ferny thing

A new definition of pain


The IASP definition of pain has been revolutionary. It has helped shift the focus away from mechanisms involved in producing the experience we all know, towards defining the nature of that experience. The definition is relatively simple, easy to remember and contains several important qualitative definitions that are integral to the experience. For those of you who haven’t attended one of my classes, the definition is:

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

It was first proposed in 1979, and has not been substantially changed since then, although the accompanying note has.

Now two prominent pain researchers are proposing a new definition: Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive and social components (C de C Williams & Craig, in press).

Their arguments centre on some important aspects that have influenced our understanding of pain and represent advances in scientific understanding of pain since the first definition. The first definition was ground-breaking but acknowledged only sensory and emotional features of pain: our understanding of pain now recognises the influence of and effect on  cognitive and social components. These aspects are important because in many ways the original definition seems to discourage clinicians to be aware of emotional, sensory AND cognitive and social aspects of pain in ACUTE pain as well as chronic.

They further argue that pain is more than “unpleasant” if it is clinically problematic, and suggest that “distressing” be used to describe the nature of that experience. And it is this aspect that I am less comfortable with – because, as many readers of this blog know, it is possible to experience pain without distress, particularly if that pain is being managed using approaches such as mindfulness and acceptance. To my mind, a definition that equates experiencing pain with distress risks invalidating those who, because of their understanding of pain, or their social context, or even concurrent competing goals, fail to identify their pain as distressing but instead experience it as “negative but irrelevant”, or those who, because of social context and learning, don’t frame their pain as distressing and present as stoic and calm.

Despite this difference in opinion, the rest of the arguments for changing the definition of pain appeal to me. There is the need to acknowledge not only verbal report, but also nonverbal behaviours as part of the way humans express and communicate their experience of pain. Unfortunately, researchers and clinicians can focus on a single dimension: intensity – although thankfully most effective clinicians will incorporate more than one dimension and include assessment of behaviours, voice, facial expression, interference on daily life, quality of pain etc.

C de C Williams and Craig also propose revising the note. The note is often not included when people are discussing the definition of pain – in fact, one prominent clinician I know declared that “Pain is not a psychological phenomenon” – er…. take a look at the last sentence of the note, please Dr K. As a result, there are those who still do not recognise that pain is not just about nociception and nociceptive pathways. This means some unfortunate patients do not have very real and clinically important psychosocial aspects of their experience attended to, despite years of research showing just how critical these factors are!

Their first recommendation is to remove reference to “pain in the absence of tissue damage… are probably psychological” – because as we know now, neuroplasticity provides an explanation for this phenomenon.  Additionally, they note that psychological phenomena exist even in acute pain, such as emotional responses, problematic thinking styles, avoidance, social disruption – and these can all occur with diagnosable tissue pathology. Finally, ruling out prickling, dysaesthesia etc seems to ignore the presence of these as part of many reports of pain.

What would I suggest? I think it’s still useful to use the word “unpleasant”, perhaps it could be relabelled an “aversive” experience, rather than necessarily “distressing” which seems to restrict painful experiences to only those that people identify as distressing – even people who participate in body suspension where the entire bodyweight is carried on hooks inserted into the skin and who experience this as a process in which they may ultimately feel euphoria describe the pain as “aversive” (or, to use their words “It hurts like a bitch”!).  Aversive implies the call to action potential that is present in all pain.

My definition? Pain is an aversive experience associated with actual or potential tissue damage with sensory, emotional, cognitive and social components .

DE C WILLIAMS AC, Craig KD.
Updating the definition of pain. 
Pain. 2016. 
PubMed: www.amedeo.com/p2.php?id=27200490&s=pai&pm=84c33420cb43501
20160509_090844

How do help someone change their beliefs about pain?


This post is my little attempt to educate clinicians! Some of you will know I really don’t like the term “pain education” or “educating” people. The reason doesn’t go back as far as the original definition of “educate” which is, according to the Online Etymology Dictionary “educate (v.) Look up educate at Dictionary.commid-15c., “bring up (children), to train,” from Latin educatus, past participle of educare “bring up, rear, educate” (source also of Italian educare, Spanish educar, French éduquer), which is a frequentative of or otherwise related to educere “bring out, lead forth,” from ex- “out” (see ex-) + ducere “to lead” (see duke (n.)). Meaning “provide schooling” is first attested 1580s. Related: Educated; educating.”In other words, educate means to “bring out, lead forth”.

Pain education is a buzz word right now. It’s not a new concept, but it certainly has been hitting the consciousness of a whole bunch of people who previously would have thought of pain either in terms of “oh it’s something to do with the tissues” or “if I can’t find the cause, it must be something in the person’s head”.  Learning about pain and the neurobiology of pain is an excellent thing, a wonderful first step for clinicians who may have missed out on learning this stuff in undergraduate training, and I’m not disrespectful of the need to know more. What I’m a lot uneasy about is thinking of pain education as a primary means for pain reduction, particularly when it’s carried out as “pain ed” where information is dumped without finesse.

We know that simply giving people information in order to change behaviour does not work unless the person is at the “preparation” stage of making a change.  In fact, mass media campaigns about back pain education haven’t been altogether successful despite an early study in Australia showing some really positive gains (Buchbinder, Jolley & Wyatt, 2001; Gross, Deshapnde, Werner, Reneman, Miciak & Buchbinder, 2012). Despite this, there have been numerous studies showing that there are positive gains if people experiencing pain are given good information about pain neurobiology (Louw, Diener, Butler & Puentedura, 2011; Louw, Diener, Butler & Puentedura, 2013; Louw, Puentedura & Mintkin, 2012; Moseley, Nicholas & Hodges, 2004). So… why am I so antsy about pain “education”?

