Making the first contact


How do we begin working with someone who is asking for help with their persistent pain? In this post I’ll describe some of the considerations I have when I begin, because as Benedetti points out, the “meet the therapist moment” is one of the most potent times in the therapeutic ritual (Benedetti, 2011). It’s the time when the person’s expectations and the clinician’s empathy and competence meet, and the “meaning response” blooms.

My two clinical questions are:

  1. Why is this person presenting in this way at this time, and what’s maintaining their predicament?
  2. And what is this person’s main concern?

But before I ask these questions, I want to take a moment to think about the person and what might be going on in his or her mind.

Benedetti points out that expectancies are an important part of a response to treatment – whether that treatment has any active action, or not. Expectancies are about what a person brings to a therapeutic encounter: there are two, one is stimulus expectancies (anticipations of external events – eg that the next painful experience will be less), and the other is response expectancies (predictions of your own nonvolitional response – eg that after doing this thing, I expect to experience less pain) (Kirsch, 1985).

People who come to see a clinician, especially a clinician from a little-known profession (occupational therapy!) will hold expectancies about what that person will do, but these will likely be weaker than the expectancies a person might hold about seeing a well-known profession. The strength of an expectancy is different from the direction of an expectancy – for example, a negative experience with a physiotherapist might lead to a strongly negative expectancy about future treatments, while not having had an experience with an occupational therapist might lead to a weakly positive expectancy about what’s about to happen.

Along with expectancies, the person will likely be anxious about what’s to come. The possibility of something that might help (or not), meeting a new clinician, and living with pain are all stressors – and anxiety erodes a person’s ability to absorb lots of information, while biasing them towards remembering threatening words (Reidy & Richards, 1997).

So there’s a lot going on in the person’s mind when they attend that first session.

There’s also often a large power imbalance (Joseph-Williams, Edwards & Elwyn, 2014). This emerges from the fact that often clinicians hold a lot more information about the person we’re seeing than they do about us. Especially after we’ve asked a bunch of questions, often quite intimate in nature. For a person seeking help, this imbalance can make it hard to ask questions, to direct the conversation, to hold a sense of independence throughout the encounter.

So having set the scene for you, I’m sure you can agree that how we go about collecting information from a person is incredibly important – especially so that relationship can begin to build.

Introductions

In the introduction, I seek to give the person some information about who I am – not just as a clinician, and the kind of treatments I use, but also about who I am. I’ve drawn inspiration from tikanga Māori here, where the cultural tradition entails letting the person know where I come from and who I’m connected to. I like to let people know my childhood roots are in Turanganui a kiwa, or Gisborne. That the mountain my heart connects with is Mount Hikurangi – the first mountain in NZ to see the sun. The river I connect with is the Taruheru, flowing into the sea in Gisborne. I also let people know my whanau connections – the Lennox’s, and the Thompson’s, are my whanau (extended family), and I’m a 5th generation New Zealander. I now live in Otautahi/Christchurch. This introduction only takes a few minutes, and your culture might not value this form of introduction. For me in Aotearoa/New Zealand, it’s one way I can show respect and follow a tradition that means the person I work with knows something more about me than just my name.

I also include my profession – what I do. I’m an occupational therapist, my job is to help people do what matters in their life contexts.

I like to then let the person know that they’re brave and courageous for seeking help – it’s not easy to say you can’t do this on your own. It takes courage to tell someone that.

Questions

Then I open with a broad question about what has led this person to come to see me. I might add in something about “tell me about your pain and what you’ve done so far for it.” I’ll often ask what their theory is about their pain, what they think is going on.

Then I ask “What is your main concern today?”

Throughout this process I’m reflecting what I’ve heard, to ensure I’ve understood what the person has experienced. I’m NOT giving reinterpretations, I’m NOT giving out new information, I’m just listening.

I often spend time asking about four areas of life: relationships, fun, work, and health. Or I might ask the person to take me through a typical day, from the time they wake up.

I like to find out not just what the person has done to help themselves, but also what they’ve learned from these experiences. The messages they’ve received over time, and the things they’ve tried but perhaps didn’t like or that didn’t help.

Questionnaires

I was a big fan of questionnaires filled out ahead of time, and I am still a fan but don’t use them as much. This is mainly because so many people have filled out endless questionnaires and nobody has sat down with them to talk about what they mean! So I’m a little more selective and focus much more on listening first then choosing something that will offer me and the person some insight into what might be going on. For example, I might choose the PASS20 (McCracken & Dhingra, 2002) because it helps me figure out where to begin with reducing pain-related anxiety. It’s a good measure to use each week to track changes over time, and I’m beginning to delve into repeated measures of progress rather than a pre-post-follow-up approach that’s typical.

Observation

Covid has meant it’s not as easy to carry out observational assessments, but I’m always watching how the person sits, moves, walks, and body language. What I’m not doing is interpreting these observations without talking to the person about them! Too many clinicians make judgements about the person based on maybe one or two observations, out of context of the person’s life and environment, and without checking in with the person to work out what might be contributing to what they see. Let’s not do that – the person might be completely oblivious that they’re guarding their sore hand, or they keep shifting in the chair, or that a habitual movement like taking a jacket off might be easier to do than being asked to perform some weird movement at the command of the clinician!

Pulling it all together

Just as we wouldn’t expect to be marched in for surgery straight after our first consultation with an orthopaedic surgeon, I don’t believe it’s OK to offer something to a person on their first visit just because we feel internal pressure to do so. Having said this, I will often suggest to the person that they spend a bit of time doing some brief “noticing without judging” exercises. We’ll give it a go at this first appointment, so they’re not being expected to go do it without knowing how. The reason I start with brief noticing experiments is that it’s something we could all do more often, it gives the person a new skill (usually) to develop, and it’s often an introduction to being fully present without judging. Being fully present without judging is hard to do when you’re sore because the mind likes to anticipate how bad it’s going to be (“you’ll need to take it very quietly or you’ll pay for it”) or remember previous pains (“last time you just sat around your pain went nuts, you don’t want to risk that now do you?”).

Notes/Documentation

I write conversational notes directly to the person, going through what we’ve talked about and pulling together all the information I’ve gathered in this first meeting. I find it helps me to make sense of what’s going on, it allows me some time to reflect on what I’ve observed and heard, and I can assemble it in a case formulation that the person and I can explore if/when we meet again.

Assessment is never over. Every time I meet with a person I’ll be learning more about what’s going on. I don’t feel pressured to “find it all out” at that first session just because there are goals that must be developed. In fact, one goal I leave in for everyone is “develop goals” (well, I don’t use goal language – it’s more about directions and actions that take you there). Because seriously, how can anyone meet someone and immediately develop goals – that’s disrespectful to the person who may not have had time to think about what matters the most, and it’s disrespectful to the complexity of goal setting as a process anyway.

Theme and variations

I’ve written one approach I use for learning about the person I’m trying to help. There are others – a time line, drawing a life map, mind-mapping, walking and talking, making a coffee – all of these and more can be used to explore the same information.

Let’s not call it “the subjective” – let’s call it what it is, our first “getting to know you” meeting.

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189–1202.

