blossom of snow

Deciding when to say when: pain cure? or pain managed?


I think the subject of this post is the singularly most important yet neglected topic in chronic pain research today. When is it time to say “All this looking at pain cure, or reducing your pain isn’t working, it’s time to accept that pain is going to part of your life.” It’s difficult for so many reasons whether you’re the person experiencing the pain, or the clinician trying to help. It’s also incredibly important for everyone including our community.

Cures for pain that persists are not easily found. One possibility is that the underlying disease or dysfunction has not yet been treated – pain in this case is the experience we have when there’s an unresolved threat to body tissues. Find the source of the problem, treat it, and voila! No pain.

Another possibility is that a new or groovy treatment has been developed – something extraordinary, or something that’s being applied to a different problem or something that’s emerging from the experimental phase to clinical practice.  This means clinicians need to have heard about it, maybe will have had to think hard about their clinical reasoning, have developed skills to apply it, and be ready to talk about it with the person they’re treating.

In the case of much chronic pain, pharmacological approaches simply do not work. Machado and colleagues (2009), in a large meta-analysis of placebo-controlled randomised trials, found 76 eligible trials reporting on 34 treatments. Fifty percent of the treatments had statistically significant effects, but for most the effects were small or moderate … the analgesic effects of many treatments for non-specific low back pain are small”, while Machado, Maher and colleagues found that paracetamol was “ineffective” for reducing pain intensity or improving quality of life for people with low back pain, and although there was a statistically significant result for paracetamol on osteoarthritis pain (hip or knee), this was not clinically important (Machado, Maher, Ferreira, Pinheiro, Lin, et al_2015).  Clifford Woolf said “most existing analgesics for persistent pain are relatively ineffective… the number of patients who are needed to be treated to achieve 50% reduction in neuropathic pain in one patient is more than four – a high cost for the three unsuccessfully treated patients and their physicians” (Woolf, 2010).

Woolf’s sentence ends with an important statement: A high cost for the three unsuccessfully treated patients and their physicians. I have emphasised the final three words, because this might be the most difficult to process. It’s hard for clinicians to say “I can’t reduce your pain”, and “there isn’t a cure”. It’s incredibly hard. And it’s perhaps because it’s so hard that I’ve found very little published research looking at the way clinicians go about telling people their pain is likely to be ongoing. It’s like a taboo – let’s not talk about it, let’s pretend it doesn’t happen, after all it doesn’t happen often.  Really?

Amongst allied health (I can’t bear to use the word “non-medical”), and in particular, physiotherapists, there continues to be a push to address pain intensity and (ultimately) to cure pain.  Innovative treatments such as mirror therapy, graded motor imagery, therapeutic pain neuroscience (we used to call it psycho-education in the 1980’s when I first started working in this area), reducing the threat value of the experience have all come into their own over the past 15 years or so. Even long-standing pain problems apparently respond to these approaches – people cured! Who wouldn’t be keen to try them?

Most of these latter treatments are based on the idea that our neurology is plastic; that is, it can change as we change input and thoughts/beliefs about what’s going on.  Unfortunately, the systematic reviews of trials, and at least one “real world” trial of graded motor imagery haven’t shown effects as great as promised from the early research (eg Johnson, Hall, Barnett, Draper, Derbyshire et al, 2012). There are sure to be people who can point to amazing outcomes in the people they treat. I’m certain that it’s not just the “treatment” but an awful lot to do with the person delivering the treatment – and the treatment context – that might make a difference to outcomes.

But where this all leads me to is who makes the decision to stop chasing pain reduction and pain cure? When does it happen? What’s the process? And what if we treatment providers are actually prolonging disability out of the goodness of our hearts to find a cure?

Let me unpack this a little.

In my research, several important factors led to people deciding to begin flexibly persisting (and getting on with life as it is, not as it was, or might be).

  • The first was knowing the diagnosis and that it would not be completely cured but could be managed.
  • The second, that hurting didn’t mean harm (pain is just pain, not a sign of ongoing damage).
  • The third, that there was something important the person wanted or needed to do to be themselves.