Well, mainly because I think we’re often not trained to do “education” very well. We’re clinicians, we’ve spent years learning about our profession, but on the whole we haven’t been taught to teach – or even, truth to tell, how to help other people change their minds! With the exception of my psychology colleagues, I think most of us learned about what to tell people, rather than how to lead or guide people. And none of us like to be told what to do!

So… how do I go about helping someone think differently about their pain?

The first thing is, I’m not “educating”. The end result of “education” can simply be “Oh goody now I can get on with the real work”, “Yay! I’ve told them what to think, and now if they don’t get it, it’s their problem.” I think if we can change our language we might begin to approach this part of our therapy a little differently. If we aim to help people understand, think differently, reconceptualise or make sense of their experience we can begin to use a whole range of approaches to get to that end result. If we “educate” we might only think about the process of giving information.

How else can we help people think differently about their pain? I think it’s a process of helping people discover for themselves because we know this is a more successful process for learning than if we just give the answers. Think about kids – if we tell a kid how to ride a bike, they probably won’t be very good at riding even though they might know all about centrifugal forces, and inertia, and coordination and how a bike is made.  The reason we want to give information is that it might help give a kid more knowledge about what to think about when they’re riding – but it won’t change that they  need to hop on the bike to learn to ride it. Similarly, in helping people who are experiencing pain, we want people to be able to do things again – and while knowing more about pain might help reduce the fear from not knowing, but in the end people have to DO something differently to truly enact change.

How do I help someone discover for themselves? I begin by asking what people understand about their pain. I ask them what goes through their mind when they experience pain, what they think is going on and how they feel. I draw a diagram like the one below, and begin to fill in the gaps.

I will ask then what they think is going on – their theory – and add that into the diagram. I might ask what do they think that means for them? What do they think they need to do now? What would it mean if that was true? What would it mean if it wasn’t true? What would it say about them if it wasn’t true? How would they know if it was true?

I might ask about other experiences in the body, other sensations, things the person might not notice – maybe by saying “what do you notice in your shoulders? your breathing? your hands?” and so on. And then what these things mean as well. I’m primarily seeking information on the presence of sympathetic arousal (“stress response”) because this often presents at the same time as people experience pain – pain can be anxiety-provoking, so it’s a common reaction but often not noticed.

I include external factors – like what other people might have said, their response to the person’s experience – like advice, warnings, or even behaviours. When I think of other people I often separate “healthcare professionals”, “family”, and “work”, and sometimes include recent media campaigns that may have influenced how the person interprets his or her pain.

The resultant diagram can look a lot like this – but with the person’s own comments and phrases contained within each circle:

20160510_110132The idea behind listening and completing a diagram like this is to help me as a clinician to really hear what the person has been experiencing. We know all these aspects affect the experience of pain, but so often we go in with our own ideas about the problem, and fail to put together this complex web of interactions that help us answer the two questions:

  • Why is this person coming to see me in this way at this time?
  • What can be done to reduce both distress and disability?

My intention at the time I work through this diagram isn’t to change anything. It’s simply to listen and reflect what I’ve heard and to assemble that information in a way that makes some sense. It’s only after I’ve done this that I feel OK to begin to consider intervention/treatment priorities. For some people there is no point in trying to change what they believe – anything I say is likely to be countered by all these other things the person is hearing from everyone else. So instead I might begin by exploring movements and how these might be influencing what the person is focusing on. Or I might think about the impact or effect of avoiding things and talk through “what if” pain was less of a problem.

Sometimes I will address the thoughts and beliefs, basing my suggestions on looking at either the evidence that the belief is true – or the effect of that belief on the person’s experience. We might work out some small behavioural tests to see what happens if the person tries something out – maybe trying a movement they’ve avoided, just to see if their memory of how it was is accurate, or as bad as they recall.

When, and only when, the person indicates they want to know more about their pain, or they’ve found that their assumptions about pain don’t work out (because we’ve established some discrepancies between what the person thinks they’ve been told and their own experiences), then I can begin to go down the pain neurobiology education route – but it’s embedded in two important things:

  1. That they’ve indicated a need and readiness to know more, and
  2. I’ve already listened and tried to understand where they’re coming from

To my mind, doing anything before these two conditions are met is bound to be met with resistance, and risks being either ignored or rejected.

 

To summarise: giving information alone is not enough (usually) to help someone change their understanding of their own pain.

Some people don’t need to be given the whole pain education thing – what they want is to be heard and understood.

People learn more by doing, and if we want to help people do more (ie be less disabled and distressed by their pain) then we not only need them to know more, we need to help them DO more.

That means a lot less talking and a lot more doing.

Telling is less helpful than exploring together.

 

Buchbinder, R., Jolley, D., & Wyatt, M. (2001). 2001 volvo award winner in clinical studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine, 26(23), 2535-2542. doi:dx.doi.org/10.1097/00007632-200112010-00005

Gross, D. P., Deshpande, S., Werner, E. L., Reneman, M. F., Miciak, M. A., & Buchbinder, R. (2012). Fostering change in back pain beliefs and behaviors: When public education is not enough. Spine Journal: Official Journal of the North American Spine Society, 12(11), 979-988.

Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 92(12), 2041-2056. doi:http://dx.doi.org/10.1016/j.apmr.2011.07.198

Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy Theory and Practice, 29(3), 175-194.

Louw, A., Puentedura, E. L., & Mintken, P. (2012). Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiotherapy Theory and Practice, 28(1), 50-62.

Moseley, G., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi:http://dx.doi.org/10.1097/00002508-200409000-00007

softness

Why does “doing exercise” work?


Bless all the physiotherapists in the world, they keep us doing exercises. And exercises are good because they get us doing the things we want to do in our daily lives. But how does it work?  This is not an exposition on exercise physiology – I’m not au fait enough with physiology to do that and there are many other people out there with vast amounts of knowledge giving us the benefit of their wisdom who have written at length about exercise and why it’s important. Instead I want to talk about some observations – and maybe pose some critical questions too.