Joseph-Williams, N., Edwards, A., & Elwyn, G. (2014). Power imbalance prevents shared decision making. Bmj, 348.

McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research & Management, 7(1), 45-50.

Reidy, J., & Richards, A. (1997). Anxiety and memory: A recall bias for threatening words in high anxiety. Behaviour Research and Therapy, 35(6), 531-542.

Thought experiment: Would therapists be out of a job if we could “fix” persistent pain?


Every few years someone, somewhere, announces that “it won’t be long before we have a treatment to rid the world of persistent pain.” And there’s a hiss and roar to celebrate this momentous finding, and much ado about how wonderful it will be.

I’m still waiting. BUT I thought it might be an interesting thought experiment to wonder what might happen if a “cure” was available for fibromyalgia.

As readers will know, I have lived with what eventually was named “fibromyalgia” since my early 20’s, and probably longer. I’ve dabbled in various treatments over the years but sadly, nothing but good clean living has helped (by which I mean early to bed, good diet, maintain healthy movement, manage stress, have good friends to connect with, play, have fun). So I would dearly love a treatment that would remove the constant aching, reduce the prolonged DOMs, keep a lid on delayed recovery after injury, and generally offer me a life relatively “normal.”

I am definitely pro-pain reduction and pain treatment. I just haven’t found anything that changes mine.

We have had some spectacular developments in therapies over the past 25 years – particularly in the inflammatory rheumatological diseases like ankylosing spondylitis, rheumatoid arthritis and ulcerative colitis. Treatments with anti-TNF alpha biologicals means that my partner who lives with anky spond now has normal C reactive protein levels, no pain, the disease activity has stopped, and he’s tickety-boo.

So why am I just a tad reserved about the notion of a “fix” based on new discoveries about mechanisms associated with neuropathic and nociplastic pains? Why am I just a little skeptical of a new psychological study showing outstanding results (Ashar, Gordon & Schubiner, 2021)? Am I just worried I’ll be out of a job if there’s an effective treatment?

Nope.

You see, even though some people like my Manly Jack have had a wonderful response to treatment for inflammatory disease, there are many more who have not. Or, who have significant reductions in inflammation – but not to “normal” levels, and accompanied by complications/adverse effects, and, in many instances, continued pain. Why is that? Well – I think it’s because while treatments target mechanisms, people are enormously variable in both biology and more importantly, psychology and sociology.

And it’s these last two that have been identified as amongst the most important contributors to ongoing disability and limited participation.

Now the social deserves a little attention. Drug developments are not cheap. The medication my partner uses is extremely expensive – NZ$1200 every two weeks. Luckily for us, this drug is fully funded by the NZ Government. There’s an economic argument for having meds like these publicly funded – without this drug, it would have been very difficult for my man to carry on working. He was having trouble rolling over in bed at night, had trouble coughing, couldn’t inhale fully, and walked like a little old man. He’s now fit as a buck rat and pays his taxes because he’s working.

The problem is, as we can see from the Covid vaccination roll-outs world-wide, people and countries without resources have less access to effective treatments. Even in NZ where we don’t have the “vaccine hesitancy” of other countries, the people who are least likely to be vaccinated right now are those who have trouble traveling to a centre, who don’t feel “at home” in healthcare, who are hard to reach, perhaps not very literate, don’t speak English or te reo Māori. The NZ government is working incredibly hard to ensure the vaccine is given to these people, and I’m proud of the variety of ways they’re doing so.

But spare a thought for countries where there is no relative affluence. Where other countries don’t have the will to help. Where infrastructure is poor. Where women, children, and people from different cultural backgrounds or religions are discriminated against. In these countries, vaccinations are very slow to reach those in need.

So one risk from a fancy new treatment is that people who need it but can’t afford it, don’t trust healthcare (who would after the stigmatisation so many people receive?), and people who are from countries where the rest of the world doesn’t help out – they risk missing out.

Another risk is that while pain might be reduced or even eliminated, these address only the biology, and people are people, and pain is multidimensional. People remember what it was like to be in pain. People have their own narratives about what’s going on to create their pain. We all learn from our experiences, and beliefs, attitudes, emotions, the influence of others around us, the communities and families and workplaces we come from, all of these have an effect on “what it is like to be experiencing pain.”

We know that people who have completely successful joint replacements without pain, don’t resume the activities they were doing before their joints became painful (see my last blog post). People successfully treated with biologicals still hold fears about future harm that developed before they got their treatment. We know that many people take years before being diagnosed and treated successfully – and that’s a long time to develop beliefs, habits, routines and relationships that don’t support recovery. We also know the trauma of unhelpful and stigmatising healthcare interactions can live long, even after successful care.

Resuming daily life and valued activities is integral to pain rehabilitation. Helping people safely do what matters to them in their life contexts is still needed. In the enthusiasm for applauding treatment advances, we need to remember that people are more than the sum of their diagnoses, more than their biology, and our societies are not fair.

Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669
h ttps://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694?fbclid=IwAR23strMuoUXYs_Ae9EmTVz9eNAzYxgxAR1IBj64SePpbWeLQL_M_DOaXr8

Pain – or pain-related disability?


I’m struck at how often clinicians focus on pain intensity when how much pain intrudes on life matters more. I wonder whether new therapists might not have read some of the old studies looking at the relationship between pain intensity and disability – because while there is a relationship there, it’s not nearly as strong as we might think.

Let’s define a couple of terms first: pain is, I think most of us can agree, “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”. (click for full definition and notes)

Disability isn’t quite as clear-cut a term and it’s gone through a few permutations over time. Probably the way I define it fits more with “functional limitations” – but the diagram below from WHO describes their model of disability .

In other words, disability is the combined impact of all of these aspects of health on a person. Pain arises from some kind of health condition (yes, even pain where we’re not entirely sure of the “diagnosis” and where we can’t quite yet be definitive about what’s going on). In turn, pain influences body functions (and perhaps structure – certainly there’s a lot of evidence showing altered neural networks while someone is experiencing acute pain, and changes are also present in persistent pain conditions. See the refs below – but interpret cautiously, this is an emerging area of research).

All of the relationships above are bidirectional, meaning that there’s no linear path from one aspect to another – it’s complex.

What this means is that we shouldn’t be one bit surprised that the relationship between experiencing pain, the health condition, what a person wants to do, how much they participate, and their context is not at all straightforward. Yet so often I see research papers looking at altering one aspect of a disorder or disease, measuring pain as the primary outcome, and being a bit surprised that even though the pain might have reduced a little – the person isn’t “taking advantage of it.”

A good example of this is returning to golfing after knee arthroplasty. Prior to surgery many people have taken to golf carts so they can get around the course. After surgery, with less pain in most instances, you’d think people would go back to walking the course – it’s a great way to keep fit, it’s not as difficult to do as a bunch of gym-based knee exercises, and it makes for an enjoyable game. What actually happens? Jackson, Smith, Shah, Wisniewski and Dahm (2009) found that over half (57%) returned to golf within 6 months, with 81% playing golf as much or more often than before surgery. They reported less pain with 83% reporting no pain – 28% had walked the course before surgery, so what percent do you think would carry on walking now that their pain was less?

