Waitangi Day – or how to live together in unity

Today is New Zealand’s Waitangi Day ‘Mondayisation’ – the actual day was Saturday 6th Feb. It’s an important day in New Zealand because it’s the day when two completely different nations signed a treaty allowing certain rights between them – and allowed my ancestors to travel from Ireland and England to settle in the country I call my home. Unlike many country’s celebrations of nationhood, Waitangi Day is almost always a time of turbulence, dissension and debate. This is not a bad thing because over the years I think the way in which Maori (Tangata Whenua, or original settlers) and non-Maori settlers (Tangata Tiriti) relate in our country is a fantastic example of living together well. Not perfectly – but certainly in a more integrated way than many other countries where two completely different cultures blend.

Thinking of Waitangi Day, I’m reminded of the way in which the multidimensional model of pain attempts to integrate biological, psychological and social factors to help explain this experience and how such a primitive response to threat can ultimately lead to adaptation and learning – in most cases – or the most profound misery and disability in others.

Like the treaty relationship in New Zealand, there’s much room for discussion and debate as to the relative weight to place on various components of the model.  And like the treaty relationship, there are times when each part is accused of dominating and not giving the other/s due credit. Truth, at least to me, is, we need all of us (and all the factors) to integrate – not to become some bland nothing, but to express the components fully.

Just last week I was astonished to find that a clinician thought that I believed low back pain is “psychological”. Absolutely astonished because this has never been my position! While this blog and much of my teaching and reading is around psychological and more recently social factors influencing pain and disability, my position has never been to elevate the influence of these factors over the biological. I suppose I shouldn’t be surprised – it’s hard to deal with the state of play in our understanding of low back pain which finds that many of the assumed causal mechanisms (like disc prolapses, poor “core” muscles, the biomechanics of lifting and so on) just don’t apply. It’s also really difficult to know that so far there are no particular exercise treatments that work more effectively than any other. Cognitive dissonance anyone? Just because these factors are less relevant than presumed does not mean that (a) I think low back pain is psychological and (b) that all biological factors are irrelevant. What it does mean is that we don’t know. I’ll say that again. We. Don’t. Know. Most back pain falls into this “nonspecific” group – and by calling it “nonspecific” we are actually admitting that We. Don’t. Know.

How do people assume that because I point out that we don’t know the causal mechanisms of low back pain but we DO know the critical importance of psychosocial factors on disability associated with low back pain – and the treatments that can mitigate these factors – that I believe back pain is psychological? I think it’s a simple fallacy – some people believe that because a person responds to psychosocial interventions this therefore means their problem is psychological. This is not true – and here are some examples. Exercise (a physical modality) is shown to be an effective treatment for depression. Does this mean depression is a purely biological disorder? Biofeedback provides visual or auditory information related to physical aspects of the body like blood pressure, heart rate, and muscle tension – does this mean that blood pressure is “psychological”? Diabetes management often includes learning to resist the urge, or “urge surf” the impulse to eat foods that increase blood sugar levels – does this mean diabetes is psychological?

Here’s my real position on nonspecific low back pain, which is let me remind you, the most common form of low back pain.

Causes – not known (Golob & Wipf, 2014), risk factors for onset are mainly equivocal but one study found the major predictor of an onset was – prior history of low back pain, with “limited evidence that the combination of postural risk factors and job strain is associated with the onset of LBP” (Janwantanakul, Sitthipornvorakul,  & Paksaichol, 2012), exercise may prevent recurrence but mechanisms of LBP remain unclear (Macedo, Bostick and Maher, 2013), while subgroup analysis carried out by therapists were “underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting” (Mistry, Patel, Wan Hee, Stallard & Underwood, 2014).

My take from this brief review? The mechanisms presumed to be involved in nonspecific low back pain are unknown.

Treatments – mainly ineffective but self-management provides small effects on pain and disability (moderate quality) (Oliveira, Ferreira, Maher, Pinto, Refshauge & Ferreira, 2012), “the evidence on acupuncture for acute LBP is sparse despite our comprehensive literature search” (Lee, Choi, Lee, Lee, Shin & Lee, 2013), no definitive evidence supports the use of orthoses for spine pain (Zarghooni, Beyer, Siewe & Eysel, 2013), acetaminophen is not effective for pain relief (Machado, Maher, Ferreira, Pinheiro, Lin, Day et al, 2015), and no specific exercises are better than any other for either pain relief or recovery – not even motor control exercises (Saragiotto, Maher, Yamato, Costa et al, 2016).