For many years I’ve worked in a chronic pain management centre where people with chronic pain attend a three week intensive pain management programme. Staff members from outside the Pain Management Centre (we were located as an outpatient facility on the grounds of a rehabilitation hospital) always told us they could spot a person with pain the moment they saw them wandering from our building to the main cafeteria: people walking slowly, sometimes limping, but often just walking very slowly towards the cafe.

Over the course of the three weeks, this group of people would go from this slow amble to walking briskly and attending the hydrotherapy sessions, doing a daily exercise session (circuit-style); and in the final week of the programme, catching a bus to the shopping centre, purchasing food, coming back and preparing a shared barbecue for friends and family. What a turn-around!

Now, I said I wasn’t going to talk about physiology and I won’t, but I WILL point out that three weeks is not a long time. It’s so little time that it’s impossible for muscle length and strength to change significantly. And yet movements (measured using the six minute walking test and timed up and go) were quicker. Postures changed. People looked more alert and took more notice of the world around them. The question of how it is that this group of people could go from being recognisably “pain patients” to people who could do everyday activities has to be asked.

There are a couple of points to make before I do my thing. Firstly, while the people attending the programme were undeniably uncomfortable, clearly slow in their movements, and most definitely disabled, they weren’t, by usual measures “deconditioned”. In other words, they were of pretty average fitness – and indeed, many had been attending daily gym sessions at the behest of a case manager and under the supervision of a physiotherapist for months! At the same time they were not DOING much and felt extremely limited in their capabilities.

The second point is that although the programme had two “exercise” sessions each day, these were not high intensity sessions! The aim in most cases was to help people establish a baseline – or a reliable, consistent quota of exercise that they could do irrespective of their pain intensity. Most of the work within the exercise sessions was to help people become aware of their approach to activity, to modify this approach, and to then maintain it. Movement quality rather than quantity was the aim.

Here’s where I want to propose some of the mechanisms that might be involved.

  1. Humans like to, and almost need to, compare their performance with other people. It’s not something we choose to do, it’s an innate social bonding mechanism and whether we then modify what we do to match others – or deliberately try to do the opposite to mark out our own stance – we’ve based our behaviour on having observed what’s “normal” around us. And this applies even when people develop disability (Dunn, 2010), but perhaps more importantly, may well be fundamental to how we experience our world – and ourselves (Santiago Delefosse, 2011). When a group of people meet, their behaviour rapidly becomes more similar – similar gestures, similar body positions, and similar facial expressions. I wonder if one of the mechanisms involved in change within a group of people who live with chronic pain is this tendency to mirror one another’s behaviour.
  2. Having proposed that mirroring is one mechanism of change, why don’t groups of people with chronic pain ALL remain slowed and showing pain behaviour? Well, another mechanism involved in behaviour change is operant conditioning. When a group is performing exercise under the supervision of a “wise and caring authority” (ie a physiotherapist), many reinforcements are present. There’s the “no, that’s not quite the right movement” response, and the “oh you did it!” response. The “you can do it, just push a bit more” response, and the “if you can do that, how about another?” At the same time people are set quota or “the number of repetitions” to complete within a timeframe. Simply recording what is happening is sufficient to change behaviour – just ask someone who is on a diet to record their food intake for a week and you’ll likely see some changes! But add to this a very potent response from the wise and caring physiotherapist, and you’ll get warm fuzzies for doing more, and possibly cold pricklies if you don’t try.
  3. And finally, and possibly the most powerful of all, is the process of confronting feared movements – and doing them. Doing them without “safety behaviour” and doing them to specifically confront the thing that makes them scary. And doing them in many, many different settings, so as to alter the tendency to avoid them because they’re scary. A recently published systematic review and meta-analysis of graded activity (usually based on operant conditioning principles, and perhaps on cardiovascular fitness training principles) compared with graded exposure (deliberately confronting feared and avoided movements in a whole range of different contexts) found that graded exposure more effectively reduces catastrophising than just doing graded activation. This shouldn’t surprise us – one of the mechanisms involved in disability associated with nonspecific low back pain is avoiding doing things because people are fearful either of further injury, or of being unable to handle the effects of pain.

Where am I going with this post? Well, despite the face validity of exercise for reducing pain and disability, it’s not the physiological effects that first produce results. It can’t be because tissues do not adapt that quickly. What does appear to happen are a range of social-psychological processes that influence whether a person will (or won’t) do something. What this means is two things:

  • Physiotherapists, and indeed anyone who helps people do movements to reduce disability, really need to know their psychological processes because they’re inherent in the work done.
  • Becoming expert at analysing what a person wants and needs to do, and in being able to analyse then carefully titrate exposure to the contexts in which things need to be done is vital. That’s fundamental to occupational therapy theory, training and expertise.

 

 

Dunn, D. S. (2010). The social psychology of disability. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology, (2 ed., pp. 379-390). Washington , DC: American Psychological Association

Lopez-de-Uralde-Villanueva, I., Munoz-Garcia, D., Gil-Martinez, A., Pardo-Montero, J., Munoz-Plata, R., Angulo-Diaz-Parreno, S., . . . La Touche, R. (2015). A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. doi:10.1111/pme.12882

Santiago Delefosse, M. (2011). An embodied-socio-psychological perspective in health psychology? Social and Personality Psychology Compass, 5(5), 220-230.

Shebadog

Self-managing chronic pain


I have long been a proponent of helping people who live with pain to take control of their situation and actively self-manage as much as possible. My rationale has been that people who feel they are in control of some parts of their life are more likely to feel confident when their pain flares up, or when they have a life set-back. Today I took a second look at some of the papers on self-management published over the past few years, and I think it’s time to be a little critical.

