Secondary gain: really?


One of my most popular posts ever is one I wrote many years ago on malingering. Secondary gain, like malingering or symptom magnification is one of those terms used by people who don’t live with persistent pain, and commonly used when a person with pain doesn’t seem to be progressing “as expected”. The term is an old one, originating in the psychoanalytic literature, brought into compensation and insurance environments but never really examined (Fishbain, Rosomoff, Cutler & Rosomoff, 1995) until well after it had become a popular label.

Freud first identified the potential for gains from being unwell – primary gains referred to the direct gains obtained from developing a psychiatric illness in the face of unresolved psychic conflict while secondary gains were considered to be “an interpersonal or social advantage attained by the patient as a consequence of his/her illness”.

The sick role, or illness behaviour, is a sociological phenomenon (Bradby, 2009). As a society we permit people who are unwell to take time off responsibilities of paid employment, caring for others, socialising and doing the everyday life activities that people do. We also, in some cases, pay people to stay away from work, both to undertake recovery and to protect others from the illness in the form of sick leave entitlements and compensation. To ensure “fairness” or a sort of moral agreement between the ill person and society, humans have used healers, shaman or religious authorities to ensure the person has an authentic problem: ie, that they are morally fit to receive our help.

To most of us, particularly people in Australia and New Zealand, UK, Canada with largely socialised healthcare systems, the idea of sharing the burden of ill health through socially sanctioned support seems natural. We allow people a period of time to get well and then, when recovered, the person can return to normal activities. If the person sustains some nasty event, like spinal cord injury or brain injury, leaving him or her with ongoing ill health, we support ongoing payments (some more than others, depending on the funding bucket used). It’s easy to justify this when the person’s problems are visible – but for people with less visible, or truly invisible disabilities, our moral compass starts going awry.

For example, we have Mobility Parking: but woe betide the person with an invisible disability such as irritable bowel disorder, or panic disorder, using the park even when displaying the appropriate sticker! Tut! tut! tut! It is even more difficult with an invisible problem such as persistent pain, and even more so when the person’s problem hangs around. Secondary gain is the word whispered in the wind as people judge whether this person really has a problem – or is it “secondary gain”?

Let’s unpack the notion of secondary gain. From a behavioural perspective, behaviour is repeated if (1) something introduced afterwards increases the likelihood of the behaviour being repeated, eg a tearful child is cuddled after tripping, meaning the next time the child trips, he will look for someone to cuddle him; (2) something unpleasant is removed as a result of the initial behaviour, eg the pain of a grazed knee reduces with some topical analgesia. In these situations, the child is not usually aware that the contingency offered changes what they do – they just do what makes sense.

It’s when we start looking at people who don’t fit the typical response curve after an injury, that commentators begin flinging the term “secondary gain” around as if the person deliberately chooses to remain ill. Of course, insurers who fund compensation received by the person have a vested interest in reducing their payments and, given persistent pain can’t be objectively measured either directly or indirectly (Tuck, Johnson & Bean, 2019), will question the motives of a person who doesn’t recover. And therein lies our problem.

In our societies, medical practitioners are pseudo priests in many ways. The word of a doctor holds a great deal of weight: medical certificates, death certificates, oh and judgements about diagnosis and recovery. When it comes to insurers, the opinion of a doctor is used to verify that a person really has the problem they say they have, and can then continue receiving payment. The problem with pain is, yet again, having no direct objective measure of pain. The doctor is assumed to have special powers to detect whether a person really has pain – and yet there is considerable evidence that many medical practitioners have very little training in pain and even less in persistent pain in their training (Shipton, Bate, Garrick, Steketee, Shipton & Visser, 2018).

How is the term “secondary gain” experienced by the person living with persistent pain? Lang, Igler, Defenderfer, Uihlein, Brimeye & Davies (2018) undertook an intriguing study of how the various ways pain in adolescents can be “dismissed” by clinicians. They report that 40% of adolescents indicate their pain was dismissed by others, with almost 30% of those individuals stating this was done by a physician (p. 664). It’s probably not surprising that this kind of dismissal happens more often to female adolescents! Their study established that no, the sense of being dismissed wasn’t an indication of adolescents being “too sensitive”, but rather, that being dismissed by either misbelief (you don’t really have this pain); minimising (you have pain but it’s not as bad as you think it is); secondary gain (you’re using this as a way to avoid something like school); and psychogenic (it’s your emotional state that’s the real problem and cause) – are all likely to lead adolescents to look for another opinion, and to feel stigmatised.

So – is secondary gain a real thing? I like to look at it through a different lens. Taking the moral judgement tone out of the equation (that belief that only people who truly ‘deserve’ help should get it), I like to look at the problem of delayed recovery through a lens of problem solving.

Yes, there can be some gains from being unwell – who doesn’t like a bit of fussing or to be excused from doing something you don’t enjoy. The question is whether these gains come at the expense of other things – and there’s pretty compelling evidence that the losses outweigh any possible gains (Worzer, Kishino & Gatchel, 2009). At the same time, telling someone “you’re just doing this because you don’t want to get better” or words to that effect is not likely to help them have any desire to change what they’re doing – it seems to shift the person towards resisting any change in how they’re coping. It’s counter-productive.

Let’s look at a few losses:

  • employment (and people DO value working for reasons other than money! – think self concept, identity, social interaction, daily routine…)
  • relationship loss (partners, family roles, friendships – some of the most profound stories I hear come from men saying they no longer have mates they spend time with)
  • emotional impact (depression, anxiety, anger, demoralisation, shame, guilt)
  • financial loss (with loss of employment and increased healthcare costs) (Worzer, Kishino & Gatchel, 2009)

What traps someone into these losses? What might maintain someone’s helplessness and demoralisation? Pain, of course, but so too does shame; stigma from time away from work (employers want to know if you have a “bad back” – then run a mile); lack of confidence about capabilities (am I reliable? can I be counted on?); disability (there are some things I cannot do); limited communication (how do I ask for help?) and a myriad of other things. For the avoidance of doubt, people do not magically “get better” once they obtain their insurance payout (Fishbain, Rosomoff, Goldberg, Cutler, Abdel-Moty, Khalil, et al, 1993).

What can we do?

  1. First do no harm, that means avoiding moral judgements about motives for ongoing disability. It doesn’t help and does harm.
  2. Second, begin working on the actual problems the person is experiencing – things like building consistency in activity levels; improving communication skills; increasing confidence.
  3. Third, start addressing the social stigma associated with persistent pain. This means taking a long, hard look at ourselves as clinicians, and at our workplaces and social scenes, and insurers or funders.