My take from this set of references is that movement is good – any movement, but no particular form of exercise is better than any other. In fact, the main limitation to exercise is adherence (or actually continuing exercising after the pain has settled).

The factors known to predict poor recovery are pretty clear – catastrophising, or thinking the worst (Kim, Cho, Kang, Chang, Lee, & Yeom, 2015), avoidance (usually arising from unhelpful beliefs about the problem – see commentary by Schofferman, 2015), low mood – which has also been found to predict reporting or treatment seeking of low back pain (see this post from Body in Mind, and this one).

What can I take from all of this? Well, my view is that because psychosocial factors exert their influence at multiple levels including our nervous system (see Borkum, 2010), but also our community understanding of what is and isn’t “illness” (Jutel, 2011) and who to see and what to do about it, the problem of nonspecific low back pain is one of the purest forms of an integrated biopsychosocial and multifactorial health concern in human life. I therefore rest my case: nonspecific low back pain is not psychological, but neither is it biomechanical or biological only. It is a biopsychosocial multifactorial experience to which humans are prone.

The best we can do with our current knowledge base is (1) limit and avoid the use of nocebic language and attempts to explain low back pain via biomechanical or muscle control mechanisms, (2) be honest about the likelihood of low back pain recurring and our treatments essentially doing very little, and (3) encourage return to normal activity by doing normal activity including exercise. Being honest about the state of play in our knowledge is a good starting point for better understanding – sounds a lot like race relations, doesn’t it?


Borkum, J. M. (2010). Maladaptive cognitions and chronic pain: Epidemiology, neurobiology, and treatment. Journal of Rational-Emotive & Cognitive Behavior Therapy, 28(1), 4-24. doi:

Golob, A. L., & Wipf, J. E. (2014). Low back pain. Medical Clinics of North America, 98(3), 405-428.

Janwantanakul, P., Sitthipornvorakul, E., & Paksaichol, A. (2012). Risk factors for the onset of nonspecific low back pain in office workers: A systematic review of prospective cohort studies. Journal of Manipulative & Physiological Therapeutics, 35(7), 568-577.

Jutel, A. (2011). Classification, disease, and diagnosis. Perspectives in Biology & Medicine, 54(2), 189-205.

Kim, H.-J., Cho, C.-H., Kang, K.-T., Chang, B.-S., Lee, C.-K., & Yeom, J. S. (2015). The significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 238-246. doi:

Lee, J. H., Choi, T. Y., Lee, M. S., Lee, H., Shin, B. C., & Lee, H. (2013). Acupuncture for acute low back pain: A systematic review. Clinical Journal of Pain, 29(2), 172-185.

Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.

Machado, G. C., Maher, C. G., Ferreira, P. H., Pinheiro, M. B., Lin, C.-W. C., Day, R. O., . . . Ferreira, M. L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials. BMJ, 350, h1225.

Mistry, D., Patel, S., Hee, S. W., Stallard, N., & Underwood, M. (2014). Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: A systematic review. Spine, 39(7), 618-629.

Oliveira, V. C., Ferreira, P. H., Maher, C. G., Pinto, R. Z., Refshauge, K. M., & Ferreira, M. L. (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64(11), 1739-1748.

Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1).

Schofferman, J. A. (2015). Commentary on the significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 247-248. doi:

Zarghooni, K., Beyer, F., Siewe, J., & Eysel, P. (2013). The orthotic treatment of acute and chronic disease of the cervical and lumbar spine. Deutsches Arzteblatt International, 110(44), 737-742.

bars across my window

Deconditioning? Or just not doing things any more?

For years there has been a general wisdom that people with chronic pain who gradually stop doing things “must” be deconditioned. That is, they must lose fitness, cardiovascular and musculoskeletal, and this is often used to explain low activity levels, high disability and the prescription of graded exercise.

While this explanation makes sense (remember what happens to limbs when they’re in plaster for six weeks? all skinny and wasted?) – it doesn’t inevitably hold, in my experience. I vividly recall a person who routinely swam 20 lengths of an Olympic pool in very fast time every day, yet could not, in his estimation, return to any kind of work, and who did not sit – for an entire three week programme. It’s always seemed a bit odd to me that even though people report they can’t do many everyday activities, they can complete a rigorous gym programme.