The first issue to deal with is defining self-management. To me, self-management means knowing as much as possible about the health condition (whatever it is), knowing as much as possible about various treatments, working hard to learn and integrate ways of coping so that I (because yes, self-management is something I use for my fibromyalgia) can do the things I most value. By doing this, I can be more like who I want to be, rather than being defined by my pain, or what other people expect from me. But, self-management isn’t nearly as clearly defined as this in many people’s minds.

Here’s one definition “We defined self-management as the strategies individuals undertake to promote health (e.g., healthy living, exercising), manage an illness (e.g., manage symptoms, medication, and lifestyle changes), and manage life with an illness (e.g., adapt leisure activities or deal with losses caused by illness)” (Audulv, Asplund & Norbergh, 2012). Morden, Jinks and Ong (2011) found from a study of individual’s perceptions that managing chronic conditions is not solely related to medical recommendations and that self-management is central to maintaining a sense of ‘normality’ in everyday life or to reasserting one’s position in the social world when living with a chronic illness and demonstrating competency from a moral perspective.

Interestingly, a definition from COPD management describes self -management as “… programmes that aim to teach the skills needed to carry out medical regimens specific to a long-term disease and to guide behaviour change to help patients control their own condition and improve their well-being”(Effing,  Bourbeau, Vercoulen, Apter, Coultas, Meek, et al.2012). The distinction between chronic pain self-management and other chronic illness self-management lies in the need to address broader “living” issues rather than just learning to “carry out medical regimens”. And that is both the problem and the distinction between chronic pain self-management and other chronic disease self-management approaches.

Let me unpack this: For people living with COPD, or diabetes, there are critical medical management practices that need to be learned and integrated into daily life so that the underlying medical condition doesn’t get worse and lead either to complications, or even early death. The focus on self-management in these situations seems to be on the medical tasks that must be undertaken. The end results are often measured in terms of reducing the number of extreme events – like having hyperglycaemia, or being admitted with a chest infection and needing oxygen.

Now if I turn to the qualitative literature on self-management in chronic pain, what is very obvious is that self-management isn’t about the medical procedures that must be followed. It’s far more about living life – and integrating ways of getting to do what’s important without too many flare-ups that get in the way of doing these things. In fact, Morden, Jinks & Ong (2011) found that in people living with knee osteoarthritis, self-management wasn’t something people identified with – what might have been classified by clinical people as “exercise” or losing weight or keeping active weren’t thought of as “self-management” by people living with knee OA. They thought this was “just getting on with it”. I particularly liked one comment : “because people perceived their activities to be an integral part of their daily routine they were not surfaced as deliberate action.” In other words, when people focus on living life, coping strategies become habits and routines that are secondary to the doing of life.

Mike Nicholas and colleagues have looked into coping and self-management extensively as part of ongoing research associated with the Royal North Shore Pain Management Programme. they were interested in whether it’s possible to find out if adhering to strategies introduced within a programme was predictive of outcome: in other words, did people who strongly adhered to what they learned during a programme ultimately gain better quality of life, lower pain, less disability and feel better? Surprisingly, they did – I say surprisingly because in a couple of meta-analyses (for example Kroon, an der Burg, Buchbinder, Osborne, Johnston & Pitt, 2014; Oliveira, Ferreira, Maher, Pinto et al, 2012) self-management approaches made very little, if any, difference to pain and disability both over the short and long-term.

What does this mean? Well, quite apart from the blurry definitions of self-management, and the lack of standardisation inside self-management programmes, I think we need to ponder on just what we’re asking people to do – and how they (we) regard the strategies we hope people will develop. Cutting to the chase, in chronic pain management we risk people knowing “about” strategies, but failing to adopt them in daily life because we haven’t really thought about daily life and what this is to each individual. When I think about the vast number of changes to self-concept that chronic pain wreaks on people, I think it’s hard to be ready to adopt these new techniques until “who I am” is included in the mix. Maybe one reason for the modest improvements after self-management is that we’re not thinking about self-identity and values and that these need attending to so that using coping strategies is worthwhile. It’s yet another reason I think occupational therapists offer a great deal in chronic pain self-management – who are you? what do you want your life to stand for? what things do you do (or want to do) that makes your life yours? Finally, to paraphrase as my colleague Ben Darlow, living with low back pain (read: any chronic pain) means balancing the need to minimise pain fluctuations with the things that make life worth living. That’s what I call “flexibly persisting”.

Audulv, A., Asplund, K., & Norbergh, K.-G. (2012). The integration of chronic illness self-management. Qualitative Health Research, 22(3), 332-345. doi:http://dx.doi.org/10.1177/1049732311430497

Effing, T. W., Bourbeau, J., Vercoulen, J., Apter, A. J., Coultas, D., Meek, P., . . . van der Palen, J. (2012). Self-management programmes for copd moving forward. Chronic respiratory disease, 9(1), 27-35.

Morden, A., Jinks, C., & Bie Nio, O. (2011). Lay models of self-management: How do people manage knee osteoarthritis in context? Chronic Illness, 7(3), 185-200.