Why do we run from the conversation that yes, pain does persist for a good number of people? Why don’t we acknowledge that even the best treatment in the world may not reduce pain – and that this is not the person’s fault for not trying?

This doesn’t mean researchers and clinicians should stop searching for pain reduction approaches – it does mean giving those who are not helped the chance to view living well with pain as a viable option.

Bradby, H. (2009). Defining health, defining disease. In Medical sociology: An introduction (pp. 51-64). London: SAGE Publications Ltd doi: 10.4135/9781446211724.n4

Fishbain, D. A., Rosomoff, H. L., Cutler, R. B., & Rosomoff, R. S. (1995). Secondary gain concept: a review of the scientific evidence. The Clinical journal of pain.

Fishbain, D. A., Rosomoff, H. L., Goldberg, M., Cutler, R., Abdel-
Moty, E., Khalil, T. M., et al. (1993). The prediction of return to
the workplace after multidisciplinary pain center treatment.
Clinical Journal of Pain, 9, 3–15.

Shipton, Elspeth E, Bate, Frank, Garrick, Raymond, Steketee, Carole, Shipton, Edward A, & Visser, Eric J. (2018). Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain and therapy, 1-23.

Tuck, Natalie L., Johnson, Malcolm H., & Bean, Debbie J. (2019). You’d Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain. Journal of Pain, 20(2), 133-145. doi: http://dx.doi.org/10.1016/j.jpain.2018.07.002

Worzer, W. E., Kishino, N. D., & Gatchel, R. J. (2009). Primary, secondary, and tertiary losses in chronic pain patients. Psychological Injury and Law, 2(3-4), 215-224.

International Chronic Pain Virtual Summit 2020


I am so happy to be part of this virtual summit especially under our current COVID19 disruptions! It’s FREE and more than 20 speakers from around the world are talking about the things that matter in pain rehabilitation and management. I might even drop in a word or two about occupational therapy….!
Click the link and find out more! – click

Just to give you an idea of the speakers involved, you’ll get to hear from:

Professor Peter O’Sullivan

Professor Tasha Stanton

Lissanthea Taylor

Vidyamala Burch

Dr Stephen Grinstead

Kathy Hubble

Pete Moore

Prof Kim Burton

Prof Ann Taylor

Dr Adriaan Louw

Dr Shilpa Patel

Dr Saurab Sharma

Knowledge translation: beyond the peer reviewed papers


Oh the risks and pitfalls of trying to get research into clinical practice! There’s an often-cited figure estimating it takes around 17 years for a new practice to enter routine clinical care (Dilling, Swensen, Hoover, Dankbar, Donahoe-Anshus, Murad & Mueller, 2013) – that’s a long time!

There are many reasons for this delay:

  • Inertia – change is hard!
  • Systems – often support the status quo, may not fund new or innovative practice
  • Peer pressure – to keep on doing the same as everyone else
  • Questioning whether the benefits are truly there
  • Busy clinical practice making it difficult to think differently
  • Contradictory reports in research
  • Lack of confidence to make a change (original training maybe didn’t include the skills now needed)
  • Expectations, perhaps from the people we hope to help
  • Holding on to beliefs that feel good/provide short-term effects but may not provide long-term ones

Blogs, like this one, are one way to bridge the research to practice gap. Social media has become a powerful influence, at least in explicit attitudes even if not necessarily daily clinical practice. There are risks, however, in using social media for ongoing learning though I will say that there are also risks in attending conferences, workshops, reading books, reading journals and the like!

The main risk, in my humble opinion (see what I did there?!), is that authors write what they know, and everything that’s put out “there” is filtered through the author’s opinion. Now that’s not novel, it happens in peer-reviewed research as well. The difference in peer-reviewing is that at least two other people, often more, also have read and critiqued the article. This doesn’t mean unbiased papers though, but perhaps a better quality of bias!

Knowledge translation is a real thing. It’s the process of disseminating information from research into clinical practice. This process isn’t straightforward, because all research is biased and no research (pretty much) will fit directly into the nuances of your particular practice context. Although few quantitative research studies openly declare their philosophy of science, it’s assumed that their findings are devoid of values and context: a dangerous assumption given that our clinical worlds are full of competing values and our contexts are hugely variable.

To translate something from research into practice takes some skill. Firstly to distill the research findings into usable bits and pieces, while understanding the contexts and assumptions built into those results. Then to have awareness of the context in which the research might be implementing. Finally, to have creativity to work out which parts of the research will fit well into this clinical context

To do knowledge translation means recognising different philosophical traditions – knowing that all research holds assumptions, and these aren’t declared in many cases (because it’s assumed everyone knows them!). Qualitative researchers, by and large, are more likely to openly state their philosophical stance, making it far easier to understand the assumptions they’ve made in conducting their research. Once assumptions are known, it’s easier to establish which parts of the research will hold in a different context.

When I look at the list of reasons people don’t implement new information, what strikes me is how human they are. They’re about how WE as humans respond to change. They’re about systems and links between actions and what happens next (contingencies). They’re about our social nature, and that we’re motivated by needing to belong, to feel competent and for things to make sense. Introducing new ideas means someone has to be the first one to try it – this means that person is “different”, they don’t belong. Any new thing needs to be learned: that means a time when it’s likely people using it will feel less than competent. And new things often mean letting go of old beliefs and habits, so for a time at least, things don’t make sense as they used to.

One way social media has worked to translate knowledge into practice is by making it OK to belong to a “tribe”. When there are enough people saying similar things, it’s easier to feel like this new idea is acceptable – and by implementing it, we still belong.
Social media might also break the complex ideas developed in research into smaller, bite-sized chunks, so making it much easier to put into practice without feeling incompetent.

But social media doesn’t work as well at helping us let go of old beliefs and habits. What seems to happen is a lot of “he said” and “she said” and argumentation that only serves to reinforce each person’s current stance. It’s relatively uncommon for these kinds of discussions to move beyond posturing, and frankly, I think this is destructive. It’s one of the reasons I don’t engage in critiquing posts where I think the person’s incorrect. My strategy is to post positive information because the more often positive information is made available, the more likely it will be seen. But given recent readership stats on this blog, perhaps it’s not such a good strategy! Gone are the heady days of 1200 hits on a post in a single day!

Nevertheless I post to help disseminate information that is otherwise locked up in journals behind paywalls, to write the long-form because one of the first steps in knowledge translation is to read the research then summarise it. I also do it for myself (mainly I do it for myself) – because when I write, I’m sorting out what I think. Writing to learn is recognised as a useful strategy for deep learning and understanding (Stewart, Myers & Culley, 2010).

