyway!”

You’d have to be hiding beneath a rock to avoid learning that people with musculoskeletal pain with psychosocial risk factors such as feeling that back pain is terrible and it isn’t going to get better, believing that it’s not safe to move or exercise with back pain, having worrying thoughts going through their mind, or not enjoying things very much should have special attention when they seek help for their pain. And we’ve all read studies showing that many of our frontline clinicians who see people with musculoskeletal pain aren’t comfortable, confident or clear about what to do with people who are, frankly, scared and distressed.

Papers like Caneiro, Bunzli & O’Sulllivan’s (2021) Masterclass clearly show that messages people with pain get told include avoiding certain movements to prevent damage, being advised that special exercises ‘protect’ the body, and that clinicians believe that certain postures and movements are inherently unsafe (bending, lifting with a rounded back). At the same time, Sajid, Parkunan & Frost (2021) found that only 11.8% of people referred by GPs for musculoskeletal MRIs had their mental health problems addressed, while only 16.7% of the MRI results were correctly interpreted by GPs and in 65.4% of cases were referred for “spurious overperception of surgical targets.”

Worse, Nicola, Correia, Ditchburn & Drummond (2021) conducted a systematic review of the effects of pain invalidation on individuals – invalidation from family, friends and healthcare individuals, and the person themselves. They found five themes: not being believed, lack of compassion, lack of pain awareness and understanding, feeling stigmatised and critical self-judgement. Perceived social unacceptability of experiencing pain was found to have an impact on the emotional state and self-image of those with persistent pain. Ya think?!

If I return to the case I presented last week, Angelina, a pretty common case of someone with a neck pain who is having trouble sleeping and generally handles her pain independently, we could assume that she doesn’t have significant psychosocial risk factors. After all, she’s managing to stay working, does a bit of self-help, and she’s not depressed though she’s a bit irritable.

What would you do?

I guess my first thought is: would Angelina even get a screening assessment to see whether she has any psychosocial risk factors? Might she present superficially well enough for her therapist to think she’s fine, let’s just treat the neck?

Of all the neck pain treatments available, what would she be given? And what might she be told about the rationale for that treatment? A recent systematic review with meta-analysis pointed out that while specific exercises helped in the short to medium term, the quality of that evidence was low (Villaneuva-Ruiz, Falla, Lascurain-Aquirrebena, 2021), while a systematic review with network meta-analysis of 40 RCTs found “There is not one superior type of physical exercise for people with chronic non-specific neck pain.
Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective.” (de Zoete, Armfield, McAuley, Chen, & Sterling, 2020).

More than this: would her sleep and relationship concerns be discussed? What about her safety while driving? How about how she manages her work, and her belief that perhaps her pain is happening because of a period at work where she wasn’t positioned “correctly”?

You see, at the moment in our musculoskeletal treatment literature, the focus has been almost entirely on grouped data. And this, folks, is where Steven Hayes points out that the ergodic theorum is violated. Ergodic theory is “…the idea that a point of a moving system, either a dynamical system or a stochastic process, will eventually visit all parts of the space that the system moves in, in a uniform and random sense. This implies that the average behavior of the system can be deduced from the trajectory of a “typical” point. Equivalently, a sufficiently large collection of random samples from a process can represent the average statistical properties of the entire process.” (I stole that from https://en.wikipedia.org/wiki/Ergodicity).

Hayes, Hofmann & Ciarrochi (2020) point out that “We cannot assume that the behavior of collectives (e.g., a volume of gas) models the behavior of an individual element (e.g., a molecule of gas) unless the material involved is “ergodic” and thus all elements are identical and are unaffected by change processes.” Humans are not ergodic (only a few noble gases are…) and what this means is that “statistical techniques based on inter-individual variation cannot properly assess the contribution of given elements to phenotypic change.” In other words: humans actively respond and change to what they’re exposed to – each of us presents to treatment with our own incredibly unique range of responses and past history, and these influence how we respond to a treatment. And perhaps this explains why most of our treatments (RCTs, using grouped data and uniformly applied and consistent treatments) particularly for persistent pain problems end up showing pretty small effect sizes. We’re violating the assumptions of the ergodic theorum. What we need are more sophisticated ways to analyse the impact of any therapy, and far fewer algorithms and cookie cutter treatments.

Where does this leave us? I have loads of ideas about where to from here, but not nearly enough space today to write about them!

My first suggestion is to avoid blindly following a treatment algorithm that fails to support YOU to sensitively and reflexively offer treatments that fit for your patient.

My second is to avoid measuring the impact of what you do only at the end of treatment (or worse, not at all!). Measure often, and measure things that matter – either to how you get to the end outcome, or that the person values. Or both.

And third: Get reading outside of your profession. Dig into psychology (I especially recommend Hayes); look at sociology (try Jutel); anthropology (try Sarah Pink’s “Sensuous futures: re-thinking the concept of trust in design anthropology”); make 2022 the year that you lean into uncertainty. I know the past two years have been incredibly unsettling – but this is the perfect time to continue on this journey into new ideas, fresh concepts, and ambiguity.

Caneiro, J. P., Bunzli, S., & O’Sullivan, P. (2021). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther, 25(1), 17-29. https://doi.org/10.1016/j.bjpt.2020.06.003

Nicola, M., Correia, H., Ditchburn, G., & Drummond, P. (2021, Mar). Invalidation of chronic pain: a thematic analysis of pain narratives. Disability and Rehabilitation, 43(6), 861-869. https://doi.org/10.1080/09638288.2019.1636888

Sarah Pink (2021) Sensuous futures: re-thinking the concept of trust in design anthropology, The Senses and Society, 16:2, 193-202, DOI: 10.1080/17458927.2020.1858655

Sajid, I. M., Parkunan, A., & Frost, K. (2021, Jul). Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Quality, 10(3). https://doi.org/10.1136/bmjoq-2020-001287

Villanueva-Ruiz, Iker, Falla, Deborah, Lascurain-Aguirrebeña, Ion. (2021) Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise—A Systematic Review with Meta-Analysis, Physical Therapy, 2021;, pzab259, https://doi-org.cmezproxy.chmeds.ac.nz/10.1093/ptj/pzab259

de Zoete, R. M., Armfield, N. R., McAuley, J. H., Chen, K., & Sterling, M. (2020, Nov 2). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2020-102664