Nicholas, M., Asghari, A., Corbett, M., Smeets, R., Wood, B., Overton, S., . . . Beeston, L. (2012). Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16(1), 93-104. doi:10.1016/j.ejpain.2011.06.005

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.

cold sea

Pain measurement: Measuring an experience is like holding water


Measurement in pain is complicated. Firstly it’s an experience, so inherently subjective – how do we measure “taste”, for example? Or “joy”? Secondly, there’s so much riding on its measurement: how much pain relief a person gets, whether a treatment has been successful, whether a person is thought sick enough to be excused from working, whether a person even gets treatment at all…

And even more than these, given it’s so important and we have to use surrogate ways to measure the unmeasurable, we have the language of assessment. In physiotherapy practice, what the person says is called “subjective” while the measurements the clinician takes are called “objective” – as if, by them being conducted by a clinician and by using instruments, they’re not biased or “not influenced by personal feelings or opinions in considering and representing facts”. Subjective, in this instance, is defined by Merriam Webster as “ relating to the way a person experiences things in his or her own mind. : based on feelings or opinions rather than facts.”  Of course, we know that variability exists between clinicians even when carrying out seemingly “objective” tests of, for example, range of movement, muscle strength, or interpreting radiological images or even conducting a Timed Up and Go test (take a look here at a very good review of this common functional test – click)

In the latest issue of Pain, Professor Stephen Morley reflects on bias and reliability in pain ratings, reminding us that “measurement of psychological variables is an interaction between the individual, the test material, and the context in which the measure is taken” (Morley, 2016). While there are many ways formal testing can be standardised to reduce the amount of bias, it doesn’t completely remove the variability inherent in a measurement situation.

Morley was providing commentary on a study published in the same journal, a study in which participants were given training and prompts each day when they were asked to rate their pain. Actually, three groups were compared: a group without training, a group with training but no prompts, and a group with training and daily prompts (Smith, Amtmann, Askew, Gewandter et al, 2016). The hypothesis was that people given training would provide more consistent pain ratings than those who weren’t. But no, in another twist to the pain story, the results showed that during the first post-training week, participants with training were less reliable than those who simply gave a rating as usual.

Morley considers two possible explanations for this – the first relates to the whole notion of reliability. Reliability is about identifying how much of the variability is due to the test being a bit inaccurate, vs how much variability is due to the variability of the actual thing being measured, assuming that errors or variability are only random. So perhaps one problem is that pain intensity does vary a great deal from day-to-day.  The second reason is related to the way people make judgements about their own pain intensity. Smith and colleagues identify two main biases (bias = systematic errors) – scale anchoring effects (that by giving people a set word or concept to “anchor” their ratings, the tendency to wander off and report pain based only on emotion or setting or memory might be reduced), and that daily variations in context might also influence pain. Smith and colleagues believed that by providing anchors between least and “worst imaginable pain”, they’d be able to guide people to reflect on these same imagined experiences each day, that these imagined experiences would be pretty stable, and that people could compare what they were actually experiencing at the time with these imagined pain intensities.

But, and it’s a big but, how do people scale and remember pain? And as Morley asks, “What aspect of the imagined pain is reimagined and used as an anchor at the point of rating?” He points out that re-experiencing the somatosensory-intensity aspect of pain is rare (though people can remember the context in which they experienced that pain, and they can give a summative evaluative assessment such as “oh it was horrible”). Smith and colleagues’ study attempted to control for contextual effects by asking people to reflect only on intensity and duration, and only on pain intensity rather than other associated experiences such as fatigue or stress. This, it must be said, is pretty darned impossible, and Morley again points out that “peak-end” phenomenon (which means that our estimate of pain intensity depends a great deal on how long we think an experience might go on, disparities between what we expect and what we actually feel, and differences between each of us) will bias self-report.

Smith et al (2016) carefully review and discuss their findings, and I strongly encourage readers to read the entire paper themselves. This is important stuff – even though this was an approach designed to help improve pain intensity measurement within treatment trials, what it tells us is that our understanding of pain intensity measurement needs more work, and that some of our assumptions about measuring our pain experience using a simple numeric rating scale might be challenged. The study used people living with chronic pain, and their experiences may be different from those with acute pain (eg post-surgical pain). The training did appear to help people correctly rank their pain in terms of least pain, average pain, and worst pain daily ratings.

What can we learn from this study? I think it’s a good reminder to us to think about our assumptions about ANY kind of measurement in pain. Including what we observe, what we do when carrying out pain assessments, and the influences we don’t yet know about on pain intensity ratings.

Morley, S. (2016). Bias and reliability in pain ratings. Pain, 157(5), 993-994.

Smith, S. M., Amtmann, D., Askew, R. L., Gewandter, J. S., Hunsinger, M., Jensen, M. P., . . . Dworkin, R. H. (2016). Pain intensity rating training: Results from an exploratory study of the acttion protecct system. Pain, 157(5), 1056-1064.

look what's coming

What should we do about acute low back pain?


There’s no doubt that low back pain presents a major healthcare problem in all parts of the world. It’s probably the most common form of musculoskeletal pain around, it can be highly disabling – and its management is one of the most contentious imaginable. As someone once said “if there was an effective treatment for low back pain, there wouldn’t be such a range of treatments available!”

I want to take a step back and consider people living with nonspecific low back pain only, it’s by far the most prevalent, and while no-one would say there is a single diagnosis that can be applied to all forms of back pain, there seem to be some similarities in how this kind of pain responds.

What we’ve learned over the past year is that acetaminophen hardly touches the pain of nonspecific low back pain Machado, Maher, Ferreira, Pinheiro et al, 2015). This means anti-inflammatory medications (NSAIDs) are the most likely group of medications to be prescribed, or perhaps codeine. Exercise was the recommended treatment for osteoarthritis of the hip and knee, suggesting that this approach might also be recommended for low back pain.

Turning to exercise, it seems that there is no clear indication that any particular type of exercise is any better than any other exercise for low back pain (not even motor control exercise)(Saragiotto, Maher, Yamato Tie, Costa et al, 2016), and all exercise improves pain and disability – and even recurrences (Machado, Bostick & Maher, 2013). What seems important is that people get moving again, and do so quickly after the onset of their back pain.

Graded exposure has also been in the news, latest being a study using graded exposure for elderly people living with chronic low back pain, where it was found to not only improve function (reduce disability) but also found to reduce pain (Leonhardt, Kuss, Becker, Basler et al, in press). OK, pain reduction wasn’t reduced a great deal, but neither have many treatments – and at least this one has few adverse effects and improves disability.