Occupational therapy could be considered the “knowledge translation” profession – much of our work involves taking skills developed in the comparatively controlled world of the clinic out into daily life. Occupational therapists are also practical problem solvers, given the philosophical basis for the profession is likely pragmatism (Ikiugu & Schulze, 2006). It’s probably where occupational therapists who are enthused about research and its application could do the most good. The philosophy of science I think most suits occupational therapy is functional contextualism – how workable are solutions given the values and context of the person?

Research deserves to be used. It’s usually why people begin to do research – they’re curious about a situation or a problem, then want to work out why. Implementing that research may not fit so well but this is where we need to be to make a change in our world.

Dilling, J. A., Swensen, S. J., Hoover, M. R., Dankbar, G. C., Donahoe-Anshus, A. L., Murad, M. H., & Mueller, J. T. (2013). Accelerating the use of best practices: the Mayo Clinic Model of Diffusion. Joint Commission journal on quality and patient safety, 39(4), 167–176. https://doi.org/10.1016/s1553-7250(13)39023-0

Ikiugu, M. N., & Schultz, S. (2006). An argument for pragmatism as a foundational philosophy of occupational therapy. Canadian Journal of Occupational Therapy, 73(2), 86-97.

Stewart, T. L., Myers, A. C., & Culley, M. R. (2010). Enhanced learning and retention through “writing to learn” in the psychology classroom. Teaching of Psychology, 37(1), 46-49.

Wensing, M., Grol, R. Knowledge translation in health: how implementation science could contribute more. BMC Med 17, 88 (2019). https://doi.org/10.1186/s12916-019-1322-9

5 Things I Learned from Lock-down


As New Zealand emerges from the most severe lock-down levels to greater freedom (but still not back to life as usual) I’ve been reflecting on what I’ve learned – no, not a new language, new baking skills, or sudden competence in using R (see here for a great tutorial), but things about myself. Odd though it may seem, I’m leaving lock-down with a sense of wistfulness. You see, the time from the end of March to end of April has been a lovely time for me.

I’m lucky, I have a good job, my work hasn’t changed much (well, a bit), my family are safe, I live close to the beach and a park, and the weather has been kind. It’s autumn in Christchurch, and it’s been mainly fine. The bird life has been flourishing. The foot traffic past my house has been families – Mum, Dad, kids on bikes and in pushchairs. Apart from the occasional drop-kick lighting fireworks or playing the Zombie Apocalypse Siren, and hammering from 7.00am to 11.30pm, our neighbourhood has been peaceful. And yet I know so many people in New Zealand and around the globe who are really struggling. Strange times indeed. So what have I learned?

  1. Solitude is not the same as loneliness. Solitude is being alone and being OK with it. Loneliness is being alone when you don’t want to be. Being with my own thoughts, listening to the murmuring of sounds around me, letting my mind wander then gently bringing it back to focus is a pleasure, almost an indulgence. Having headspace to let what passes through my mind just pass by, without music or talking or anything interrupting my musing is a pleasure. Better still: being with someone who also appreciates being together in silence. I’ve learned to love solitude.
  2. Some kids will remember this time with gratitude. I’ve watched whole families walking together, making huts from driftwood, spotting the teddies in the windows, making low-tech memories of time being together. I have a fairy door (and a fairy) at my gate, and watching the little kids search for the fairy (who flies from tree to tree each day!) is such a joy. I’ve seen Mums and Dads out cycling with their kids then heading home to do the DIY together. What a treasure! I’ve learned (again) that families need time being families.
  3. Some things stay the same – especially if you live with pain. Even though my days have been peaceful, my pain has not. With changes to my routine, the weather, sleep, and world events playing on my mind, my life with fibromyalgia still needs managing. I’ve had aches in places I don’t usually have aches, and the things I do to live alongside my pain still need doing. For me these things are: making sure I carry on with mindfulness (I savour those moments when I can be with my thoughts but not part of them), go for my walk for headspace and body movement, keep my sleep/wake routine reasonably consistent, and eat normally (hah! there’s chocolate and alcohol and crisps. I may have slipped up a little there…). I’ve learned that pain management is really life management.
  4. Comparing myself with others is a waste of time. Yes, there are people out there learning new things, self-improving all over the place, doing their on-line socialising (and CPD), being creative and producing a lot. Good for them! I admire their achievements, and I’ve even contributed to a few of those online Zoom talks. Meanwhile, I thought I’d have been truly productive in the studio making loads of silver jewelry (those of you who don’t know – that’s my ‘hobby’ that seems to have taken over my photography, painting, sewing and everything else!). I’ve created a few pieces – but when I caught myself feeling pressured to come up with a “COVID19 Collection” I realised that this pressure wasn’t me. It was my mind being competitive and wanting to prove something to others. The need to belong can lead me to also want to be acknowledged as Something Special. Better than. As good as. Because, of course, underneath that is “I’m not good enough as I am”. So I decided to let that rope go. I don’t have to compete. There isn’t a prize for She Who Produces The Most because in the end, life is a process not a goal. I’ve learned (again) that comparisons are one way my mind beats up on me, and my mind doesn’t know everything.
  5. Resilient people are adaptable people. Resilience is a word many people in Christchurch, NZ, are well and truly over. Since 2010, and the 10,000 earthquakes since, plus the Port Hills fire, and the terror attack on Al Noor Mosque, people in Christchurch have been challenged more than many in our wee country. Resilience doesn’t mean we’re unchanged. Resilience means we change with circumstances and we develop new ways of being, ways of expressing who we are and what matters to us. I sometimes think people believe resilience means “Oh you’ve bounced back and life goes on as it was” but for me the events since 2010 have had a profound effect on my life. I can’t walk through my city without seeing earthquake-wrought changes. I see bumper stickers saying “they are us” and “kia kaha“. I walk past the memorial wall Oi Manawa when I head in to work. The new streetscapes, city buildings, ongoing roadworks and repairs – all part of the way my city has changed. That underground subversive element in Christchurch has touched so much of our lives. Resilient people have found ways to express who they are despite the enormous impact of events over the past 10 years. I’ve learned that holding on to what I value while finding new ways to express these has given me freedom and growth – but I’ve had to let go of the form, the habitual, the routines that used to frame them. It’s painful. It’s tiring. It’s real and raw and hard work.

How does all this fit into a blog about pain? If pain doesn’t challenge clinicians and people experiencing it, I’ve wasted the last 30-odd years of my clinical career, not to mention my hours of social media involvement!

Change, as a clinician, can be tough – letting go of the form of what we offer (because … science) while holding on to why we ever started working as clinicians requires flexibility.

And solitude – to reflect on what it is we really want. We do it for families, those closest to our hearts (our own families, and others), so people can be who they really are.