There were other things as well, like having a clinician who would stand by the person even if the person didn’t “do as the Doctor ordered”, and developing their own personalised model or explanation for their pain as it fluctuated from day-to-day. BUT the single most important factor was knowing that the problem needed to be managed because there was no cure. Knowing this meant that energy used chasing a cure was redirected towards learning to live well and be the person they were, rather than a patient or being dominated by pain.

Unfortunately, I think that many clinicians confuse the idea of managing pain with that of resignation to a lesser life. Even the wonderful Lorimer Moseley and crew wrote recently that “CBT literature seemed to focus on this idea of ‘pain is now unavoidable so it is now time to learn how to cope with it.’ He goes on to argue that because a CBT approach focuses on thoughts and beliefs (much like Explain Pain does), it’s not incompatible with the idea that the plastic brain can learn to reduce the threat value even further to ultimately “helping them live well with less pain, or perhaps without any pain at all.”

Here’s my concern: Right now there are many people living with chronic pain who have lost their sense of hope. They’ve pursued pain cure after pain cure, and in doing so, they’ve lost normal routines and habits, lost their usual occupations (activities), stopped being around people, stopped working, and have suffered in the true sense of the word – they’ve lost their sense of self. While I applaud the efforts of researchers like Moseley and colleagues, and I think we must continue to seek treatments to reverse the neurobiological underpinnings of pain, at the same time I think we need to look at the psychological and social aspects of our attitudes and expectations towards experiencing pain. And we must think of the negative effects of our emotional response to seeing another person who is experiencing pain.

Is it so terrible to experience pain every day? Speaking as one who does – despite my knowledge of neuroplasticity – my pain doesn’t represent a threat. It’s just an experience. It’s there. I notice it, I can feel it. And the participants in my research similarly acknowledged pain as present – but it didn’t have the emotional primacy that pain can represent before it is explained. In fact, some of the participants said they’d learned important things because they’d had pain. A lot like having a mood disorder (that must be managed), or diabetes (that must be managed), or heart disease (that must be managed), or respiratory disease (that must be managed), perhaps it’s OK to have pain – that must be managed. Because until our research has advanced a LOT further than it has, there are an awful lot of people living with chronic pain, and who will continue to live with chronic pain. And even more sadly, there are an awful lot of people who don’t even get the opportunity to know that it’s possible to live well despite experiencing chronic pain because we (as part of society) still don’t accept that pain can be present without it being a threat.

Sometimes I wonder at our (clinicians and researchers) blind spot. We just don’t seem to be ready to accept persisting pain as something that can be lived with. Is it time to look at our own discomfort with allowing pain to be part of life?

 

Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. Journal of Pain, 14(1), 3-13.

Cossins, L., Okell, R. W., Cameron, H., Simpson, B., Poole, H. M., & Goebel, A. (2013). Treatment of complex regional pain syndrome in adults: a systematic review of randomized controlled trials published from June 2000 to February 2012. European Journal of Pain, 17(2), 158-173.

Johnson, S., Hall, J., Barnett, S., Draper, M., Derbyshire, G., Haynes, L., . . . Goebel, A. (2012). Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain. European Journal of Pain, 16(4), 550-561.

Machado, LAC, Kamper, SJ, Herbert, RD, Maher, CG, & McAuley, JH. (2009). Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology, 48(5), 520-527.

Machado, Gustavo C, Maher, Chris G, Ferreira, Paulo H, Pinheiro, Marina B, Lin, Chung-Wei Christine, Day, Richard O, . . . Ferreira, Manuela L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials (Vol. 350).

Woolf, Clifford J. (2010). Overcoming obstacles to developing new analgesics. Nature Medical, 16(11), 1241-1247. doi: doi:10.1038/nm.2230

CPU #deepdream

Some people are ready to change and others are not – James Gordon


The full quote is actually:

“It’s not that some people have willpower and some don’t… It’s that some people are ready to change and others are not.”
― James Gordon

Oh how true is that. And any health professional will tell you that there’s just no point pushing for change when the person isn’t ready for it. So often we encounter people who are unhappy with their lot in life, struggling with this and that, and yet they just don’t make changes that seemingly sit right in front of their faces. It’s SO frustrating!

Or, in my case, it used to be so frustrating – because a few years ago I discovered an approach that revolutionised my practice and made me take another look at my expectations and beliefs about motivation. More about that shortly.