Go on.

Guess.

Only 14% walked the course after surgery.

No relationship between walking and age, sex, BMI, pain, receiving advice not to, bilateral or unilateral prosthesis, or current golfing handicap.

Even in acute musculoskeletal pain, where we know that to wait until all pain has gone will harm the person (think of your ankle sprain) it seems clinicians would rather address pain intensity than the impact of pain on what a person wants and needs to be able to do. Case in point: Adam Meakins recent back pain.

There’s an assumption that people seeking treatment want their pain dealt to over and above anything else. How true is that, really? As clinicians we might ask the person “what’s your goal from treatment?” and they may reply “get rid of my pain” but that’s a superficial approach to understanding treatment seeking.

I’d love to hear clinicians dig just a little deeper – like “so if pain was less of a problem, what would you be doing?” Because we know that people seek treatment for back pain because of the effect on what the person wants to do – Ferreira, Machado, Latimer, Maher, Ferreira and Smeets (2010) showed this in a meta-analysis over a decade a go.

Is it either/or though?

Well by now readers of this blog should know that I don’t think anything is as simple as a dichotomous yes or no. Of course pain intensity matters – but what I often see, especially on social media, is an almost exclusive focus on pain intensity and “proper” form and “exercise” with little attention to what it is the person wants to do.

Because the unknown part of the Jackson et al (2009) study is why these people didn’t resume walking, even though they were in less pain, and were playing golf more.

I’m picking the reasons lie within those pesky contextual factors – who is around the person, their physical environment, community attitudes and beliefs, their fears and anxieties, what’s thought to be normal or expected – the bread and butter of occupational therapy, and coincidentally, the most complex part of health to research and understand. No wonder there are those who prefer the conceptually simple mechanistic, biomedical approach – these psychosocial (emphasis on the social) can’t be rote learned and spat out in an exam, they need conceptual understanding and unique, individualised solutions.

Barroso, J., Wakaizumi, K., Reis, A. M., Baliki, M., Schnitzer, T. J., Galhardo, V., & Apkarian, A. V. (2021, Mar). Reorganization of functional brain network architecture in chronic osteoarthritis pain. Human Brain Mapping, 42(4), 1206-1222. https://doi.org/10.1002/hbm.25287

Ferreira, M. L., Machado, G., Latimer, J., Maher, C., Ferreira, P. H., & Smeets, R. J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. https://doi.org/http://dx.doi.org/10.1016/j.ejpain.2009.11.005

Geuter, S., Reynolds Losin, E. A., Roy, M., Atlas, L. Y., Schmidt, L., Krishnan, A., Koban, L., Wager, T. D., & Lindquist, M. A. (2020, Jun 1). Multiple Brain Networks Mediating Stimulus-Pain Relationships in Humans. Cerebral Cortex, 30(7), 4204-4219. https://doi.org/10.1093/cercor/bhaa048

Jackson, J. D., Smith, J., Shah, J. P., Wisniewski, S. J., & Dahm, D. L. (2009, Nov). Golf after total knee arthroplasty: do patients return to walking the course? American Journal of Sports Medicine, 37(11), 2201-2204. https://doi.org/10.1177/0363546509339009

Wager, T. D., Hu, B., Jepma, M., Krishnan, A., Schmidt, L., Roy, M., Atlas, L. Y., Goldstein, P., Yao, Z., Woo, C.-W., & Zheng, W. (2020). Pain-Evoked Reorganization in Functional Brain Networks. Cerebral Cortex, 30(5), 2804-2822. https://doi.org/10.1093/cercor/bhz276

One plus one may not always equal two


If it hurts – take notice, and avoid it. Learn from it. If there are other people around, make sure your behaviour is noticeable so they take care of you and don’t do what you just did. If they look after you, you’ll probably do the same thing again when you hurt, if they don’t you probably won’t.

This is one description of pain behaviour and how it works. It’s the only part of our pain experience that we can share directly with one another (actions and words). The “doing” part is also the part that is most affected by pain – even distress is signalled to others – so it’s unsurprising that a lot of attention has been paid to how therapists can change behaviours that are unhelpful.

Many of us start with offering an explanation. Language is something that sets humans apart from other creatures because we learn concepts, and associate one concept with another through it (see Beeckman, Hughes, Kissi, Simons & Goubert (2019) for excellent insights into relational frame theory and pain). I’m sure there are many clinicians who’ve tried to give information (to “educate”) to a person and found it works well. And then there are those who just don’t get it. There are three main points that people who respond well to “education” seem to find useful: (1) pain doesn’t mean my body is damaged (the old “hurt does not equal harm” message that originated with Fordyce. Butler (2017) offers us a selection of Fordyce’s wisdom – and wit); (2) thoughts, emotions and experiences affect my pain (again, something the cognitive behavioural therapists have been sharing with people since the beginning of multidisciplinary pain management programmes); and (3) I can retrain my over-protective nervous system (yes, another thing we’ve been doing in pain management for many years… not that we are unlearning pain, we’re helping the nervous system settle down and becoming less distressed by the experience).

We quite like talking to people – maybe because it appeals to our often dictatorial mind (read A Liberated Mind for a new take on this!). And so for people experiencing pain, we talk. But talk on its own isn’t super-effective. After all, for every one time we hear “pain doesn’t mean my body is damaged” we can Google and find literally hundreds of messages telling us our spine is fragile, our joints are damaged and pain is a sign there is harm.

So what is more potent than words? It’s learning by experience. Doing.

A brand new analysis of “sufficient conditions” for psychological therapy was published in Pain (Batho, Kneale, Sutcliffe & Williams, 2021).

Now I do have some reservations about calling this “psychological” because that word is loaded with meanings, not all of them helpful. Truth to tell, we humans use psychological approaches effortlessly in daily life – and it’s not “in the head/mind/emotions” which is almost inevitably what people first think of when they hear it…

In this analysis (which is complex – go read the paper!), the authors investigated 38 studies, did some horrendous statistical analysis and compared the ten most effective treatments with the ten least effective treatments. What they found was quite surprising, and I’m still pondering what it means.

They established that “interventions using graded exposure, graded exercise or behavioural rehearsal (exposure/activity), and interventions aiming to modify reinforcement contingencies (social/ operant) reduced disability levels when either approach was applied but not both.” [italics mine] They also found “exposure/activity can improve distress levels when combined with cognitive restructuring, as long as social/operant methods are not included in treatment.” [italics mine]

It pleased me to find that graded exposure or reactivation, when applied in the absence of social and operant contingencies, reduced disability and distress. And that social/operant approaches reduced disability on its own. The reason I’m happy is that graded exposure and reactivation with a dab of “let’s notice your thoughts and check out whether they’re helping you” are very common approaches used across occupational therapy, physiotherapy, chiropractic, osteopathy, coaching and a whole bunch of therapists who work with people in pain. Graded reactivation with information has been the mainstay of pain management since at least the 1980’s. We know it’s helpful. Graded exposure has gained popularity since the mid-1990’s and we know that it’s helpful too. And we use social reinforcement just because we’re humans.