Comparing ourselves with others leads to a popularity contest, and the self-management approach to pain is most definitely not a popular meme. I am not part of the Instagram/Twitter/TikTok/whatever meme culture. I don’t do short, snappy sound bites. There are, as far as I can see, no short-cuts or quick fixes for learning to live well with pain. There are only connections between people who care, who are willing to be vulnerable, who will let go of some things in order to take on new things in the pursuit of what matters.

This is what I’ve learned from Lock-down.

On labels and boundaries


What we call a disease matters. It matters to the person because a diagnosis is a marker: this problem is known, it’s recognised, it’s real (Mengshoel, Sim, Ahlsen & Madden, 2017). It matters to the clinician, particularly medical practitioners, but also those clinicians working within a largely “disease-oriented” framework (for example, physiotherapists, osteopaths) (Haskins, Osmotherly, Rivett, 2015; Kennedy, 2017). It matters also to insurance companies, or funding providers – who is in, and who is out.

The diagnostic label itself hides a great many assumptions. The ways in which diagnostic labels are grouped reflects assumptions about underlying similarities (and distinctions) between groups of symptoms. Added to this complex situation is uncertainty in how the person presents: are they a “typical” presentation? Who decides what is ‘typical’? Think of the classic signs of chest pain signifying myocardial infarct – but this applies to males, and less so to females. Women are less likely to be resuscitated after chest pain, and also less likely to be transported to the Emergency Department using lights and sirens (Lewis, Zeger, Li, Mann, Newgard, Haynes et al, 2019).

It is the physician’s quest for certainty and the patient’s illusion of certainty, however, that leads to many of the current decision-making techniques in the practice of medicine. Evidenced-based medicine seeks to provide information to physicians and patients to allow for more informed recommendations, and yet our current evidence base is imperfect owing to unreliable clinical data, incomplete taxonomy of disease, and a weaker focus on clinical reasoning.

Correia, Tiago. (2017). Revisiting Medicalization: A Critique of the Assumptions of What Counts As Medical Knowledge. Frontiers in Sociology, 2. doi: 10.3389/fsoc.2017.00014

With any luck, clinicians working in persistent pain management will have moved beyond a simple medical diagnosis when working with someone. While a diagnosis is crucial for acute management, once the pain has been hanging around for a while the illness-based aspects of dealing with pain become more important.

What do I mean by this? Illness is about the personal experience of living with a disease. If we think of disease as being about biological aspects, illness is about the “what it is like to live with” the disease. Talcott Parsons, a sociologist at Harvard University wrote that illness could be considered “deviant” behaviour: “…behaviour which is defined in sociological terms as failing in some way to fulfill the institutionally defined expectations of one or more of the roles in which the individual is implicated in the society.”(Parsons, 1951). While Parson’s language and some of his concepts represent the outdated views of society at the time, the notion of illness being “what it is like to” live with a disease is an important distinction for us as clinicians.

For clinicians working in pain management/rehabilitation, particularly with people who have been living with pain for months or years, understanding that on top of the biomedical label, each person also has months or years of the stress of dealing with that problem. For any of us, experiencing pain even for a short time can be puzzling, represents changes in how we view our bodies, often elicits irritation or anger, sometimes sadness and typically, actions to avoid or control the problem.

Now here’s the point of my writing this blog today. If any of us face an unnamed challenge, or if our situation doesn’t change despite “following all the rules” (thinking Covid-19 maybe?), whatever typical stress response we get is likely to be elicited. If we’re inclined to worry, we’ll probably worry. If we’re inclined to withdraw from being with others, we’ll probably do that. If we tend to have trouble sleeping, we might do that. If we get irritated and tetchy when we’re stress, well we’re probably going to do that too. This is normal.

Now if someone saw you and me today, and went through a structured clinical interview for diagnosis, I’m sure I’d at least begin to show signs of anxiety or depression. Two weeks of saturation coverage of Covid-19 will do that to you, and add the challenges of being penned up in my home without any shops open, and I’m probably going to be not my usual self.

Let’s think about the person we see who has been living with persistent pain for a few years. This person is enduring pain every single day. Has possibly looked everywhere for something to help – usually we’d think of this person as pretty motivated, but for some clinicians this begins to look like “doctor shopping”. The person might have fallen out with one or two previous clinicians who persisted in treating the problem the same way they’d treat an acute pain problem. This begins to look like “difficult patient” territory. Add to this some mood problems, lots of anxiety about everything else in life – and lo! we have a person ripe for a psychiatric diagnosis. Or at the least, “yellow flags” (risk factors for prolonged disability).

Now, the whole idea of risk factors for ongoing disability was intended to help us as clinicians pay attention to doing some different for people with those risk factors in their lives. That’s right: for clinicians to take on the responsibility for either assessing in more detail, reviewing more frequently, integrating active coping strategies into treatment, and perhaps referring for specialised care if that was warranted.

Yellow flags are not some kind of warning for clinicians to negatively label, perhaps even diagnose, a person as being “difficult”. Yellow flags should elicit from clinicians (us) an awareness that this person is vulnerable. That’s right, vulnerable – and needing more care.

I’ve heard talk over the years of clinicians stepping out of their scope of practice when looking at psychosocial risk factors. I’ve always thought that it’s a good thing to be aware of risk factors so that something can be done about them, because this person is a greater risk of poor outcomes. The problem arises when someone, without appropriate training, gives a person a psychiatric label. There are a few labels that spring to mind: personality disordered, especially borderline personality disordered; attachment disordered; somatic disorder…

The problem with labels is that they don’t get erased when the clinician who gave them that diagnosis discharges them. Those labels live forever on clinical files, insurance files, claims files, medical and hospital notes. Those labels can, and often do, invoke highly discriminatory behaviour. One person sent to Emergency Department with chest pain was told they should come back when they have a real problem (duh, chest pain = real problem) because, sitting at the top of the list of diagnoses was “somatic disorder”.

Clinicians – do not use labels without thought. Don’t use labels that sound technical (thinking ‘catastrophising’), don’t make a diagnosis that is outside of your scope, don’t over-interpret a questionnaire score, don’t judge people because today they’re distressed and cranky, or worried and tearful. For goodness’ sake: stick to your clinical boundaries!

Haskins, R., Osmotherly, P. G., & Rivett, D. A. (2015). Diagnostic clinical prediction rules for specific subtypes of low back pain: a systematic review. Journal of Orthopaedic & Sports Physical Therapy, 45(2), 61-76, A61-64.

Kennedy, Ashley Graham. (2017). Managing uncertainty in diagnostic practice. Journal of Evaluation in Clinical Practice, 23(5), 959-963.