So, skeptical me was very pleased to see another paper by the wonderful Nicole Andrews, occupational therapist and PhD, and her colleagues Jenny Strong and Pamela Meredith. This one is about approach to activity engagement, certain aspects of physical function and pain duration and was published in Clinical Journal of Pain in January this year (reference at the bottom of the page). It’s an important paper because it challenges some of the assumptions often made about activity levels and “fitness”, as well as the use of an operant conditioning model for pacing – pacing involving working to a set quota, rather than letting pain be the guide. The concept of pacing has been woven into most pain management programmes since the early days of Fordyce, but more recently has been criticised for lacking a clear definition, and for very little in the way of empirical support as a stand-alone treatment.

In this study, Andrews and colleagues examined the relationship between certain activities and a “habitual” approach to activity engagement, and pain duration. This is a different approach to studying activity and over- or under- activity in that it examines specific activities rather than using a global measure of disability – and this is important because the people we work with do specific activities (or occupations as I’d call them) and it will be more important to be able to predict the types of activities people do, or not do, rather than simply using a general guide.

Andrews and colleagues used a tool I particularly like called the Pain and Activity Relations Questionnaire (McCracken & Samuel, 2007) – this is a 21-item measure that looks at how people approach their activities. It has three subscales – avoidance, confronting, and pacing. Confronting measures “over”activity, while the other two are self explanatory.  They also used the Oswestry Disability Index, an old standard in measuring physical functioning.

The analysis was really interesting, and well-described for those who want to dig deeper into how this team found their results. I’ll cut to the chase and simply point out that they used the items rather than the overall score of the ODI, which allows for a more fine-grained analysis of the kinds of activities individuals engaged in, and how they approached those activities. This is the stuff occupational therapists and physiotherapists really want to get their teeth into!

So, what did they find?

Firstly, individuals who reported high levels of avoidance and low over-activity also reported significant restriction in personal care tasks, compared with those people who reported low levels of both avoidance and activity. There was no relationship between this item and pain duration, but there was a relationship between pain intensity and interference.

Lifting tolerance, however, was affected by pain duration and pain intensity rather than avoidance patterns. Walking tolerance wasn’t affected by approach to activity, or pain duration, but age and pain intensity were important factors. Sitting tolerance was not related to approach to activity, and only pain intensity was a contributor rather than pain duration. Finally, standing was also not associated with approach to activity and was only related to pain intensity.

Sleep was influenced by approach to activity engagement – and with pain duration. This means people with pain for one year and who were inclined to be “over” active and not avoidant, and those who were highly avoidant and highly “over”active were more likely to report problems with sleep than those with low avoidance and low “over” activity. (BTW I put the “over” in quotes because it could also be called “confronting” or “pushing” or “doing” – I think it’s weird term not yet well-defined). The group most likely to report poor sleep were those reporting high “over”activity and low avoidance who reported sleep problems 9.23 times more than those reporting low “over”activity and low avoidance. Once again, pain severity was the only other variable influencing reporting.

Sex life was not associated with approach to activity engagement, nor to pain duration. Social life, however, was associated with approach to activity engagement with those reporting high avoidance and “over”activity reporting more restrictions than those with low levels of both, along with similar results for those reporting high avoidance and low “over”activity – again, pain duration wasn’t associated, but pain intensity was.

Finally, travel was more likely to be reported a problem by all those compared with the low avoidance, low “over”activity group, with the high avoidance, low “over” activity group most likely to report problems.

What does all this mean?

Bearing in mind that the population from whom these participants were taken were attending a tertiary pain management centre programme, and that this is self-report, the findings from this study are really very exciting. As the authors point out, when the ODI is mapped on to the ICF (International Classification of Functioning, Disability and Health) the instrument covers sleep (body function), personal care, lifting, walking, sitting and standing (activity limitations), and social life and travel (participation restrictions). Activity limitations can also be divided into two domains – mobility and daily activities (basic and instrumental activities of daily life) – walking, standing and sitting are therefore “mobility”, while personal care and lifting are “daily activities”.

These findings show that mobility activities were not associated with an individual’s approach to activity engagement – they differ from the other items in that they’re performance skills, that is, they make up other activities can’t be reduced to a smaller component. The authors suggest that the responses to these items in this study may reflect the individual’s perceived capability to engage in daily activities, as opposed to their actual physical performance to engage in these tasks.