In the analysis, ACT was used in only one study. ACT doesn’t do cognitive restructuring and instead, uses six interwoven processes that together support psychological flexibility. I use ACT as my primary approach, both for myself in daily living, and with people who come to see me for help with their pain.

What I like about ACT is that it’s flexible, allows people to notice what their mind tells them, but helps them to step back from that dictator within to make a choice about what to do. It’s the doing part (based on what matters in a person’s life) that I enjoy because it involves both graded exposure and graded reactivation. And if a person doesn’t relate to what they’ve been told about their pain, we don’t have to offer another explanation, we can help the person work out what works for them in the context of their own life.

So where are we with this now? Given that we can’t stop being social animals, and that we respond to one another without knowing it, I’m not sure we can avoid inadvertently using social and operant approaches as therapists. What we can do, though, is become more knowledgeable about behavioural approaches in pain management and rehabilitation – and that undoubtedly means learning a whole lot more psychology. Perhaps we might need to reframe our own understanding of psychology so we feel more comfortable with it – a bit like explaining pain and cognitive functional therapy have both helped us feel OK to step into doing what has often been the territory of psychologists.

Batho, A., Kneale, D., Sutcliffe, K., & Williams, A. C. C. (2021, Oct 1). Sufficient conditions for effective psychological treatment of chronic pain: a qualitative comparative analysis. Pain, 162(10), 2472-2485. https://doi.org/10.1097/j.pain.0000000000002242

Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., & Goubert, L. (2019, Oct). How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain. Journal of Pain, 20(10), 1141-1154. https://doi.org/10.1016/j.jpain.2019.02.013

Butler, S. (2017). The wit and wisdom of Wilbert (Bill) Fordyce (1923-2009). Scandinavian Journal of Pain, 16(1), 160-163.

Leake, H. B., Moseley, G. L., Stanton, T. R., O’Hagan, E. T., & Heathcote, L. C. (2021, Oct 1). What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education. Pain, 162(10), 2558-2568. https://doi.org/10.1097/j.pain.0000000000002244

“Research says” – and why lived experience matters


It’s no secret that I enjoy using social media to discuss topics associated with pain. After all, I wouldn’t have been blogging for as long as I do if I didn’t find this medium interesting in some respect!

At the same time, social media “debates” can truly be unhelpful, unpleasant and even harmful. Yet possibly one of the most harmful communicative strategies that I see is reference to “research says”. What? you say – but, but you LIKE research! Well yeah I do – but research is not a neutral “Truth” that means we can simply grab a published paper, find the results we like, then hang on to that for the rest of our careers!

What do we mean when we say “Research says”?

You know the Background part of a paper? And you know the Discussion section? The only bits read by some people – if they go past the abstract? These sections are important, but not perhaps for the reasons you might think. When I first started reading research papers, I used to think the Background was intended to highlight an unanswered question, and the Discussion was to put the answer (from the Results) into context and to establish “where next”? And there’s truth to this perspective. But it’s a beginner’s look at research. It’s a start to understanding the context of a piece of investigation. Reading these sections does give an insight into how the authors want to frame their piece of research.

Let’s pick it apart a bit. As Schostak and Schostak (2012) put it: “Each text is itself a framing of voices and their agendas, shaped to present a debate slanted towards a conclusion.” They go on to say “…whilst acts of framing bring and impose order, those very processes of ordering and categorisation select and edit so that some things are chosen
to be foregrounded, others to be background and yet others to be excluded.”

In other words, these pieces of writing offer a selected view of what is going on in this part of the research and knowledge landscape. It’s understandable that people new to an area of study might not know what else is being said, or what else has been prioritised – but it’s rather less forgivable in people who have been working in, or studying or teaching in an area for many years.

So how do we “interrogate” research so we go beyond accepting the literature review and discussion at face value? And why does it matter?

I’ll answer the last question first.

It matters because Truth with a capital T is not really a thing, at least not when it comes to pain. Pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Further to that,

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

In particular, I want to draw your attention to the first note: “Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors.” My interpretation of this is that my experience of pain is mine. And while some people may have similar experiences, the particular way I experience pain is unique. It’s different from anyone else’s.

For clinicians – and researchers – respecting the unique experience of the person in front of us (or participating in a research study) is crucial. Yet we mainly read about GROUPED experiences in research, many of which are reduced to a single number on some questionnaire or scale.

One of the unspoken assumptions in much of our research, particularly quantitative studies, is that although we lose detail by grouping information, we retain essential information. Another assumption is that only the essential data really matters. Those details, that nuance, the individual isn’t relevant, or at least, it’s less relevant than the consistent information.

So interrogating, reading research critically matters – not only reading the methods section, but also reading the background and discussion. Because the background and what is selected from previous research and writing is used to frame what is thought important, while the discussion is used to illustrate and situation the importance of the research results. The reader’s job is to read these sections and look to the voices that are put in the foreground (thought important) and to look at those placed further back, or perhaps not even included.

And one set of voices often omitted are the people who live with persistent pain, those who experience acute pain, and those who care for and are affected by pain of any kind. We have yet to move pain research and management towards an inclusive “nothing about us without us” stance. Our research is dominated by studies about but not with people in pain.

How do we interrogate research?

Some key points (because people write whole books on this!)

  1. Hold all research very lightly.
  2. Never consider a single study to be sufficient.
  3. Read widely. Read the background to the research and ask “Who isn’t included?” and “Which voices are foregrounded, which voices are backgrounded?”
  4. When reading, ask yourself who will gain benefit from this? Who might lose?
  5. What assumptions (explicit or implicit) are held when asking the research question, deciding on a method, analysing the results, and situating the piece in other research literature.

I really like the “cheat sheet” below for stretching my critical reading muscle.

And at the foreground for me is always “how is the voice of people experiencing pain represented in this paper?”

This is a great piece on critical reading – click – from Pavel Zemilansky and OpenOregon.

This piece from Massey University is also very helpful – click

And this is the book – click – by Schostak and Schostak

Adam’s slow recovery


Not long ago I wrote about Adam Meakins back pain, and the astonishing response he’s had from fellow clinicians as he’s documented his recovery. Sadly, the polarised views of how therapists should approach a person with low back pain show me just how appallingly badly we adhere to low back pain guidelines… and worse, the kind of language and attitudes shown to a colleague who knows what he’s doing, demonstrates why change is so very slow.

What do I mean? Well, Adam has been following evidence-based low back pain guidelines that haven’t really changed a great deal since the advent of New Zealand’s “Yellow Flags” and guide to low back pain published waaaaay back in 1997. I’ve jumped to the NICE guidelines, as an example of one guideline, but you could look to many others.

NICE suggest these steps:

Assess for alternative diagnoses – in particular, “cancer, infection, trauma or inflammatory disease such as spondyloarthritis”

Risk assessment – basically, sorting people into those who are pretty OK with their pain, non-distressed and recommending those people receive “reassurance, advice to keep active and guidance on self-management.”

If Adam was distressed, or had a whole lot of risk factors for ongoing disability, then he might benefit from “more complex and intensive support for people with low back pain.” And yes, this mentions exercise programmes, manual therapy, psychological approaches.

Imaging – is not recommended, with imaging only used if the result is likely to change management.