This post arose out of the recent publication of a paper by Sarah Hardcastle and colleagues from the Health Psychology and Behavioural Medicine Research Group at Curtin University in Perth. “Motivating the unmotivated: How can health behavior be changed in those unwilling to change?”

This paper outlines several theoretical approaches that have given health professionals some powerful tools to use when working with people who could change but haven’t.  In order to help people in this space, the authors argue that we really need to understand why it is they don’t have “motivation”. So, what is motivation? Simply put, it’s the desire to do things. And for many of us, we think of it as a “thing” that you either have, or you haven’t. But motivation is a tricky thing – ever been disinclined to go visit someone who’s invited you to dinner, dragged yourself there and then had a fantastic time? Or had one of those ideas that flash through your mind, get all excited about it … but never get around to it? Motivation is a fluid thing and doesn’t always equate to action!

Amotivation, or lacking in motivation, is quite specific to a particular action or set of actions. It may be because a person doesn’t think he or she will be successful if they try. Why bother if you know you’re going to fail? This is about having low self-efficacy, or low confidence and thinking it’s not possible to obtain skills or capabilities to be successful.

Amotivation can also occur if a person thinks it’s going to take more out of them than the rewards from doing it. The costs outweigh the benefits. And it can occur when the effort needed to overcome barriers or to push through feels too much, or the change just doesn’t seem worth it because it’s not that big a deal.

Here’s where I come back to my revolution a few years ago – I found that by using motivational interviewing, I was able to shift the responsibility for making a decision to change back to the person (instead of trying to “make it” happen), but at the same time, recognising the reasons for the person staying where they were. To me, it boils down to respecting that people don’t do dumb stuff for fun. There’s usually very good reasons for them having made a decision, either to make a change, or NOT to make a change. What they’re currently doing works, at least to a certain extent.

Using motivational interviewing, the first and most important thing to learn is to respect the person and take the time to understand the good things they recognise about their current situation. Because there are always some good things about being stuck – it’s easier, for one, than making a change. It’s familiar. It’s worked once or twice. People know what to expect. Change always means disruption somewhere, and that’s not comfortable or easy.

If we look at the reasons I outlined for NOT making a change, and work through them, I think (and so do the authors of this paper!) that there are some things we can do to make change less difficult, and in so doing, build momentum for change.

  1. Lack of self-efficacy – if someone doesn’t think he or she will succeed, why would they even begin? Personally I think this is a big part of “lack of motivation for returning to work” which is something I’ve seen written in way too many clinical reports. If someone doesn’t think they’ll be successful, how could we make the change less challenging? Increase support? Make the steps smaller? Look at other things the person has been successful in? Find out how they’ve made changes successfully in the past and use that?
  2. Not valued highly – or, something else is more valued than this right now. Respecting that there is a time and place for things to be done, and that other things in life can over-ride making changes is both authentic and human. It means that this change isn’t yet important enough – so, how do you build importance? To me, importance is about values and what a person wants in his or her life. There are often discrepancies between what we want and what we’re doing, and sometimes this is because it’s too difficult or messy to think about it. I think part of our job as health professionals of any discipline is to help people consider things that are tough. To reflect on the short and long-term outcomes of carrying on in status quo, and the same if we made a successful change. Things we do because they’re more comfortable in the short-term can be incompatible with what we really want long-term. It’s part of my job to help people think about this. NOT, I hasten to add, to “make” them decide in any particular direction. That’s not my job, I’m there to help people think about how their actions today might affect the future, and let them make their own decisions. At the same time, I can choose to reflect the reality of the long-term effects of today’s actions. That’s being responsible as a health professional.
  3. Feeling the end result isn’t worth it, or that there are too many things in the way – again, to me this feels a lot like addressing self-efficacy. If there are things in the way, or it feels too hard, then part of my job is to help the person find a way that is within their capabilities, and to grab a vision of what it might feel like to have successfully achieved that end result. Asking the person to “look forward” to a few months, years down the track – what would it look like if they made a change that worked? How would this affect what’s important to you? If you decided not to make a change, what would things be like? Would that be what you want?
  4. Habits making it hard to think about changing – It’s easy to over-indulge on chocolate when there’s one of those “treat boxes” in the workplace. It’s easy to go home and stay at home rather than go for a run if you don’t have running shoes and a change of clothes in your car. Environmental triggers where it’s easier NOT to do a healthy thing make it difficult for someone who’s just not even thought about making a change. Employers, healthcare facilities and both local and central government can make it harder for people to do unhealthy things simply by structuring when and where people can access them. So the carpark a little further from the workplace can make it easier to get more exercise each day, banning smoking from healthcare facility grounds makes it harder to get a smoke break, having healthy options in the “treat box” can make it easier to choose something healthy. This set of changes can feel a bit “nanny state”, but they’re effective and useful when it’s those simple little changes that make the difference between living well, or not.