Where am I going with this?

Well, recently I made some apparently radical suggestions: I said that

  1. sub-typing low back pain doesn’t yet seem to be consistent;
  2. that no particular exercise type seems better than anything else;
  3. that ongoing disability is predicted more by psychosocial factors than by physical findings – even when injection treatments are used (van Wijk, Geurts, Lousberg,Wynne, Hammink, et al, 2008).
  4. that people with low back pain seem to get better for a while, and often find their back pain returns or grumbles along without any particular provocation;
  5. and that perhaps treatment should focus LESS on reducing pain (which doesn’t seem to be very effective) and LESS on trying to identify particular types of exercise that will suit particular people and MORE simply on graded return to normal activity.
  6. Along with really good information about what we know about low back pain (which isn’t much in terms of mechanics or anatomy, but quite a lot about what’s harmful and what doesn’t help at all), maybe all we need to do is help people get back to their usual activities.

For my sins I was asked not to remain involved in the group planning health system pathways (I also suggested maybe osteopaths, chiropractors, massage therapists and both occupational therapists and psychologists might also be good to be involved – maybe that was the radical part because I can’t see an awful lot radical about my other suggestions!).

Here’s my suggestion – when one of the most difficult aspects of low back pain management is helping people return to normal activities within their own environment (work, home, leisure), why not call in the experts in this area? I’m talking about YOU, occupational therapists! So far I haven’t been able to find a randomised controlled trial of occupational therapy graded exposure for low back pain. I’m sorry about this – it’s possibly a reflection of the difficulty there is in even suggesting that DOING NOTHING (ie not attempting to change the tissues, just helping people return to normal activity) might be an active form of treatment, and one that could work.

I don’t want to denigrate the wonderful work many clinicians do in the field of low back pain, but I suspect much of what seems to work is “meaning response” – well-meaning clinicians who believe in their treatments, patients who believe in their therapists, treatments that appear plausible within the general zeitgeist of “why we have low back pain”, all leading to a ritual in which people feel helped and begin to do things again.

Many of us have read Ben Darlow’s paper on The Enduring Impact of What Clinicians Say to People with Low Back Pain (Darlow, Dowell, Baxter, Mathieson, Perry & Dean, 2013). We have yet to count the cost of well-meaning clinicians feeding misinformed and unhelpful beliefs (and behaviours) to people with acute low back pain. I think the cost will be extremely high.

I just wonder if we might not be able to cut out much of the palaver about low back pain if we went directly to the “feeling helped and begin to do things again” without the misinformation and cost of the rituals involved. While other clinicians can contribute – the process of doing in the context of daily life is where occupational therapy research, experience and models have focused for the discipline’s history. That’s the professional magic of occupational therapy.

 

Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine, 11(6), 527-534. doi:10.1370/afm.1518

Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S.(in press). Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study. Journal of Geriatric Physical Therapy.

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 (Vol. 350).

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). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012004/abstract doi:10.1002/14651858.CD012004

van Wijk, R. M. A. W., Geurts, J. W. M., Lousberg, R., Wynne, H. J., Hammink, E., Knape, J. T. A., & Groen, G. J. (2008). Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain. Pain Medicine, 9(2), 212-221.

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Live Plan Be


There are times in my work when I feel like I’m banging my head against a brick wall. Even though I’ve been saying most of what I write about on here since forever, it seems to take SUCH a long time for anything much to change! BUT then along comes something totally cool to brush my frustration away, and today I want to talk about Live Plan Be developed by Pain BC in Vancouver, Canada.

A couple of years ago I was given the privilege of being asked to prepare a document analysing the content and approach of self management programmes. I reviewed the Cochrane systematic reviews which all supported a multidisciplinary self management approach as the foundation for chronic pain management. I then turned to the qualitative research to investigate what it’s like to be part of a programme from the participant’s perspective. I found that people attending these programmes enter a journey of self-discovery, that some of the skills don’t seem to make sense at first – but do when the person returns to their own setting. I also found that people living with chronic pain relish the opportunity to feel that their pain is acknowledged, that others on the programmes know what it’s like to live with chronic pain so they don’t have to spend ages trying to explain themselves, and to have the chance to be with others who ‘get it’ means breaking out of the isolation that chronic pain can bring.

I also took a look at the ways these programmes can be delivered. While many programmes are face-to-face, with technology making online programmes increasingly more responsive and flexible, I wanted to see whether there were major differences in the outcomes of each programme. Although it’s difficult to tell because the populations using both approaches are not exactly the same, from what I could find, the outcomes were comparable. This is really exciting because it means more people can get access to approaches that have solid research underpinning them without having to travel to and from, and without the staffing needed for face-to-face programmes.

As a result of my report, I suggested that Pain BC might like to investigate developing a whole new programme for helping people live well with chronic pain, and to make this an online programme with some of the features that the research into online behaviour change programmes has identified as useful. Things like having a discussion forum so participants can connect and share their experiences of the reality of living with chronic pain. Having action prompts so that people don’t just read something – but also get prompted to DO something with that information – and most importantly, have this tied to where the person is currently at in their journey towards making changes to live with their pain. I recommended having some self-assessments so people can track their progress, and a place where they could record the things that worked, and those that didn’t work, so it’s easy to share with other people including health professionals.

I’m SO excited to see how Live Plan Be has come together – and it’s now LIVE!

The team that has put this together has done an amazing job, exceeding my wildest dreams of what the programme might look like. It’s sophisticated, easy to use, has lovely graphics and video recordings of real people doing real things, has SO MUCH information on it – and it’s free! If you have chronic pain, or you work with people living with chronic pain, I would love you to take a look at it, and try it out. Then let me know what you think. Whatever feedback you give, you’ll know that the team will work hard to keep on making it better and more useful, so please let them know.