Treatment – self-management, no orthotics or belts, no traction, and only offer manual therapy as part of an overall package that includes exercise.

No acupuncture, no electrotherapy.

Maybe use psychological therapies in conjunction with exercise.

Add in some NSAIDs

And don’t do much else…

In other words – exactly what Adam has been doing.

Why are there so many clinicians offering unsolicited opinions, without examining Adam, and without listening to his preferences, and without referring to the evidence?

What does this say about our clinical practice? What does it say about our confidence? What does it say about knowledge translation?

Most of all, what does this DO to the people we hope to help?

Seriously, folks. Watching the responses gives me nightmares.

I’ve been working in this field for 30 years now, and saying essentially the same thing about low back pain management for most of those years. I worry that an enormous business is built around scaring people, offering treatments with limited effect, for a condition that is common and responds well to doing normal movements.

In fact, one gripe I do have with the NICE guidelines is that they utterly and completely ignore daily life activities that a person needs to return to, and quickly. There’s nothing on managing sleep – and Adam’s described really rotten sleep until two days ago. There’s nothing on how to manage washing yourself, driving your car, sitting at a desk, doing the grocery shopping, preparing a meal, care for kids (or older parents) – absolutely nothing on the daily life activities that people need and want to do.

But, then again, I would say this – occupational therapists are the profession concerned about daily doing. The context of every day life. Knowledge translation from clinic/gym/exercise to what people actually do in their daily routines. It looks oh so simple – until you have to do it.

Back to Adam’s slow recovery. As I’ve watched Adam’s videos, I’m struck with the thought that many people just don’t know what to say – and so offer advice because that’s one way to deal with their own disquiet at helplessness. Clinicians, we need to develop better skills at managing our OWN emotional responses. We need to develop greater skills at sitting with our uncertainty. We need to stop leaping in with unsolicited advice that we offer just because we’re not comfortable doing nothing.

Could we just, for a moment, stop thinking about our reactions – and listen to what Adam (and I’m sure a whole bunch of our patients, too) says he wants? Listening means stopping that inner voice that’s got the “good” advice. It means really hearing what a person says. And only formulating a verbal response after we’ve digested the meaning the person is trying to convey.

Kia kaha Adam. You’re a brave man, a strong man, and I have much respect for you.

“Just a little scratch”


If you’ve had a blood test, flu jab or Covid-19 vax (please do, not just for you but for the vulnerable) you’ll probably have heard those words “Just a little scratch” then the needle goes in and ouch! I’ve wondered why phlebotomists and vaccinators use those words: is it to reduce the pain? give you some warning so you don’t pull away? why use the word “scratch” when it’s not a scratch?!

I suspect, though I haven’t read up on it, that the reason people say “just a little scratch” is to influence expectancies. Expectancies are defined as “cognitions regarding the probability of future experiences, events, and behaviour” (Peerdeman, van Laarhoven, Peters & Evers, 2016). In other words, what we expect to experience, happen or do influences what we actually experience, what happens, and what we do. Expectancies are really important when we consider placebo – and nocebo. Despite commentators who don’t consider placebo to be a thing (the response to being in a treatment ritual, over and above the effects of any active therapeutic agent), in pain, it is most definitely a thing, and one we need to be aware of as clinicians.

Back to expectancies.

Mostly, what we expect is what we experience. If we expect something to REALLY HURT then it’s likely to REALLY HURT! But what happens when we don’t expect something and it happens? Or when we expect something not to really hurt, but it actually does?

Peerdeman, Geers, Porta, Veldhuijzen and Kirsch (2021) investigated this mismatch between what we expect and what actually happens. It’s fascinating because the results weren’t quite in line with what the researchers thought…

What did they do?

The authors selected 82 healthy adults, aged between 18 and 30, with no health problems (physical or psychologist), no chronic pain, no current pain, no medications, no pacemakers, and no pregnancy. The participants weren’t allowed to use any medication, alcohol or other drugs in the 24 hours before the experiment.

Two experimenters undertook the experiments – one wasn’t aware of who was getting what, while the other was unaware of what was getting what until just before she gave the verbal suggestion. The experimenter who was blinded left the room before the second one gave the suggestion, in order to remain blinded throughout.

The participants were wired up to record heart rate, skin conductance, and then thermal and nociceptive perception thresholds were identified – at least in part to give participants a chance to get used to the heat stimulus. The experimenters went in to increase the heat to identify the temperature where participants indicated the pain was “moderately high” (who volunteers for these experiments? Oh – they recruited from around the university and on social media...). Then the experimenters got to work: participants were randomised to get either a suggestion of “no pain” (they’d already had three occasions where the thermal stimulus wasn’t painful, and three where it was), or a suggestion of moderately high pain. Then the stimulus was applied four times, with participants having to rate the expected pain intensity, how certain they were of this prediction, and how afraid they were. Afterwards, they were asked to rate pain intensity and unpleasantness.

For all the details of this experiment, head to the paper itself – it’s very detailed, and could be replicated.

Results

One person dropped out before the trial began – it was too painful – leaving 81 people remaining. The average age was 22 years, but the investigators don’t report gender.

When people were told “it’s not going to hurt” participants rated the pain lower than those who were told it was going to hurt, and while the ratings changed depending on what they experienced, when it was again suggested they’d feel no pain – again their pain ratings were lower than expected. Who knew pain intensity could vary so much? Reported pain intensity in the people who were told they wouldn’t experience pain was 4/10 points lower than the other group who were told it would hurt, and a bit over 2 points lower the second time (on a 0 – 10 numeric rating scale). That’s a thumping great amount of pain reduction! Add to this, these participants also were less afraid of their pain than the other group.

BUT, and this is important, participants in the “it’s not going to hurt” group reported less trust in the experimenter (who would have thought, huh?!). So beware: if you tell someone “oh this won’t hurt a bit” – they may experience less pain, but they’ll look at you sideways and be a bit wary of you because you violated their trust.

Discussion

I haven’t described the second experiment because of space, but go ahead and read it. Essentially they added some more participants, varied the procedure a little to reduce the memory burden on participants, and added a “medium” underprediction element into the process. The results showed similar outcomes – lower ratings of pain in both the “you won’t feel a thing” and the “it’ll hurt but not much” experiments, and yet again, less trust in the experimenter suggesting that it wouldn’t hurt.

Lessons to learn?

Think carefully about inflating how much pain relief someone will experience, especially if you’re going to see that person again. While people might experience less pain, losing someone’s trust in a therapeutic setting is a serious problem. The authors point out that healthy volunteers in a lab setting, getting short-term pain, is not like a therapeutic setting where it’s probable that trust is well-established. We don’t know what effect violating trust in a longer-term relationship might have.