Motivating for health behaviour change starts with building confidence and importance. Maintaining behaviour change involves a lot more – but that’s for another post. In the meantime, I think Atoine de Saint-Exupery had it right when he said:

“Quand tu veux construire un bateau, ne commence pas par rassembler du bois, couper des planches et distribuer du travail, mais reveille au sein des hommes le desir de la mer grande et large.

If you want to build a ship, don’t drum up people together to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea.” Antoine de Saint-Exupery

Hardcastle, S.J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C., & Hagger, M.S. (2015). Motivating the unmotivated: How can health behavior be changed in those unwilling to change? Frontiers in Psychology, 6, 835. doi: 10.3389/fpsyg.2015.00835

chilly lake

“Sleep is my drug, my bed is the dealer, and my alarm clock the police.”


Sleep.  The “little death”, the “golden chain that binds health and our bodies together”, “sleep is a hint of lovely oblivion”.

There’s no doubt that having pain and sleeping well just don’t go together – having trouble with sleep is a common problem for people living with pain.  One study reports that over a period of 26 months, 67% of people living with chronic low back pain experienced poor sleep (Axen, 2015). More than this, in the same study one single day of bothersome pain increased the risk of reporting 2 to 7 nights with disturbed sleep by two, and people with chronic low back pain were more likely to report poor sleep than those with acute low back pain.

In another study, (Harrison, Wilson & Munafo, 2015) teenagers from a large cohort study in the UK were surveyed to identify the presence of sleep problems, mood problems and pain problems. 21% of the population reported trouble with sleep, 5.5% reported pain problems, and 2.8% experienced both pain and sleep problems.

And in yet another study, participants with fibromyalgia had significantly shorter and more frequent wake bouts than those with primary insomnia, and the researchers argue that sleep disruption in fibromyalgia does not lead to prolonged periods of wakefulness, but seems to be a disorder of the sleep system whereby internal or external events repeatedly disturb and fragment sleep, and suggest the resulting increased frequency of awakenings may be, at least in part, due to pain, as studies have shown that reducing pain also improves sleep.