Meantime, I’m hoping that this will bring some hope to people who have struggled with chronic pain, and would like to learn to live well.

solo

Gone fishin’


Easter break – and I’ve gone fishin’

Back next week with more from Healthskills. Don’t forget that you can subscribe to my blog, you can send comments and ask questions, make topic requests and connect with me via Facebook (Bronnie Lennox Thompson), Twitter (@adiemusfree), Tumblr: Miss Miche’s Mother, and LinkedIn: Bronnie Lennox Thompson. Introduce yourself via my “About” page, and enjoy browsing the many posts I’ve put up over the last 8 years.

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sentinals at dawn

bridge to

Neuroplasticity: Transforming the brain


Neuroplasticity is a concept that’s taken the world by storm over the past years – take a look at this Google graph of the growth in searches for the term!Capture

 

The idea behind using the brain’s ongoing neuroplasticity is that we can influence the connections between neurones by doing and thinking differently. Great idea, and definitely one we can use. There have been many discussions about how much we can influence plasticity – or not (this post refers to education and neuroplasticity, this to an old discussion about Norman Doidge’s book – and some of the points that have been omitted). Whatever the real situation, there’s no doubt that our brains do continue developing, forming and reforming connections between synapses and generally responding to our world and the interactions we have with our world via our bodies.

Pain researchers have been particularly enraptured by the idea that the brain can develop new connections, driven it seems by a greater understanding that our experience of pain is an integration of information from the body, modulated at every step of the way by both ascending and descending influences, right until that information is processed by various parts of our brain and, in combination with past experience, expectations, beliefs, predictions for the future, current goals and priorities and in our sociocultural context, produces what we know as pain. Long, long sentence – but you know what I mean!

So, the reasoning seems to go, if pain is an output of our nociceptive system and produced via all these interactions, then neuroplasticity should mean painful experiences can be reversed using the same principles. And yes! Lo and behold! In some cases this happens – vis all the research produced by Moseley and crew in Adelaide, and promoted by the NOI group, and others.

While Lorimer’s group has produced probably the most consistent body of work in relation to therapy based on neuroplasticity, with NOI promoting many of these approaches, it’s not the only group to do so.  Today I’m taking a look at Michael Moskowitz and Marla Golden’ book Neuroplastic Transformation: Your brain on pain, and the accompanying website.

I’ve been asked to take a look at this by a follower, and it’s been an interesting and fun project to work on.

The book is a spiral bound, colour printed A4 sized book with large print (yay!) and gorgeous illustrations of brain sections and neurones and other beautiful diagrams relevant to understanding the brain. The principles underpinning the book are that if we can understand a bit more about the brain, we can harness the functions so we can train our brain to be a little more settled and out of pain. The three neuroplastic rules are: What is fired is wired; What you don’t use you lose; When you make them you break them; when you break them you make them.  The premise is that it’s possible to reverse the changes that occur when a person is experiencing persistent pain – “treathment that uses the basic principles of neuroplasticity to change the brain pathways back to normal function and anatomy”. The authors discuss using thoughts, images, sensations, memories, soothing emotions, movements and beliefs to modify the experience.

The process of treatment involves four phases: Rescue, Adjustment, Functionality and Transformation, or RAFT. Rescue involves generating hope that pain can be changed by providing information about neuroplasticity, and developing a partnership between clinician and person living with pain. Adjustment involves “stabilising” the pain disorder – using a multi-modal approach including medications, injections, and psychosocial treatments to increase activities while reducing pain – emphasising that adjusting to the pain disorder is not the end goal. Functionality involves the person, every time he or she experiences pain, challenging the experience with non-painful stimuli. In other words, every time the person becomes aware of his or her pain, they need to use thoughts, beliefs, images, sensations, movements and emotions to “reverse the neuroplastic processes that cause persistent pain”. Finally, Transformation involves using the experience of overcoming pain to establish new ways to give pleasure.

What I like about this approach is that it is explained and illustrated very well, using up-to-date information and illustrations. It strongly supports self-management or the person being as much part of the treatment as any clinician. That’s good – because, as any of us who have ever tried to change a habit know very well, change is hard! And that’s probably one of the three main concerns I have about employing this approach as a core pain treatment.

My concerns:

  1. Reversing or altering cortical pathways is truly difficult – and it’s perhaps not possible to completely reverse, especially if the problem has been present for a long time. Here’s why: can anyone remember learning to ride a bike? Remember all that falling off, the wobbling, the stopping and starting, the weaving all over the place? How many hours did it take to learn to do that successfully, smoothly and to the point where you were safe to ride in traffic? Now, for some of you, it will have been YEARS since you jumped on a bike. Do you forget how to ride? No. You might wobble a bit, but you don’t actually forget. Similarly, in phobic states, pathways associated with avoiding the feared stimulus remain “wired together” even when new pathways associated with approaching the stimulus are developed. What this means is that it’s possible for a spider phobic to remain somewhat jumpy around a spider even after treatment has reduced the screaming heebie-jeebies. When we think about pain and the myriad associations between the experience, context, interoception (internal body feeling-sense), memories, emotions, language, treatment visits, investigations – there are so many connections that become wired together as a result of experiencing persistent pain that to completely reverse it is an almighty monumental challenge requiring hours or dedicated practice.
  2. While the principles of a neuroplastic approach are well-known, there are some differences in the approach depicted in this book that I’m not aware of being tested formally in pain research. For example, while it’s nice to have a pleasant smell or memory brought to mind, I’m not aware of studies showing that doing this changes memory for pain (or pain intensity). I may well be wrong about this and I’d love someone even more geeky than me to bring some studies to my attention.
  3. My third reservation relates to the well-established research showing that persistent pain is not easily changed, and meanwhile, in the pursuit of pain reduction, many people lose out on good things in life. While people are sitting in waiting rooms, spending time with therapists, monitoring and checking on pain intensity, it becomes very difficult to carry on with valued actions. There are many ways to make space to have your pain and live as well. This doesn’t mean you need to give up hope of pain reduction, but it does mean the focus moves from this as a life focus and on to the things that make life of any kind worthwhile. Maybe the two approaches can go hand in hand, but to my mind the very intensive nature of the approach within this book means that attention must be shifted away from valued actions and towards doing the things that this book argues will reverse pain.