I think this means it’s important to ask about what people do in daily life, rather than rely simply on reported levels of walking or sitting. Tie self report into activities – for example, sitting tolerance might be best described in terms of whether a person can sit to watch a whole TV programme, or whether they need to get up during the ad breaks.  It’s important to note the relationship between approach to activity and poor sleep – sleep being one of those aspects of living with pain that people most want addressed. Perhaps by moderating the approach to activity we might be able to help people develop more effective sleep patterns. It also seems to me that we need to tie outcomes from pain management to real life activities in which an individual wants to participate – rather than a more “objective” measure such as the six minute walk test – which might satisfy our urge to measure things in a nice orderly way, but might not be relevant to an individual’s life.

Finally, this study shows that overactivity and avoidance patterns are not inevitably associated with reduced capacity over time. I think this is a “received wisdom” that needs to be unpackaged



Andrews, N. E., Strong, J., & Meredith, P. J. (2016). The relationship between approach to activity engagement, specific aspects of physical function, and pain duration in chronic pain. Clinical Journal of Pain, 32(1), 20-31

McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity patterns in chronic pain. Pain. 2007;130:119–125.


Treat the pain… or treat the depression? Carpal Tunnel Syndrome management
Carpal tunnel syndrome is a very common pain disorder associated with compression of the median nerve at the carpal tunnel. Approximately 139 women and 67 males per 100,000 people will report this problem over the course of one year, although this depends on the definition used. The problem with CTS is not only that it is common, but also that it affects function – it is really difficult to carry out normal daily life with a numb or tingly hand, poor grip strength (particularly in the fingertips), and disruption to sleep from the ongoing deep achy sensation in the hand. Additionally, some studies show that people with CTS also experience widespread pressure pain hypersensitivity, and an increased response to heat, suggesting that the problem either triggers, or is part of a central sensitisation process.

Diagnosing CTS is conducted using two main approaches – firstly the clinical signs of pain, paraesthesia in the median nerve distribution, symptoms worse at night, and positive Tinel and Phalen signs; secondly, electrodiagnostic testing must show deficits of both sensory and motor median nerve conduction.

In this study, the authors were interested in establishing the relationship between clinical signs and symptoms, physical signs and symptoms (notably CROM and pinch grip force), as well as neurophysiological measures – and they also measured depression. I wish they’d included measures of pain anxiety, or catastrophising, but this was not included in this study.

224 women were included in the study, which carefully screened out individuals with potential confounding contributory causes such as whiplash, pregnancy or diabetes.  The initial and expected findings were that women with higher reports of pain also demonstrated poorer CROM, pinch grip, lower heat pain hypersensitivity, and overall poorer functional hand use.

The first interesting finding was that women in this study reporting only moderate levels of pain also reported poor functioning. The authors suggest that, as a result of this finding “it may not be necessary to report higher levels of pain to find a repercussion in functional activities.” In other words, the impact of CTS on functional use of the hand appears ahead of the pain intensity, although the two are associated.

The study also found that heat pain hyperalgesia over the carpal tunnel as also associated with the intensity of hand pain – they suggest this may be due to peripheral sensitisation which is present from very early on in the presentation.

Looking at depression and the relationship with CTS, interestingly, the women did not demonstrate very high levels of depression, which surprised me a little given they had been selected for inclusion on the basis of having CTS symptoms for 12 months or more. The analysis found that depression was associated with poorer hand function and greater pain, even though the women did not report very high levels of depression. These authors suggest that “perhaps proper management of depressive symptoms in CTS may reduce, not only chronicity, but also induce an improvement in hand pain-related disability.”

Somewhat more controversially for some physiotherapists, these authors also argue that because depressive symptoms resolve during (as a result of perhaps?) physiotherapy treatment in 40% of people with work-related musculoskeletal pain injuries, perhaps those treatments should target mood management as well. So much for “but it’s not in my scope of practice”!

In fact, the authors are very clear that “proper management of individuals with CTS should include therapeutic interventions targeting physical impairments, that is, manual therapies; psychological disturbances (cognitive behaviour), and mechanical hypersensitivity (that is, neuromodulatory pain approaches).” If ever there was a time to get upskilled in a whole person approach to rehabilitation, this paper supports doing so now.