These researchers also considered that there is a relatively intact homeostatic drive in participants with fibromyalgia that causes them to quickly return to sleep after an awakening. This is evidenced by shorter initial sleep latency (LPS) and increased slow wave sleep, in addition to shorter duration of wake bouts compared with individuals with primary insomnia (Roth, Brown, Pitman, Roehrs & Resnick, 2015).
People who experience chronic pain can often experience depression, while those who have depression commonly experience sleep disturbance. There are suggestions that common neurobiological pathways exist between all three states.  Atrophy of the hippocampus and increased limbic area activation has been reported across all three conditions, while increased limbic activation occurs in all three conditions as well. Neurochemical changes are also found in all three conditions: HPA-axis hyperactivity has been found, with subsequent alteration to glucocorticoid receptor downregulation, monoaminergic neurons are inhibited as a result of glucocorticoid-induced monoamine depletion, thus reducing inhibitory drive and therefore increasing pain.
Slow wave sleep has been found to inhibit the HPA axis and cortisol secretion, with wakefulness associated with increased cortisol which could lead to increased HPA activation and subsequent elevation of pain (Boakye, Olechowski, Rashiq, Verrier, Kerr, Witmans, Baker, Joyce and Dick, 2015).
Essentially it seems clear that there are neurobiological factors that are implicated in chronic pain, depression and poor sleep.
The importance of this finding shouldn’t be under-estimated. In qualitative studies, participants report that one of the most challenging aspects of dealing with chronic pain is handling fatigue and sleep-related problems (Turk, Dworkin, Revicki, Harding et al, 2008). Pain not only affects sleep quality, but because it intrudes on cognitive processing, there is perceived effort involved in just handling day-to-day situations.
What to do about it…
Well, here’s the thing. Most of the ways GP’s manage sleep problems is through short-term prescriptions of hypnotics such as zopiclone and occasionally benzodiazepines. While there are some useful short-term effects from these drugs, chronic pain is not a short-term problem. Sleep disturbance associated with chronic pain is thus less likely to be helped by simply increasing the length of prescription – these drugs are not intended to be taken long-term. Other medications are used primarily for their pain reducing effects (such as gabapentin and the tricyclic antidepressants), but happily, also possess sedative effects.  These can be taken long-term – but may not work for everyone.
Alternatives include using cognitive behavioural therapy for insomnia. Actually, there are two alternatives – CBTi and sleep restriction, and in some cases, both together.
CBTi is a brief form of cognitive behavioural therapy that has been shown to be highly effective, and focuses on the thoughts and beliefs people hold about sleep, the habits people have associated with sleeping, and associations between habits, thoughts and sleep onset.  Sleep restriction, on the other hand, reduces the amount of time people are actually in bed overall, with the aim to consolidate sleep, and reduce the amount of time spent awake while in bed. Sleep restriction also influences the sleep architecture, so that people can descend into deep sleep more quickly, while reducing the amount of time in REM sleep and lighter levels of sleep.
A final alternative is to use mindfulness to help people become aware of their thoughts and habits about sleep, but instead of challenging or refuting them, learning to attend to them with curiosity and kindness, while at the same time reducing the amount of time awake while in bed.
As a long-time insomniac (now recovered!), I am well familiar with being awake when all else is silent, and on the troubles of trying to get off to sleep while my bed partner snoozes. I also know how hard it is to get back off to sleep after waking in the middle of the night.
Here’s what I did:
  1. Used deep relaxation hypnosis to help establish the association between being relaxed and being in bed. I used this every night for ages, then I realised that I could do the hypnosis “in my head” rather than having someone else’s voice do it for me.
  2. I got out of bed if I hadn’t been to sleep in about 30 minutes. Especially during the middle of the night! Not easy, but worthwhile so I didn’t lie there trying hard not to fidget and wake my partner. I found that if I tried to stay in bed I’d end up being so aware of my fidgeting and so strung out by trying NOT to fidget that I’d be wide awake and stressed. Not the best way to sleep!
  3. Keeping the lights down low, and reading a book I’d already read was the next step once I’d got out of bed. That way I didn’t need to read every word, and it didn’t matter if I snoozed a little.
  4. After about 30 minutes or so, I’d slide back into bed with my mind full of the story rather than being frazzled by not sleeping. And I’d return to my relaxation and breathing and gradually slip off to sleep.
  5. More recently I’ve kicked the mental hypnosis/relaxation habit, and I now go to bed and simply roll over and slow my breathing and fall asleep. Learning to do this without using the hypnosis has been fabulous so I no longer need to worry about being awake at 3.00 in the morning! If I do wake, I head to the toilet, do my business, then slide back into bed and roll over and slow my breathing.

What I’ve learned from this is that the main habit I needed to learn was how to put myself to sleep. I also learned to remind myself that the occasional night with poor sleep is OK, I can handle. And if my sleep really turns to custard I have the skills to manage it myself.

I can’t stop the fact that fibromyalgia means there are some changes to the way my brain processes information, and that this means I’m likely to have poorer sleep than many other people. What I can change is how much I allow that to affect me. And by learning how to go off to sleep by myself, without the external aids, has meant I actually do fall asleep more quickly and don’t feel the effects of disrupted sleep to the same extent as I used to.

 

 

Canada

More than something to blame when the treatment doesn’t work


A friend of mine told me that during her physiotherapy training when they discussed “psychosocial” factors it was usually in the context of explaining why a treatment didn’t work.  This still happens. Even well-informed and scientifically savvy people can unintentionally “blame” those pesky psychosocial factors for getting in the way of complete recovery. What do I mean? Well, let’s think about it: when we’ve done the “explaining” or “educating” – and the person still doesn’t understand and/or their pain doesn’t reduce, what’s our explanation?