At the same time – it does strike me as intriguing that simply being told “it won’t hurt” can influence pain intensity rating. What’s going on? How can a communication stimulus influence an experience? How could a psychological input change the way we perceive a noxious stimulus? Perhaps the way forward might be to use neutral language or, more positively, suggest that the person can handle it? “Just a little sting and you’ll get through”

Peerdeman, K. J., Geers, A. L., Della Porta, D., Veldhuijzen, D. S., & Kirsch, I. (2021, Jul 1). Underpredicting pain: an experimental investigation into the benefits and risks. Pain, 162(7), 2024-2035. https://doi.org/10.1097/j.pain.0000000000002199

Peerdeman KJ, van Laarhoven AI, Peters ML, Evers AW. An Integrative Review of the Influence of Expectancies on Pain. Front Psychol. 2016;7:1270. Published 2016 Aug 23. doi:10.3389/fpsyg.2016.01270

When therapists get hurt


“Physician, heal thyself” – usually used to suggest that the person should fix their own problems before trying to fix someone else. And when a therapist gets hurt all the armchair critics (social media proclamists) go off pointing the finger and telling that person what to do – even when the therapist is doing exactly what evidence suggests is the right thing to do.

Adam Meakins has hurt his back while lifting weights in the gym – he’s documenting his progress on social media, which I think is both a very brave thing to do and also something I’d love to see more of. If you want to follow his progress, head to The Sports Physio on Facebook where he’s posted footage of the onset, and now Days 1 and 2.

Why do I think it’s brave? Well because Adam’s outspoken and highly visible on social media. That means anything and everything he does about his LBP is likely to be scrutinised in detail. All manner of opinions have already been put forth. Diagnoses made (yeah, I know – over the interwebs…), and so many treatment options offered!

Adam’s predicament gets much more attention than Mrs Jones down the road who hurt her back the same day. Yet Adam knows what to do, is doing it, and holding strong to what research suggests is best.

Mrs Jones, on the other hand, is likely subject to some of the opinions that Adam’s getting (go on, take a look, especially on Instagram and Twitter) but without the background and experience Adam has to draw on. No wonder Mrs Jones feels confused.

Adam is brave because, as he pointed out today, having LBP means your mind leaps to unhelpful conclusions, often “thinks the worst” and in the dark of the night, it’s probable that doubts about whether he’s doing the right thing creep in. And if Adam’s recovery is slower than usual, I can hear the chorus of bystanders roar for his blood “You didn’t do what I said you should do”

Because isn’t it peculiar, and common, that when recovery doesn’t follow the standard trajectory, it’s the person’s fault…

Think of Mrs Jones – if her recovery goes the way so many people’s recovery goes and burbles along with flare-ups and periods where it settles, then she’s likely to carry on seeing at least one clinician, probably more. She’ll likely get a whole range of different ways to manage her low back pain – but usually starting with one approach and getting more of it until the clinician decides to change tack, and then onto another one until that clinician decides it’s not working and changes tack….And along the way she’ll acquire labels like “catastrophiser” or “avoidant” or “noncompliant”.

I also said that I’d love more clinicians to post about their recovery. I’ve seen a few, but couldn’t we do more? Why? Because showing how clinicians also “think the worst”, worry, have trouble sleeping, want to keep going but find it tough – despite our knowledge of pain, and all our experience working with people who have pain – is good for us as clinicians.

Because if you’ve never had a bout of back pain it’s relatively easy to think that the way a person reacts to their pain is abnormal. The label “catastrophising” gets bandied about, along with all the other psychosocial factors that can often get used and abused in a way that lays the fault for the person’s predicament on them.

But back pain is really common. Most of us will have a bout at some point in our life – maybe more severe than Adam’s, maybe less severe, maybe associated with heavy lifting as Adam’s was, maybe just bending to pick up a pair of socks. Some of us will be really fit like Adam, others of us will be less fit.

Back pain isn’t very choosy and this is why we haven’t yet found a way to prevent it from ever happening, we can only work with the person to prevent it hanging around and getting in the way of life.

Being honest enough to show that clinicians are human too helps other clinicians rethink the “them and us” divide that is common between people seeking help, and those who would offer help. Because how often do we hear that Mrs Jones was unfit, probably lazy, had a bad lifestyle, ate the wrong foods, did no exercise, and it was probable that she’d develop a back pain. Yet Adam is pretty fit, lives a healthy lifestyle, is certainly not lazy, and like Mrs Jones does not deserve a low back pain.

I hope that Adam doesn’t get the advice I’ve heard given to so many people: get fit, change your lifestyle, get back to work, do more. Mrs Jones might be working two physically demanding jobs (cleaning, and waiting tables). She might walk 20 minutes to get to the bus-stop, and is on her feet all the time she’s at work. She might leave home at 6.00am, get back at 5.00pm to prepare a meal for the rest of her household, then go out again for another three or four hours to her second job, finally arriving home to sleep at 9.00pm. And some youngster suggests she needs to “prioritise herself” and “do exercise”! Who else is going to do what Mrs Jones does for her family?

Finally, I really hope that people offer Mrs Jones a lot more of an empathic response than Adam has had. Anyone experiencing pain needs support – and don’t need a whole bunch of well-intentioned advice from people who don’t know them personally. And some of the comments offered to Adam are not well-intentioned. What does that kind of vicious behaviour show to the general public?

Below – just a small selection of the longitudinal studies exploring the trajectories of back pain in the population. Worth looking at if you think you’ve got The Answer to What To Do – because so far it’s not working.

Canizares, M., Rampersaud, Y. R., & Badley, E. M. (2019, Dec). Course of Back Pain in the Canadian Population: Trajectories, Predictors, and Outcomes. Arthritis care & research, 71(12), 1660-1670. https://doi.org/10.1002/acr.23811

Chen, Y., Campbell, P., Strauss, V. Y., Foster, N. E., Jordan, K. P., & Dunn, K. M. (2018, Feb). Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain, 159(2), 252-260. https://doi.org/10.1097/j.pain.0000000000001097

Gatchel, R. J., Bevers, K., Licciardone, J. C., Su, J., Du, Y., & Brotto, M. (2018, May 17). Transitioning from Acute to Chronic Pain: An Examination of Different Trajectories of Low-Back Pain. Healthcare (Basel, Switzerland), 6(2). https://doi.org/10.3390/healthcare6020048

Kongsted, A., Kent, P., Axen, I., Downie, A. S., & Dunn, K. M. (2016, May 21). What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord, 17, 220. https://doi.org/10.1186/s12891-016-1071-2

Pico-Espinosa, O. J., Cote, P., Hogg-Johnson, S., Jensen, I., Axen, I., Holm, L. W., & Skillgate, E. (2019). Trajectories of Pain Intensity Over 1 Year in Adults With Disabling Subacute or Chronic Neck Pain [Journal: Article]. Clinical Journal of Pain, 35(8), 678-685.

When living with pain is too hard


**If you’re a person living with pain, and this headline caught your attention because you’re feeling it’s just too hard to carry on – PLEASE take a moment to seek help. If you’re feeling you can’t because they might judge you, or try to stop you feeling this way, at the very least give yourself an hour before you take any action. If that feels too long, give yourself a minute. Get through that, and give yourself another minute. And so on – until you’ve give yourself some time to let this awful feeling ease up a little. You can always revisit your decision to wait. Speak to someone – anonymously if you need to. There are helplines in every country. Phone one. Please.**

Living with persistent pain can be really hard, and clinicians, family and the person with pain can be worried about suicidal thoughts and possible actions. There’s good reason to be concerned, too, as a recent study from the 2012 Canadian Community Health Survey shows.