Fernández-Muñoz, J., Palacios-Ceña, M., Cigarán-Méndez, M., Ortega-Santiago, R., de-la-Llave-Rincón, A., Salom-Moreno, J., & Fernández-de-las-Peñas, C. (2016). Pain is Associated to Clinical, Psychological, Physical, and Neurophysiological Variables in Women With Carpal Tunnel Syndrome The Clinical Journal of Pain, 32 (2), 122-129 DOI: 10.1097/AJP.0000000000000241


A community of practice

There is something different about the relationships I’ve developed through my blog. What started as an individual desire to share my excitement at pain management done well (and wanting to have others learn and do it too) has developed into a community. Two definitions spring to mind.

A thriving community is one in which information and resources flow smoothly through the community from where these assets exist to where they can be best applied. The people within a thriving community feel cared for, acknowledged, and yearn to give back to their community as a whole as well as the people within it. [my emphasis]

There is a sense that the community becomes greater than the sum of the parts.

Thriving communities encourage connection, foster a sense of shared purpose, highlight small as well as large successes. Thriving communities celebrate the best in the people around us, and  challenge one another other to strive further toward our edges. Conversations in thriving communities foster a sense that we are working together for something greater than ourselves (abridged from Thrivability).

I look at the various groups I belong to on Facebook, Twitter and my blog. Together I think we’ve formed a community of practice.

Communities of practice are formed by people who engage in a process of collective learning in a shared domain of human endeavor [my italics]: a tribe learning to survive, a band of artists seeking new forms of expression, a group of engineers working on similar problems, a clique of pupils defining their identity in the school, a network of surgeons exploring novel techniques, a gathering of first-time managers helping each other cope. In a nutshell: Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. (from Wenger and Traynor)

What unites us is “an identity defined by a shared domain of interest. Membership therefore implies a commitment to the domain, and therefore a shared competence that distinguishes members from other people.” We “engage in joint activities and discussions, help each other, and share information. [We] build relationships that enable [us] to learn from each other; [we] care about [our]  standing with each other.” We “are practitioners. [We] develop a shared repertoire of resources: experiences, stories, tools, ways of addressing recurring problems—in short a shared practice.” (from Wenger and Traynor)


Something missing from much of the “translation into practice” research is attention to developing a thriving community of practice. Humans are social (even introverts like me!) and we like to share stories, we like experts – but only if they spend time giving us their knowledge. We need to connect so we can ask questions, challenge ideas, push our thoughts and pose sticky questions so we CAN push our thinking as far as it will go. The communities of practice I belong to have developed informally but oh how they challenge my thinking!

I’m struck by this idea of pairing “book learning” or research with practice because it seems to me that this is one way my blog functions. I’m never happier than when learning something new from a journal. Even looking up Wenger and Traynor’s work is such a geeky thing to do, yet it’s clarified so much about the sense of connection I have with the people I’ve connected with since my blog began.


When I ran my recent survey I found that by far the majority of respondents want me to carry on doing what I’m doing – reading research, summarising it, then asking the “so what does this mean in practice?” question. These results suggest to me that I’m fulfilling an important function. While the number of hits is slowly trending down (sad face), discussions about the content I write happen in many different forums. What I hope is that the discussions feed a thriving community of practice. Want to join me?



Using a new avoidance measure in the clinic

A new measure of avoidance is a pretty good thing. Until now we’ve used self report questionnaires (such as the Tampa Scale for Kinesiophobia, or the Pain Catastrophising Scale), often combined with a measure of disability like the Oswestry Disability Index to determine who might be unnecessarily restricting daily activities out of fear of pain or injury. These are useful instruments, but don’t give us the full picture because many people with back pain don’t see that their avoidance might be because of pain-related fear – after all, it makes sense to not do movements that hurt or could be harmful, right?

Behavioural avoidance tests (BAT) are measures developed to assess observable avoidance behaviour. They’ve been used for many years for things like OCD and phobias for both assessments and treatments. The person is asked to approach a feared stimulus in a standardised environment to generate fear-related behaviours without the biases that arise from self-report (like not wanting to look bad, or being unaware of a fear).