Lewis, J. F., Zeger, S. L., Li, X., Mann, N. C., Newgard, C. D., Haynes, S., . . . McCarthy, M. L. (2019). Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest. Womens Health Issues, 29(2), 116-124. doi: 10.1016/j.whi.2018.10.007

Mengshoel, Anne Marit, Sim, Julius, Ahlsen, Birgitte, & Madden, Sue. (2017). Diagnostic experience of patients with fibromyalgia – A meta-ethnography. Chronic Illness, 14(3), 194-211. doi: 10.1177/1742395317718035

Parsons, Talcott. (1951). Illness and the role of the physician: a sociological perspective. American Journal of orthopsychiatry, 21(3), 452.

When life is topsy turvy


I had intended to write about a piece of research today, but as I read all the news reports about how much life has changed and needs to change more, I’ve decided it’s time to address important issues facing health professionals working in pain management and rehabilitation.

In New Zealand the alert level is at 2 out of 4. I suspect this has been instituted to soften the shock later in the week when we’re asked to completely lock down. We are currently being asked to maintain physical distancing, older folks are asked to self isolate as much as possible, GPs and nurses are being asked to move to virtual consultations, and all of us who can are being asked to work from home.

What is not happening is guidance from the Occupational Therapy Board NZ, or the Physiotherapy Board NZ. Further: ACC has permitted psychology and medical consultations via video links, but not occupational therapy, physiotherapy or the group programme under the Community Pain Contracts.

I’ve watched my massage therapy colleagues in NZ close their businesses because it’s not possible to provide safe therapy in this environment. Video conferencing is, however, completely feasible for occupational therapy and physiotherapy – I’ve been offering services via video for some years now. But apparently we’re somehow not included in those privileged to provide video services? It seems out of step, and perhaps demonstrates how little those making policy actually understand about our work.

I intend to run my next group session (tomorrow) as my last, the 4th week of six. The remaining two sessions will be run by video link. I’ll be working from home except Wednesday morning when I’ll go into work to pick up some things. The University is still arguing that we can go into work – but I work in offices in the Hospital building. I have elderly parents. My partner is immune compromised. I don’t want to distribute bugs from my perambulations to my partner, my parents, or casual encounters in at the Hospital.

In preparation for working from home, I’m returning to strategies I used while working on my PhD. That means maintaining my daily routine – up and about and at the computer by 8.00am. Working steadily through the day, breaking the day up using Pomodoro technique (how many tomatoes can I smash?). I’ll finish the day at 4.30pm. I’ll make sure I have my 5 minute movement snacks, along with glasses of water (and coffee!).

My office is set up with the “Focus” setting so I don’t get interrupted by social media, email, or news notifications. I have good lighting, heating, and a comfy seat. This is my work space. Luckily I can keep it separate from where I relax! I have access to reference books and journals, and I can video conference from where I sit. As usual it’s a clutter, but that’s the way I like my environment!

I suppose what I’m saying is that life will go on, albeit differently. And that adjusting to it means allowing myself to work differently but maintaining some of the habits that keep me on-task and focused. Being disciplined allows me the freedom to work without distractions – oooh squirrel! And I can still stop and notice what is beautiful in my environment.

Kia kaha (stay strong), arohanui (much love), and remember this:

Naku te rourou nau te rourou ka ora ai te iwi

With your basket, and my basket, the people will live

Coronavirus (COVID19), catastrophising – and caution


I don’t often leap aboard a popular topic and blog about it, but I’m making an exception right now because, although COVID19 is new – catastrophising is not.

There are a number of people who really do not like the term “catastrophising”. There are comments that this is a pejorative term, used to deny the validity of a person’s experience. That it means the person is exaggerating or being melodramatic or in some way not believable.

But as I read the many, many headlines about COVID19, including the international toilet paper frenzy, reading about Vitamin C or “anti-inflammatory foods” to combat it, I even saw a serious post about using hands-on therapy to “shift the toxins”…. And I wonder whether we can take a good hard look at ourselves and our response to this virus.

Firstly, getting accurate information about COVID19 has been difficult. There are some authoritative sources “out there” but they’re not necessarily the most sexy sites to visit. Not many memes coming out of our Ministry of Health in New Zealand! Much of the information we read on a daily basis is in the general news media, giving a “personal story” slant on “what COVID19 means”. Some really good information coming from our politicians in NZ – but also some scaremongering from the political opposition.

Does this sound familiar? Where does the good, accurate and evidence-based information about persistent pain come from? And in the absence of readily accessible and “memeific” information, where do people go to learn about pain?

Secondly, it’s not the virus itself that’s causing the majority of trouble for people – except for the small percentage for whom the virus is deadly, mainly because of comorbidity, and health vulnerability. People who are older, already have immune compromise, and who are not able to access good healthcare are most at risk. The rest of us are experiencing the fallout of containment measures, economic insecurity, and lack of toilet paper. Sorry, couldn’t resist that last one. Seriously, most of us are being affected by the cancellation of meetings, by the need to self-isolate, by travel restrictions, by people having less money to spend because suddenly their jobs are less secure – watching my savings melt day by day…

Sounds quite similar to the experiences of people with persistent pain: often it’s not the pain itself that’s so awful, but the effects of losing contact with people you love, of having to take medications to reduce pain that leave you feeling dreadful, of not being able to play sports or do work – the loss of income security, access to healthcare, connection with people who matter. These are amongst the most debilitating aspects of living with persistent pain, let along the pain…

If you’ve found it hard to think of anything else but COVID19. If you’ve had trouble taking your mind off how you’re going to get by if patients can’t come to see you because they’re worried about giving you COVID19, or of catching it from you – that’s rumination, or brooding on it.

If you’ve caught yourself heading to the supermarket to get some extra pantry staples “just in case”. If you’ve found yourself checking in to see what your local health authorities are recommending. If you’ve been wondering if you should shut your business down for a while – and then been wondering what you’re going to do for a income if you do that. If you’ve looked up your bank balance and wondered what you’re going to do if your kids are off school for the next month, while you’re meant to be at work and there’s no-one to look after them…. you’re magnifying, or estimating that the demands of this situation might well exceed your current resources to deal with it.

If it all feels a bit overwhelming and you’re not really sure what to do next. If you’re feeling pretty stuck and getting a bit panicky. If this feels just way too much to handle – that’s hopelessness, or feeling really overloaded.

And each of these three clusters of cognitions, emotions and behaviours are part of the catastrophising construct.

Do they feel normal to you? Do you think you’re exaggerating? Do you think your reaction is over the top? No? Well you’d be (generally) quite right (except maybe the toilet paper hoarding… that’s just weird). Thinking the worst is normal in the face of uncertainty. Some commentators and researchers believe it’s one way we learn to convey our need for social support (Bailey, McWilliams & Dick, 2012; Lackner & Gurtman, 2004; Thorn, Keefe & Anderson, 2004).