Grocott, Sommer and El-Gabalawy (2021) used the data obtained from this Canadian Health Survey to explore the relationships between pain intensity and suicidality in people with arthritis, migraines and low back pain.

The first question is how many people in the overall population involved in this study had any of the three diagnostic groups – and, as expected and in line with many epidemiological studies, between 10.3% (migraines) and 18.1% (low back pain) indicated they had been diagnosed. The “usual” pain levels across all three groups were between 25.9 – 27.7% indicating their pain was “mild”, 52.5 – 54.5% said it was “moderate”, and 19.7 – 20.9% described it as “severe”. This does not surprise me one bit – moderate levels of pain intensity are really common, and, albeit acknolwedging the difficulty of rating pain intensity on a numeric scale and the complex relationship between pain intensity and interference with daily life, demonstrate just how necessary persistent pain services are as a health services priority.

The team then identified the rates of “lifetime” suicidality – these were measured using the following questions.

“you seriously thought about committing suicide or taking your own life” (i.e., suicide ideation; yes, no), “you made a plan for committing suicide” (i.e., suicide plans; yes, no), or “you attempted suicide or tried to take your own life” (i.e., suicide attempts; yes, no).

It’s important to note that this question asked about whether the person had ever, during their life, had these thoughts – not that they were currently present. Remember this as you interpret this study, because suicidal thoughts are relatively common but acting on those thoughts is less common.

The authors found that people who were usually in pain were more likely to have suicidal thoughts, plans or had made an attempt than those who had periods of time without pain (ie intermittent pain). The different rates were reasonably large, too – just in terms of ideation, between 18.7 – 34.0% of people who were usually in pain had suicidal thoughts as opposed to those with intermittent pain (10.5-16.6%), and this association was particularly strong for people with migraine. For people with low back pain, having pain all the time was associated with much greater odds of suicidal thoughts (1.79, 95% CI [1.19-2.68], p<.05).

Pain intensity was also a factor – lifetime suicidality prevalence increased as pain intensity increased, and this was relevant to all pain conditions measured, and especially amongst people with severe pain and migraines.

A good question to ask is whether the odds were the same for people with current mental illness as for those without – and using the magic of statistics, the authors found that this only held for some forms of pain. People with arthritis (note they didn’t identify the kind of arthritis people had) reported lower levels of suicidality even in the presence of mental ill health.

The authors point out that this is an interesting study in that yes, suicidality was higher in people with migraines, and similar to other studies, but their intriguing finding was that differences in the intensity of usual pain increased the odds, along with elevated odds if people reported higher levels of pain intensity.

Why did I choose to summarise this paper?

A few reasons: one is that as health professionals, we may not be aware of just how many people in our communities live with pain. It’s a lot – and this study only included specific diagnoses. Yet, at least in New Zealand, pain management services for people with pain are scarce.

Most people in New Zealand will maybe get referred to a physiotherapist, but it’s often difficult for people with persistent pain to raise their issues with pain with their health provider and for those providers to respond with empathy (Thompson, Dowell, Hilder, Macdonald, Stubbe & Alchin, 2021). This means that many people may not be seen by clinicians with confidence to help people with psychosocial aspects of their pain (eg Holopainen, Simpson, Piirainen, Karppinen, Schutze, O’Sullivan & Ken, 2020, Zangoni & Thompson, 2017) if they even indicate that this is a concern for them during the consultation.

Another reason is that many clinicians who work mainly in “physical” health may not know what to do if someone does disclose suicidal thoughts. It is confronting to hear someone say they don’t want to live any more – and knowing what to do next can feel highly risky. How does this fit within my scope of practice? What if I say something wrong and the person goes ahead and attempts suicide?

Note though, that this study didn’t look at current levels of suicidal thought – it’s lifetime prevalence. Perhaps people who have had occasion to think about killing themselves have a greater degree of vulnerability for persistent pain, particularly when pain is intense. We don’t know – but the authors speculate. Worth reading the paper in full to find out their thoughts.

My thoughts (briefly!) are:

  • Prepare ahead of time. We’ll all likely encounter a person who is really distressed, at the end of their tether, and indicates they’re thinking of harming themselves. Being prepared makes responding to this situation much easier.
  • Preparation should include writing a policy for your practice or your setting. It should include a list of people to contact in a psychiatric emergency (when a person indicates they’re ready to take action to harm themselves), as well as specific actions to take when talking to the person.
  • We’re not all psychologists and it’s not our job to be psychologists – all we’re asked to do in this kind of situation is be a human. What I mean by this is – listen, affirm that the person is feeling really bad and support them to access the help they need. This might mean calling the psychologist if you have one you work with regularly, or calling the person’s family doctor, or calling psychiatric emergency services.
  • Ensure you hand the person to someone who will take care of them. This means not letting them go off in their car without letting their family doctor know, even if they say they’re fine. For your own reassurance this is important.
  • Take care of yourself. Don’t just go on to see the next person waiting for you. Take some time to process what’s happened, what you did, and debrief with someone you trust. It doesn’t need to be a trauma counsellor – it’s just as useful to talk to your colleagues who know you and the kind of work you do. Go have a cup of coffee, go for a walk, give yourself space to recognise that you just helped someone who was really distressed. That’s an important job.
  • Don’t ignore the person and pretend they didn’t just say that. Affirm that they’re feeling rotten. Don’t trivialise it and suggest they should just harden up, or it’s not really that bad, or that they’re at fault for feeling this way. Just be gentle and human, and recognise the privilege you have – this person trusts you enough to say how they’re really feeling. It’s an honour. So if you can’t think of anything to say, just sit with them and bear witness to their distress. Hand them a tissue. Be there for them.

Oh, and in that paper, while 18.7 – 34.0% had suicidal thoughts over their lifetime, 7.2–14.5% had made actual plans, while 6.6–14.7% had made attempts. Don’t trivialise suicidal thoughts, but at the same time, don’t freak out that the person is going to kill themselves – just take action to support them, and in most cases, the thoughts will fade as the person gains hope.

Grocott, B., Sommer, J. L., & El-Gabalawy, R. (2021, Jun 28). Usual presence and intensity of pain are differentially associated with suicidality across chronic pain conditions: A population-based study. Journal of Psychosomatic Research, 148, 110557. https://doi.org/10.1016/j.jpsychores.2021.110557

Holopainen, M. R., Simpson, M. P., Piirainen, D. A., Karppinen, P. J., Schutze, D. R., Smith, P. A., O’Sullivan, P. P., & Kent, A. P. (2020, Jan 16). Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain. https://doi.org/10.1097/j.pain.0000000000001809

Thompson, L., Dowell, A., Hilder, J., Macdonald, L., Stubbe, M., & Alchin, J. (2021, Jan 4). How do patients and General Practitioners talk about pain and negotiate empathy in consultations? A direct observational study. Health & Social Care in the Community. https://doi.org/10.1111/hsc.13259

Zangoni, G., & Thomson, O. P. (2017, 2//). ‘I need to do another course’ – Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskeletal Science and Practice, 27, 71-77. https://doi.org/https://doi.org/10.1016/j.msksp.2016.12.015

Why I don’t trust my clinical reasoning: and why this matters


“See someone experienced” I hear people with pain say. “They’ll know what’s wrong with you.”