This new measure involves asking a person to carry out 10 repetitions of certain movements designed to provoke avoidance. The link for the full instructions for this test is this: click

Essentially, the person is shown how to carry out the movements (demonstrated by the examiner/clinician), then they are asked to do the same set of movements ten times.  Each set of movements is rated 0 = performs exactly as the clinician does; 1 = movement is performed but the client uses safety behaviours such as holding the breath, taking medication before doing the task, asking for help, or motor behaviours such as keeping the back straight (rotation and bending movements are involved); 2 = the person avoids doing the movement, and if the person performs fewer than 10 repetitions, those that are not completed are also coded 2. The range of scores obtainable are 0 – 60.

How and when would you use this test?

It’s tempting to rush in and use a new test simply because it’s new and groovy, so some caution is required.

My questions are: (1) does it help me (or the person) obtain a deeper understanding of the contributing factors to their problem? (2) Is it more reliable or more valid than other tests? (3) Is it able to be used in a clinical setting? (4) Does it help me generate better hypotheses as to what’s going on for this person? (5) I also ask about cost, time required, scoring and whether special training is required.

This test is very useful for answering question (1). It provides me with a greater opportunity to review the thoughts, beliefs and behaviours of a person in the moment. This means I can very quickly identify even the subtle safety behaviours, and obtain the “what’s going through your mind” of the person. If I record the movements, I can show the person what’s going on. NB This is NOT intended to be a test of biomechanical efficiency, or to identify “flaws” in movement patterns. This is NOT a physical performance test, it’s a test of behaviour and belief. Don’t even try to use it as a traditional performance test, or I will find you and I will kill (oops, wrong story).

It is more valid than other tests – the authors indicate it is more strongly associated with measures of disability than measures of pain-related fear and avoidance behaviour. This is expected, because it’s possible to be afraid of something but actually do it (public speaking anyone?), and measures of disability don’t consider the cause of that disability (it could be wonky knees, or a dicky ticker!).

It’s easy to do in a clinical setting – A crate of water bottles (~8 kg) and a table (heights ~68 cm) are needed to conduct the BAT-Back. The crate weighed  7.8 kg including six one-litre plastic bottles. One could argue that people might find doing this test in a clinic is less threatening than doing it in real life, and this is quite correct. The setting is contained, there’s a health professional around, the load won’t break and there’s no time pressure, so it’s not ecologically valid for many real world settings – but it’s better than doing a ROM assessment, or just asking the person!

Does it help me generate better hypotheses? Yes it certainly does, provided I take my biomechanical hat off and don’t mix up a BAT with a physical performance assessment. We know that biomechanics are important in some instances, but when it comes to low back pain it doesn’t seem to have as much influence as a person’s thoughts and beliefs – and more importantly, their tendency to just not do certain movements. This test allows me to go through the thoughts that flash through a person’s mind as they do the movement, thus helping me and the person more accurately identify what it is about the movement that’s bothering them. Then we can go on to test their belief and establish whether the consequences are, in fact, worse than the effects of avoidance.

Finally, is it cost-effective? Overall I’d say yes – with a caveat. You need to be very good at spotting safety behaviours, and you need to have a very clear understanding about the purpose of this test, and you may need training to develop these skills and the underlying conceptual understanding of behavioural analysis.

When would I use it? Any time I suspect a person is profoundly disabled as a result of their back pain, but does not present with depression, other tissue changes (limb fracture, wonky knees or ankles etc) that would influence the level of disability. If a person has elevated scores on the TSK or PCS. If they have elevated scores on measures of disability. If I think they may respond to a behavioural approach.

Oh, the authors say very clearly that one of the confounds of this test is when a person has biological factors such as bony changes to the vertebrae, shortened muscles, arthritic knees and so on. So you can put your biomechanical hat on – but remember the overall purpose of this test is to understand what’s going on in the person’s mind when they perform these movements.

Scoring and normative data has not yet been compiled. Perhaps that’s a Masters research project for someone?

Holzapfel, S., Riecke, J., Rief, W., Schneider, J., & Glombiewski, J. A. (in press). Development and validation of the behavioral avoidance test – back pain (bat-back) for patients with chronic low back pain. Clinical Journal of Pain.



evening at Marble Hill

Hey, hey, which way? Future directions for Healthskills

It’s a new year and 8 years since I began Healthskills. I’m ready to review what people want from me – are you up for it?