At the same time, I want to take a pragmatic and contextual look at catastrophising.

From a pragmatic perspective, right now it’s completely appropriate to be a bit discombobulated by COVID19. And many of us have a lot of things to consider over the next few days/weeks as the situation changes on a daily and even hourly basis. The things we’re doing right now to plan for the worst are largely useful. That’s the point of being able to catastrophise – in the right context, in a rapidly evolving health and economic crisis, being able to consider the various futures and put plans in place to deal with them is probably a good thing. That’s the action part of the catastrophising construct.

The difficulty NOT checking your news media feed, and feeling a bit overwhelmed by it all seems to be a fairly reasonable response to an unreasonable situation. Logic, right?

So, from a pragmatic perspective right now, in the face of uncertainty, most of us are doing exactly what has got humans out of trouble many times in our history.

Now, what if we shift the context to 24 months in the future. COVID19 has now been largely contained, a vaccine is available, the virus hasn’t evolved, and while the economy is slowed, it is gradually picking up. What if, at that time, we have a friend who is still nervously scanning the headlines for the latest information on the virus? What if that friend is still stockpiling pasta and toilet paper and hand cleanser? What if that friend is still feeling like there’s not much they can do except hunker down and hide?

Now, my guess is that many of us would think this is being a bit extreme. Maybe even a bit OTT. Especially given that there’s likely to have been a LOT of media coverage of the COVID19 vaccine, and most economic activity will be returning. We might begin suggesting (gently) to the person doing the stockpiling that maybe it’s not necessary to keep on doing so. We’d think it’s a good idea to give them the new information about COVID19. We’d probably suggest that although they’re freaking out, maybe it’s time to reconsider the threat.

Context matters – catastrophising can be useful right now. In 24 months: not so much. New information will likely help us take a more realistic look at what’s going on with COVID19. It’s not that individual people won’t be personally affected if they get sick, but probably the crisis that’s happening right now will be over.

What about the validity of the person’s emotional response to their feared situation? Would we be dismissive? I hope not – because anyone who is still freaking out about COVID19 in 24 months time is still in distress! But we might be more willing to share the good news about recovery with them, so they don’t continue feeling overwhelmed and distressed. We’d not be likely to let them carry on thinking the worst, and we certainly wouldn’t be telling them their response is perfectly valid and appropriate for the threat.

What of the person experiencing pain and thinking the worst, feeling pretty awful and hopeless? Would we support them to stay in that highly distressed state? Would we say “there, there, you’re really feeling bad, aren’t you, here’s a tissue” – and walk away? Would we hesitate to suggest that perhaps they’re magnifying the problem and that they might have some other options?
Think about it. Catastrophising is a well-validated and studied construct. Hundreds of studies have shown that catastrophising is associated with poorer outcomes in so many situations – childbirth, knee replacements, hip replacements, multi-trauma orthopaedics, discomfort during internal atrial cardioversion, length of hospital stay after knee replacement, use of medications – on and on and on.

Catastrophising gets a bad rap. And woe betide anyone who TELLS someone “you’re catastrophising” because you seriously deserve a slap. Sheesh! But take a moment to consider the adverse impact on the person of thinking the worst… sleepless nights, endlessly checking their body, feeling overwhelmed and overloaded, having trouble thinking of anything else, perhaps anxious and depressed… this is not a recipe for recovery.

Call it what you will – over-estimating the threat of something, and under-estimating your resources can act as a galvaniser for preparation and action in the short term and in the context of uncertainty. When there are ways to move forward, and the threat is maybe not so great as you thought, and maybe you can do something to help yourself – then it’s probably time for us to show strong compassion. That’s compassion that cares enough to have difficult conversations, that helps another person consider their response in light of new information, and is willing to be there to help the person re-evaluate their next best steps.

Keep safe. Keep your social distance. Wash your hands. Don’t go out if you’re sick. Be sensible with the toilet paper.

Bailey, S. J., McWilliams, L. A., & Dick, B. D. (2012). Expanding the social communication model of pain: are adult attachment characteristics associated with observers’ pain-related evaluations? Rehabil Psychol, 57(1), 27-34. doi: 10.1037/a0026237

Lackner, Jeffrey M., & Gurtman, Michael B. (2004). Pain catastrophizing and interpersonal problems: a circumplex analysis of the communal coping model. Pain, 110(3), 597-604. doi: 10.1016/j.pain.2004.04.011

Thorn, Beverly E., Keefe, Francis J., & Anderson, Timothy. (2004). The communal coping model and interpersonal context: Problems or process? Pain, 110(3), 505-507.

“Intuition” – and clinical reasoning


Intuition is one of two main modes of thinking, according to Daniel Kahneman. Intuition is fast, considers the whole rather than components of the whole, and intuition feels effortless. Intuition can also be wrong – but often isn’t (Gruppen, Woolliscroft & Wolf, 1988).

We use intuition well when we’ve been exposed to many examples of the phenomenon under consideration – for example, if we’ve seen a lot of patients with similar health problems. We don’t use intuition well when we buy into biases or stereotypes.

The alternative to intuition is slower thinking, that typically breaks the considerations into smaller pieces, often following a linear process where data (information) is collected and assembled. This kind of thinking is reasonably easy to investigate, whereas intuition is much more difficult to study (it’s fast, people can’t describe how they arrived at a conclusion, so it’s not amenable to self-report).

Why worry about it? Well, intuition is the key strategy described by allied health, particularly physiotherapists, when considering whether a person needs further assessment for those pesky psychosocial factors (Man, Kumar, Jones & Edwards, 2019). What this means in practical terms is that a patient who doesn’t fit the stereotypical “risky yellow flags patient” may have to fail at conventional treatment before being directed towards a multidisciplinary, or biopsychosocial, approach.

What might be an alternative?

I’m pretty fortunate in that I work in a service where participants to my group programme have already completed a series of questionnaires as a requirement to participate in pain rehabilitation and management. So everyone I see will have some information I can draw on without my needing to add anything more. Of course, I can argue that some of the questionnaires don’t help me very much because they’re fairly biased towards a CBT model of chronic pain management. But the principle is pretty clear: everyone gets to complete the questionnaires ahead of time.

Practically, this isn’t always easy. Many people don’t have good literacy skills, don’t have a computer, hate the thought of paperwork (even in electronic form), and some of the questions don’t work very well/aren’t relevant to the people I see, so they choose not to fill them in. There’s no opportunity to discuss the responses with a clinician, so it’s not easy to decide whether the questions apply.

But what happens when we leave the questionnaires to luck, intuition or “the psychologist”?