Overall I like the approach within this book – I like that it’s person-centred, positive, uses underlying principles and encourages the person to be actively involved in his or her treatment. There’s no way you can be a passive recipient with this approach! I would love to see some more in-depth study of the effects of this treatment, even in a series of single-subject experiments. I think it could be very helpful, but I’m a little concerned at the focus on pain reduction as the primary goal, and the time and energy this approach demands.

artisan village

San Diego Pain Summit 2016


I’ve delayed writing about the San Diego Pain Summit to allow my thoughts to settle and to come up with a suitable distillation of the event. Good things take time to brew!

Impressions of San Diego – city of warmth and light, food and water and the sea… A lovely place to visit, and one that I would almost be happy to live in. But the setting was the least attractive aspect of this most excellent gathering of pain peeps. For me, first time attendee, it was like a gathering of the best of friends all in one place with plenty of time to geek out on pain science – and to put faces to names that I’m so familiar with that I feel like we’ve been friends for ever!

First off, hat tip to Rajam Roose who single-handedly organised this event. Without her vision and organisational strengths I would have missed a highlight of my career so far! Rajam was the most personable hostess, making sure I was picked up from the airport, fed and then dropped off at the hotel, taking photos to share on Facebook as I JUST GOT OFF THE PLANE after at 19 hour flight from New Zealand. Seriously, Rajam and her wonderful man (and assorted friends both furry and not) made my arrival welcoming and wonderful.

And this is probably one of the nicest things from the whole San Diego meeting – feeling welcomed, at home, and amongst friends. And this despite my being the only occupational therapist at the meeting! Come on, occupational therapists, you really need to get your collective acts into gear! The Pain Summit is probably the only meeting I’ve been to where everyone, no matter what background, whether body-oriented, brain-oriented, disability or function-oriented – is accepted, encouraged and enriched. Occupational therapists would feel right at home.

And now, to review the meeting itself. Well, to be honest, the meeting WAS about the people. The discussions had between different professionals from differing backgrounds and theoretical orientations, all focused on learning more about pain and how to better help people who experience pain. While the speakers were outstanding, without the community discussions, both on and off-line, I think this meeting would be much like any other. The hallmark is that the people who attend are committed, passionate and really think about the meaning of new research and how they can apply it.

I’ve talked about a community of practice before. A community of practice is a group of people who have developed a commonality in how they tackle their work. Where theory and practice are connected in the most intimate ways. Where each piece of evidence is examined in the light of the question ALL research should be evaluated against: So what? So what does this mean for ME? So what can I use from this? So what does it mean that this – and this – are both true? So what questions do I need to ask myself?

The Pain Summit is a place where choices don’t have to be made. It’s designed so that people can attend every session, rather than having to choose a stream (and miss out on the other stream). And one where ethics hold out over money-making. Rajam doesn’t want to have to take sponsorship if this means the Summit has to compromise on any information presented. It’s designed so that clinicians can meet the presenters and talk. Where presenters engage with one another and with the attendees.

The most profound talks for me personally were Lehman’s take on biomechanics – when it applies, and when it doesn’t. Argued from a biomechanical perspective. And Benedetti’s talk on placebo and the mechanisms that skew randomised controlled trials of new pharmacological and surgical agents (yes, I know placebo is a thing affecting ALL treatments, but much more difficult to study in nonpharmacological approaches). I was saddened to hear that yes, if we persist in using the WHO Analgesic Ladder, we may be inadvertently doing harm because repeated ineffective treatments can establish negative expectancies from ALL treatments – hence my take on identifying the pain mechanisms involved and providing targeted therapy specific to those mechanisms rather than a “multimodal” approach that may not provide much at all. The argument Benedetti made was that medications that don’t work create a learning effect in the recipient, reducing the potential for subsequent treatments to be effective. So if you have fibromyalgia, probably the archetypal “central sensitisation” pain problem, treating it with NSAIDs and codeine and other opiates isn’t likely to do anything wonderful – why not begin with the tricyclic antidepressants and gapabentin/pregabalin first?

I also loved Alison Sim’s work on presenting CBT for pain, clear, precise – and engaging. And yes, anyone can integrate it into daily practice.  The appetite for “psychological” approaches amongst this largely hands-on audience was amazing. Kevin Vowles impressive presentation on the futility of many approaches to “get rid of pain” and the usefulness of values-based action (using ACT) (and his wonderful workshop on ACT) made my day. Between them and Sandy Hilton’s discussion of ways to work with people who have pelvic pain, and I began to feel like this group of clinicians really knows that PEOPLE experience pain, not limbs or body parts. And to help PEOPLE we need to BE people – human connectedness is so important.

There were many other talks, but these were the ones that really stood out for me. I’m now impatiently waiting for the video recordings so I can relive the moments of the Pain Summit and pick up on the many, many details of talks I haven’t mentioned. I haven’t mentioned them not because they weren’t great, but because the ones I’ve listed resonated particularly with me in my own orientation.

Next year – will you be there? I hope so – I’ll be there, and I’m looking forward to being amongst friends again – and keeping that discussion going on Facebook, Twitter, SomaSimple in between.