When I began there were very few blogs on chronic pain, and I wanted to give good, scientific information on pain management for all those people who can’t access the research as easily as I can. I also wanted to make sure that the content was useful, could help people who were first beginning to work in pain management some of the information they might not have learned in their training (or postgraduate training even!). Things have changed in the past 8 years, there are many more blogs around and a lot more discussion about the practicalities of using modern pain science in the clinic. Is what I write relevant? Is it useful? Does it fill a gap? What would YOU like from me? Now’s your chance! The poll will be open for two weeks only.


Sweet Caroline

End of year roundup

It’s summer in New Zealand, and although the vagaries of Kiwi weather are always with us (33 degrees predicted today – but a southerly tomorrow and a drop of probably 10 degrees in half an hour!), we’re gearing up for our usual Christmas and New Year close-down. I’m also taking a break over the next three weeks, taking to the rivers (bring on the trout!) in Sweet Caroline the Caravan, complete with blue sky ceiling with tiny puffy clouds!

To end the year it’s common to come up with a top 10, so these are my top 5 posts from the year. They’re not always the ones with the most hits, they’re ones that I’m particularly pleased with. Over the next three weeks, why not take a browse through some of my favourites, and if you’re still stuck for reading matter, head to the “search” page and type in a term – or you can simply click on a Category or a Key Word and voila! there will be a bunch of posts to trawl through. Enjoy!

  1. Talking past each other: One of the weirdest things for me is being both a professional working in the field of chronic pain, and also being a person living with chronic pain. There’s a certain dread among some health professionals when they find out a person working in the field also has the condition – a bit like “so you’re in it for yourself”, “you’re living out your own issues”, “you’ll get over-involved”. Harsh. I got interested in pain management some years after I developed persistent pain. My interest began because the people I was working with (return to work programmes in the 1980’s) often had chronic pain, and I wanted to know more about how to help them. For many years I didn’t let anyone know I also had this “thing” they were trying to live with. I finally decided that being real, honest, authentic and not pretending I had it all together was far more helpful (and less stressful) than any kind of facade of professionalism I could apply. I can’t say whether what works for me will work for anyone else. I don’t always have answers. I can only say I know what it’s like to walk alone, trying to work out what will help and what won’t – and that’s a very lonely road to walk. For that reason I’ll be there, a one-woman cheering squad on your side.
  2. Telling someone they have chronic pain: Being given good advice when I first found out I had chronic pain would be one of the most important reasons I think I have learned to find wiggle room with my pain. It’s not the kind of message healthcare professionals are trained to deliver. By and large we’re taught to fix, cure, mend, heal or DO something. Chronic pain is one of those problems for which there are no easy, single bullet answers. There’s usually a mix of things that will give support – and a bunch of things that won’t do a thing, or may even harm. This post synthesises some of the things that I have found out about giving that “bad news”.
  3. Am I nuts or do I just have pain?: People living with chronic pain deal with stigma often. There’s an unwritten “moral” compass that people living around us use to identify whether someone is faking, mad, or just lazy. Is chronic pain a mental illness? Personally I would argue not – but then again, how do we define what is, and isn’t, a mental illness? Some super-slippery concepts here, but I prefer NOT to classify chronic pain inside a set of psychiatric labels. I think it’s stressful enough to live with chronic pain without the sense that it’s a mental health problem, because, after all, it’s experienced in the body. And while some of the factors involved in chronic pain are neurological, brain-based, and affect mood, thoughts and behaviour, there are many other health problems that are also influenced by the same set of issues. Personally, I don’t like labels that lump people together as if, because they have a predominant symptom, the problems arising from it are all the same. Many of you will know I use a case formulation approach – by using this approach a clinician acknowledges that there are many factors influencing the “what it is like” to live with chronic pain, and it gives priority to the everyday concerns of the person rather than trying to squish him or her into some sort of square box. I’ve got curves, they just don’t squish like that!
  4. Case formulation: I have written a few posts on case formulation – so here’s a list of them! I hope they’re useful :)  Case 1; Case 2; Case 3; Case 4; Case 5; Case 6; Case 7; Sorry if these are slightly out of order, and believe me, there are some more I haven’t yet listed!
  5. Who are you? The effect of pain on self: Nothing prepares us for the onset of a chronic illness. I mean it. Even if you KNOW you’re going to get something, when it’s finally given the label there’s a certain reality that can’t be shaken. All the assumptions of what we can or can’t do, our capabilities, our future goals, our assumptions about how life will be – these get shaken when we get told “I’m sorry, but you have _________”. Learning to deal with this new reality is both fascinating (to an outsider) and extraordinarily hidden (to the person and those outside). We don’t really know how people come to terms with having to give up aspects of self, adopt new habits, develop a focus on parts of self that weren’t previously valued. It’s an area of learning to live with pain that has been touched on, but needs far more attention, IMHO.