Firstly, we know the relevance of psychosocial risk factors. We know this so well – it’s been a theme throughout the years I’ve worked as a clinician in pain rehabilitation and management. If we don’t include these in our formulation (treatment planning), we’re probably not including them as key predictors for outcomes…

We can’t rely on our intuition because for many of us, those people who do have risk factors will only overtly show these once they’ve failed to progress – it’s at that time they’re more distressed, frustrated and afraid, so behavioural markers for psychosocial risk factors are more evident. This also means someone will have to work with the person who is now more distressed than they needed to be.

We don’t use our team to best advantage. Why refer someone to an occupational therapist, to a psychologist, to a counsellor if we don’t know why the person needs to see them? This can lead to a distinct lack of briefing or information about the referral to the person with pain – and sometimes, it seems, to the person deciding they don’t need, or want, that referral even when it would be in their best interests.

Mostly, though, I think it begins to bias our thinking. We can become judgemental – why doesn’t this person do their home-based exercise programme? Why are they just going through the motions? Why do they keep on complaining about their pain? We can begin to question the person’s motivation, their lifestyle, the validity of their perspective.

The real problem?

Our clinical reasoning models don’t help us very much when it comes to synthesising psychosocial factors. When we’re dealing with those factors using “intuition” we don’t have to incorporate them into our models – because intuition isn’t explicit, it’s quick and difficult to articulate. To date there are very few transprofessional models of pain management, and even fewer that attempt to link theoretical constructs with what we see in front of us. That synthesis of biological, social and psychological constructs that uniquely explains why this person is presenting in this way at this time, and what factors may be maintaining this person’s predicament. It’s no wonder that, in a recent study my colleagues and I have been conducting, we’ve found very few clinicians collaborating on a case formulation.

My suspicion is that until we develop a collaborative case formulation clinical reasoning approach that can integrate these many factors in a sensible and logical way, our “intuition” is likely to leave us floundering. The casualties of this particular mess are the people we hope to treat. I wonder if it’s time to work together, physiotherapists, occupational therapists, psychologists and medical practitioners (and all other variants of health practitioner!). Do we need to create a synthesis that works as a transprofessional model of pain?

Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. In research in medical education: proceedings of the annual conference. Med Educ. 1988;27:242‐247.

Man, Isabella, Kumar, Saravana, Jones, Mark, & Edwards, Ian. (2019). An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey. Musculoskeletal Science and Practice, 43, 58-63. doi: https://doi.org/10.1016/j.msksp.2019.06.004

Widerström, Birgitta, Rasmussen-Barr, Eva, & Boström, Carina. (2019). Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare. Musculoskeletal Science and Practice, 41, 6-14. doi: https://doi.org/10.1016/j.msksp.2019.02.003

Undergraduate pain curriculum: What needs to be included and what doesn’t?


One of the prominent themes in social media discussions about pain is that the subjects are not given sufficient attention at undergraduate level. The results of this omission are that many entry-level clinicians don’t have the necessary knowledge, skills or attitudes for working with people who experience pain. (As an aside, it also makes my job as a postgraduate Academic Leader much more difficult: where do I start when developing a programme?!)

Luckily there is an IASP Pain Curriculum. Actually there are many of them, for many disciplines, and they provide educators with great guidance. The problem is, however, there is so much that could be included in this kind of education – and we usually don’t have much room in a programme to include it all.

The main problems with the curriculum are: the content and levels of competency required at an undergraduate level aren’t specified; most research into this area targets postgraduates, with less attention for undergraduate pain education. Most curriculum for pain have been discipline-specific, and while a consensus on the content and desired competencies of an interprofessional pain curriculum at a pre-licence or undergraduate level has been discussed, an a-priori defined competency level across professions for the items in the IASP curriculum hasn’t been established. We need cross profession agreed competencies to allow for good collaboration. (see van Lankveld, Afram, Staal, van der Sande, 2020).

In my role as Academic Coordinator for Postgrad Programmes in Pain and Pain Management, one aspect of the interprofessional curriculum that is quite difficult to navigate is how to turn topic headings into knowledge, skills and attitudes. I’m wary of teaching directly to subject (knowledge) without accompanying this with appropriate skills and attitudes – particularly at postgraduate level, given knowledge (topics) are continuing to change over time. There’s clearly some material that is highly valued by one profession over other professions – and this is normal for every discipline! And I’m not sure we can ever hope to cover every single thing.

One consistent theme in research into attitudes and beliefs among musculoskeletal clinicians is that confidence to assess and then use information from the psychosocial domain is low (Alexanders, Anderson & Henderson, 2015; Buchbinder, Staples & Jolley, 2009; Miki, Kondo, Takebayashi & Takasaki, 2020; Singla, Jones, Edwards & Kumar, 2015). This problem is not isolated to physiotherapists, but cuts across all professions, including psychologists referred patients with “medically unexplained symptoms” (Brittni & Williams, 2020). I wondered if this area has been given sufficient emphasis in our curriculum, and most especially, whether opportunities to develop skills and attitudes that support equitable and effective pain management are developed.

van Lankveld, Afram, Staal, van der Sande (2020) used interprofessional expert panel groups, followed Delphi process, and incorporated a measure of competency (the Dublin Descriptors), to establish which of the many areas of the pain curriculum should be prioritised. This makes for interesting reading, as some of the areas considered integral to better pain management, such as the socio-political and ethical were not considered crucial, while those related to Epidemiology, Development of Pain Theories, and Mechanisms were all thought crucial. I find this interesting as stigma, equity of access to treatment, ethical use of analgesics are all areas of healthcare that directly influence what we do in treatment and in particular, what gets funded and what does not.

Developing a teaching programme from a list of topics considered important involves opinions, values, and an understanding of pedagogy. Given we live in an ever-changing information environment, I think skills and attitudes towards what is today considered “fact” need to be emphasised – how do we learn to think critically? At least part of critical thinking is reading around a topic to become familiar with current and historic models and knowledge. I also think that some of the more complex issues we need to deal with as societies are often those attitudes towards people who violate our assumptions about who is and isn’t “other”. Learning is not only about content, it’s about attitudes towards the subject matter. And some of these attitudes are buried deeply beneath community assumptions and values. To uncover these attitudes, then help people reflect critically on them and their clinical implications is, I think, one of the tasks educators need to address.

For that reason, in my 5th year undergraduate medical teaching, I ask students to undertake a case study where their job is to listen to the person with pain, identify risk factors and protective factors for recovery and return to optimal functioning and participation, and then offer individually tailored recommendations to the person, in language the person will understand. My hope is that these future medical practitioners will have developed some empathy and strategies for caring for and encouraging patients with pain to be less afraid of their pain, and more able to go on with their lives.