Well, based on the research I’ve read, I wouldn’t be so sure. In fact, I’m certain my own clinical reasoning is biased, prone to errors that I don’t notice, and influenced by factors that most clinicians would be horrified to think they, too, were influenced by.

Let me give you a few to ponder:

I’m interested in women and pain – and there’s a lot of evidence showing that women’s pain doesn’t get the same kind of diagnostic and management attention as men. Now part of this is due to the inherent bias in research where experimental studies often rely on male rats, mice and undergraduates because they don’t have those pesky hormonal fluctuations each month. Even volunteering to take part in a pain study has been found to be biased – people who volunteer have been shown to be more risk-taking and more extraverted (Skinner, 1982) – though to be fair this is an old study!

But contextual factors such as gender, distress and even the supposed diagnosis do influence judgements about pain intensity (Bernardes & Lima, 2011) including potentially life-threatening chest pain (Keogh, Hamid, Hamid & Ellery, 2004). Gender bias has been identified in a large literature review of gender bias in healthcare and gendered norms towards people with chronic pain (Samulowitz, Gremyr, Eriksson & Hensing, 2018).

And if you have the misfortune to be judged to have low trustworthiness and you’re a woman, you’re more likely to be thought to have less pain and to be exaggerating your pain (Schafer, Prkachin, Kaseweter & Williams, 2016). Beware if you’re overweight and a woman because you’ll be likely judged as having less intense pain, the pain will be judged as less interfering, more exaggerated and less related to “medical” factors – women’s pain in particular is likely to be judged as “psychological” and given psychological therapy rather than other treatments (Miller, Allison, Trost, De Ruddere, Wheelis, Goubert & Hirsch, 2018).

The weird thing is that the clinicians involved in these studies were oblivious to their bias. And let’s not even go there with people of colour or so-called “minority” groups such as LGBTQI.

So as clinicians our initial impressions of a person can lead us astray – and I haven’t even started with the contribution experience has on clinical reasoning. Let me go there then!

Something that cognitive psychologists have explored for some years now, is the type of thinking that we draw on for clinical reasoning. System one is “fast reasoning” – where we rapidly, instinctively and emotionally make decisions on the fly. Kahneman (1982) first described these two processes and noted that fast thinking gets better with rehearsal and are helpful especially for skilled clinicians needing to make decisions in pressured contexts, and draw on “pattern recognition” – or to be precise, draw on deviation from a recognised pattern (Preisz, 2019). System two is “slow reasoning” where decisions are made in a considered way, are not influenced by emotional state, and can be thought of as “rational.” Slow thinking is most useful where the situation is complex, where decisions need to weigh multiple pieces of information, where the situation might be novel, or where, for persistent pain in particular, there are multiple disease processes occurring.

OK, so we should choose system two, right? Not so fast! System one is hard to switch from – it’s what underpins “intuition” or “hunches” – and it gets more entrenched the more experienced we are. According to Preisz (2019), system one “seeks to form a coherent, plausible story by relying on association, memories, pattern matching and assumption.”

Why is system one thinking not so great? Well, we’re human. We’re human in the way we respond to any reasoning situation – we anchor on the first and most “plausible” ideas, and these might be unrelated to the actual presentation we see. For example, if we’ve been reading a journal article on a new treatment and its indications, it’s amazing how many people will present with those exact same indications in the next week! This is availability bias or anchoring bias. We’re also inclined to believe our own patients and judgements are different from “those people” – especially “those people” who might respond best to clinical guidelines. This means that even in the face of clear-cut research showing the lack of effects of knee arthroscopy (Brignardello-Petersen, Guyatt, Buchbinder, Poolman et al, 2017) an orthopaedic surgeon I know argued that “we choose our patients very carefully” – essentially arguing that his patients are different, and this approach is the best one.

If experienced clinicians find it hard to “unstick” from old practice, or move quickly to “intuitive” reasoning (even if it’s called “pattern recognition”), and if we all find it hard to recognise when we’re biased, or even that we are biased, what on earth should we do? All us old hands should retire maybe? All follow algorithms and not use “clinical judgement”? Take the “human” out of clinical management and use AI?

Some of these things might work. There is evidence that algorithms and AI can offer effective and (perhaps) less biased diagnosis and management than our unaided human brain (Kadhim, 2018) but there are also studies showing that direct comparisons between decision aids and clinical judgement are rarely made, and those that have been carried out don’t show superior results (Schriger, Elder, & Cooper, 2017). But watch this space: AI is a rapidly developing area and I predict greater use of this over time.

The risk with decision aids is – garbage in, garbage out. If we look at existing research we can see that male, pale and potentially stale dominates: this doesn’t bode well for people of colour, for women, for the unique and idiosyncratic combination of diseases a person can have, or for untangling the impact of disease on the person – in other words, disability and illness.

So, to summarise. We are all biased, and it’s best to acknowledge this to ourselves upfront and personal. We can then turn to strategies that may reduce the biases. For me, the one I turn to most often is a case formulation, using information gathered from a semi-structured interview and a standard set of questionnaires. These have been developed a priori so my biases in information gathering are limited. By taking time to follow a case formulation, my thinking is slowed to that more deliberative system two. At least some of the biases I know I’m prone to are mitigated.

And yet, I know I am biased. That’s why I use a supervision relationship to help me identify those biases, to be challenged and to reflect.

Bernardes, S. F., & Lima, M. L. (2011, Dec). A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain. Psychology & Health, 26(12), 1642-1658.

Brignardello-Petersen, R., Guyatt, G. H., Buchbinder, R., Poolman, R. W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N., & Vandvik, P. O. (2017, May 11). Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open, 7(5), e016114. https://doi.org/10.1136/bmjopen-2017-016114

Kadhim, M. A. (2018). FNDSB: A fuzzy-neuro decision support system for back pain diagnosis. Cognitive Systems Research, 52, 691-700. https://doi.org/10.1016/j.cogsys.2018.08.021

Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.

Keogh, E., Hamid, R., Hamid, S., & Ellery, D. (2004). Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain, 111(1-2), 209-217.

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018, Jan). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. J Pain, 19(1), 57-66. https://doi.org/10.1016/j.jpain.2017.09.001

Preisz, A. (2019, Jun). Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. Journal of Paediatric Child Health, 55(6), 621-624. https://doi.org/10.1111/jpc.14447

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 and Management, 2018.

Schafer, G., Prkachin, K. M., Kaseweter, K. A., & Williams, A. C. (2016, Aug). Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 157(8), 1618-1625. https://doi.org/10.1097/j.pain.0000000000000536

Schriger, D. L., Elder, J. W., & Cooper, R. J. (2017, Sep). Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior. Ann Emerg Med, 70(3), 338-344 e333. https://doi.org/10.1016/j.annemergmed.2016.12.004

Skinner, N. F. (1982, 1982/12/01). Personality characteristics of volunteers for painful experiments. Bulletin of the Psychonomic Society, 20(6), 299-300. https://doi.org/10.3758/BF03330107