OK, so a random selection of posts from the last year, and a couple from years before. If I get time before I head out in Caroline, I’ll post another set – but in the meantime, I wish you a peaceful and safe holiday period, and hope you’ll build dreams and start actions for a fabulous 2016.

Choosing the right PT: 3 things to consider

This post is a patient’s perspective on choosing a physiotherapist. Some useful thoughts about why a person might choose YOU as their therapist.

By Adnan Iqbal

I tore both my ACL and meniscus playing soccer as an undergrad at UC Berkeley. After successful knee surgery, I needed to start my physical therapy immediately.

I was lucky. As an intercollegiate athlete, I benefitted from our athletics department’s rehabilitation and training resources. I didn’t have to find or choose the best PT — I was able to work with world-class trainers and physical therapists, all at essentially no cost and within walking (or crutching) distance from class. I was back on the soccer field within months and returned to full activity.

Two years later, I tore my ACL again while playing pick-up football. This time, I needed to find and choose my own PT. As I was searching for the ‘best’ PT, I had three key criteria in mind:

Hands-on Care

I did a lot of research, met with a lot of PTs, and spoke with many prior patients — I knew how important the right PT would be to my recovery.

My goal was to get back to game-ready strength and speed. So, I focused my search for PTs to those who had directly worked with leading college and/or professional sports teams. I consulted with local coaches and athletes, looked at Yelp reviews, poured over my surgeon’s recommendations, and read the PT bios.

Once I narrowed down my list, I talked to patients the PTs worked with in the past and asked a lot of questions:

What level of recovery did they achieve? Were they able to get back to playing sports at the same pre-injury level?
Did their PT provide individualized attention, or was the PT more focused on certain high-profile clients?

Reputation equaled results and trust in my mind. Even though I was limited by my health insurance to in-network providers, I was willing to pay out-of-pocket if the PT’s reputation was stellar.

I knew myself well enough to know that if I had to drive more than thirty minutes to see my PT, I wouldn’t keep my appointment. I looked for places close to home or work. Even when I did have to cancel last minute, the short distance I had to travel made me more willing to quickly reschedule, sometimes even to a different appointment time the same day.

Convenience isn’t just about location–it’s also about the ability for a PT to work with your schedule. As a committed patient, I highly valued my PT’s flexibility to quickly get me in for a session, even if I had to cancel due to meetings, work-travel, or just unpredictable Bay Area traffic.

Keeping up with regular PT appointments is critical to recovery. I knew I had to make it as easy as possible for me to get to my PT, and to work with a PT who could easily accommodate changes to my schedule.

Hands-on Care

Let’s be honest, PT appointments can be painful. You’re essentially signing up for 45 minutes of well-intentioned torture. Just the thought of struggling through exercises can make you dread sessions. For this reason, I needed a PT who was empathetic, encouraging, spent a lot of time with me, and someone who I enjoyed spending time with.

Hands-on personal time with a PT keeps you motivated and focused on results. Some PTs resort to assigning aides to do a lot of the session with you. While this can make sense for an understaffed facility, it really changes the patient experience. Committing to physical therapy and actually continuing it requires a strong bond with your PT.

I’ve worked with three different PTs over the past ten years, and all of them spent whole sessions with me. The PT did the actual scar tissue loosening, led me through exercises, corrected my posture and form, and kept me motivated.

It’s all about accountability. Knowing that my PT was personally invested in my success ensured that I stuck to my exercise plan in between sessions.

My PTs understood my goals each time, which increased my trust in them even more. It’s important to know that your PT holds the same goals for you that you do for yourself, and it’s important for your PT to be able to guide you to goals that are the best fit for your condition and lifestyle.

I attribute my recovery and ability to enjoy an active lifestyle to the PTs I worked with, and their ability to provide stellar care, to offer flexibility and convenience, and to spending one-on-one time with me to help me achieve my recovery goals.

Thanks to Jenna Gain from