What should go in undergraduate training? I think we can weave all the content of these curriculum into our undergraduate training, but we should also leave students with the certain knowledge, skills and attitudes that this area of study is going to change. And that means lifelong learning about pain, people, science and self.

Alexanders, J., Anderson, A., & Henderson, S. (2015). Musculoskeletal physiotherapists’ use of psychological interventions: a systematic review of therapists’ perceptions and practice. Physiotherapy, 101(2), 95-102. doi: 10.1016/j.physio.2014.03.008

Buchbinder, R., Staples, M., & Jolley, D. (2009). Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976), 34(11), 1218-1226; discussion 1227. doi: 10.1097/BRS.0b013e318195d688

Crawford, C., Ryan, K., & Shipton, E. (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. N Z Med J, 120(1254), U2536.

Cowell, I., O’Sullivan, P., O’Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskelet Sci Pract, 38, 113-119. doi: 10.1016/j.msksp.2018.10.006

Jones, Brittni, & Williams, Amanda C. de C. (2020). Psychological therapists’ judgments of pain and treatment decisions: The impact of ‘medically unexplained symptoms’. Journal of Psychosomatic Research, 131, 109937. doi: https://doi.org/10.1016/j.jpsychores.2020.109937

Miki, T., Kondo, Y., Takebayashi, T., & Takasaki, H. (2020). Difference between physical therapist estimation and psychological patient-reported outcome measures in patients with low back pain. PLoS One, 15(1), e0227999. doi: 10.1371/journal.pone.0227999

Singla, Mukul, Jones, Mark, Edwards, Ian, & Kumar, Saravana. (2015). Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Manual therapy, 20(2), 328-334.

van Lankveld, W., Afram, B., Staal, J. B., & van der Sande, R. (2020). The IASP pain curriculum for undergraduate allied health professionals: educators defining competence level using Dublin descriptors. BMC Med Educ, 20(1), 60. doi: 10.1186/s12909-020-1978-z

Did you miss me?


It’s been a while since I last posted on my blog, as I’ve had other projects on the go this summer. Over this time I’ve been pondering, as I usually do, why pain management/rehabilitation has so many problems. Conceptually, I can understand that pain is a complex experience that we’re a long way from understanding. I get that it’s a philosophically challenging subject. That because it’s subjective (like love, disgust, fatigue or hunger) it’s difficult to examine dispassionately.

I also get that it’s big business. Pain is one aspect of being human that captures the entrepreneur’s imagination. People don’t like pain (on the whole), and even those who seek pain (I’m not thinking fetishes – just sports people!) aren’t inclined to want it to hang around. There’s a ready market for anything that helps “get rid of” pain – even though it’s impossible to fully “get rid of” pain without simultaneously creating other problems!

Some of us clinicians focus almost exclusively on finding a presumed cause. The search can go on for weeks, months, years. Professionals will use tests, investigations, even treatments to see whether they’re on the right track to find what’s initiating the experience. And clinicians can believe, because a treatment was followed by a reduction in pain, that they’ve found it! Happy customer, happy therapist.

Huge arguments are waged across social media platforms. The proponents of one view argue against the proponents of another view. The pendulum is said to swing violently from one side to the other. “Too much bio” “Too much psychosocial” “but what about the bio” “the bio’s always in there, it’s even in the name” – and so on.

I’m a clinician who rarely gets caught up in the “but what about the bio” argument – because I’m unashamedly clear that I don’t treat pain. I don’t attempt to change pain. I don’t try to find the cause. I don’t really look at the diagnosis very much. I don’t try to explain what’s going on. Not because I don’t have some ideas about what might be going on, but because the people I see have usually had “the bio” so extensively investigated that it’s moot. Given that most of our treatments for persisting pain are pretty mediocre, I figure that by the time someone gets to see me (on average two years after the onset) it’s time to focus more on living alongside pain. And if pain does happen to change or go, that’s a total bonus. I’d argue that being able to do that even in the early stages might go a long way towards reducing the overwhelming impact of pain on the daily lives of people.

But in not focusing on pain reduction, not locating the supposed “source” of the problem, some people are horrified. “But look at my success” or “this person suffered for X years and then I solved the problem and their pain went!”. You know, that’s awesome and I think it’s fabulous when someone finds something that reduces pain. It’s just that I don’t think it’s necessary to prioritise pain reduction over living life – I think the two can be done concurrently, albeit with care.

The energy people put in to arguing their position, whichever orientation they prefer, is extraordinary. And it’s this that makes me feel somewhat worried. When we put so much effort into defending a position, we argue ourselves into a stance that’s difficult to change. And we become less sensitive to information that doesn’t fit with our argument. We hold onto our beliefs more strongly, while filtering everything we see and hear through a lens that skews our view of our world.

I’ve argued that clinicians need to hold their beliefs about what we think we know fairly lightly. When we recognise that pretty much all we think we know is provisional and should be subject to more testing, it’s worth remembering that something we assume we know for sure could be wrong.

Take rest for low back pain: from the late 1880’s until around 1986ish, rest for seven days was The Treatment. It’s only through testing and vigorous (really vigorous) arguments that we’ve arrived at the situation we have now, where it’s pretty clear that bed rest isn’t a good option (See the two refs below!). But OH the angst over the years 1975 – 2004! Much argument and rage and frustration and even litigation…

Now we have the era of exercise is good for back pain (well, everything if you read the headlines!). But is “exercise” the panacea? How does exercise help? What are the mechanisms, and can they be activated in other ways? What if you don’t enjoy “exercise” as administered by so many therapists? (see Searle, et al, 2015, below).

I think we’ve learned a great deal about what doesn’t work in pain rehabilitation/management. Mostly, our effect sizes are modest to tiny. And what we haven’t dealt with is how do we help people move from being patients to being people. To being people with lives they want to live. Transferring what seems to help into a person’s OWN life, not the one we think they ought to live.

This year’s blogging is likely to continue my tradition of grasshoppering from topic to topic, but at the heart of my writing is my desire to see people with pain being able to live their own lives, in their own way, with their own priorities and values, and in their own context. Maybe it’s time to step outside our clinic doors, and remember the reason people come to see us: they want to be able to do what’s important in their life. The rest of this philosophical and methodological and factionistic arguing is beside the point.

Hagen, K.B., et al., Bed rest for acute low‐back pain and sciatica. Cochrane Database of Systematic Reviews, 2004(4).

Searle, Angela, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation 29.12 (2015): 1155-1167.

Waddell, G., G. Feder, and M. Lewis, Systematic reviews of bed rest and advice to stay active for acute low back pain. British Journal of General Practice, 1997. 47(423): p. 647-652.