We know that pain is an experience, not a separate thing to be treated, but the experience an individual has when his or her brain determines there is a threat to the body (and that threat is more important than other competing goals). We also know there are numerous mechanisms underpinning this experience, many of which are biological. But what we are always left with is the fact that we cannot know anything about this other person’s world except through (1) their behaviour and (2) our interpretation of their behaviour.

I’ve emphasised this because recently I’ve heard one registration board suggesting that a profession should not talk about pain, nor consider psychosocial factors because their domain of influence is bodily tissues.

I’ve also emphasised this because in our efforts to become all sciencey and sound (at least) like we know what we’re talking about, I think we may have forgotten that the only reason we know someone is sore is because they are doing something that we interpret as a signal that they’re sore. And that this occurs within a social setting that has emerged from a combination of historical practices and assumptions, and we are part of that social setting.

The biological substrates for our experience of pain have received the lion’s share of research attention and funds. What has received rather less is understanding some of the social aspects – what individuals learn throughout their life, including the assumptions we develop about what is “normal” and what is not. Unique family and cultural factors influence each individual’s experience – what does this person pay attention to? What does this person ignore? When this person recognises something as “not normal” what is the usual way of dealing with it? Who does this person first see for treatment?

More than this, what about the research looking at treatment provider’s decoding and response to the social communication of the person seeking treatment? We know, for example, that healthcare providers who view video vignettes of people displaying pain behaviour with no medical evidence but with psychosocial factors rate those individuals as experiencing less pain and interference, they have less sympathy, expect medication effectiveness to be less, and those individuals were more likely to be rated as potentially trying to deceive the treatment providers (De Ruddere, Goubert, Stevens, Deveugele, Craig & Crombez, 2014). These responses appear to use both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Observers (ie health professionals) also incorporate automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions. We seem more likely to demonstrate instant ‘‘visceral’’ emotional reactions to unintentional, reflexive expression, while controlled expression characterised by purposive (deliberate) behaviour appears more likely to suggest to health professionals (or observers) that we should think a little about the purpose behind that individual’s pain expression (Craig, Versloot, Goubert, Vervoort & Crombez, 2010). The point is: this occurs even when we know about it, and even if the individual is experiencing pain, and even though the individual is only trying to get the treatment provider’s attention!

Pain behaviour as independent from the individual’s experience of pain is one of the key features of the behavioural model of pain. Pain behaviours were what Fordyce and Loeser and Turk and the very great original thinkers about chronic pain management first thought could and should be dealt with. The reason? Because despite all the surgical and pharmacological treatments available in the late 1960’s, 70’s and 80’s,  many people were still left experiencing pain and were also highly disabled by it. By helping people reduce their pain behaviour (eg stop guarding that body part, start moving more quickly and fluidly, be more relaxed, groan less) they noticed that people were also reporting that their pain bothered them less.

Cognitive behavioural therapy (or a cognitive behavioural approach, to be more accurate) incorporated more “education”, or helping people understand the mechanisms involved in their experience of pain, helping them understand the difference between hurting vs doing damage. A CBT approach meant people were acknowledged as being able to think differently about their pain, reduce their distress and begin to do more. A CBT approach combined education with behavioural experiments and encouraged people to get on with life.

Much more recently we have physiotherapists deciding that giving people pain neurobiology education (sounds almost exactly like the CBT education/explanation to me) is really good and reduces the threat value of the experience. And combined with graded reactivation, exposure to doing things that have been avoided, using methods to reduce distress and by avoiding flare-ups of pain, people are helped.

Two or three important points for me:

  1. Health professionals need to be aware of their own psychosocial responses/background/biases when they observe another person who is indicating they are sore.
  2. If we are two people interacting, all the messy psychosocial factors are immediately present – whether we attend to them, or not.
  3. Given how important those factors are in both our response to another person and their response to treatment (eg placebo, expectancy) it is critical that we integrate effective communication skills into every clinical interaction.

And probably another important point:

In the enthusiasm for pain neurobiology education and the potential for the person to no longer experience pain, we need to remember that reducing disability is arguably more relevant than reducing pain. Despite the impressive results reported by clinicians and some researchers there are many many people who continue to live with chronic pain. As clinicians we may even inadvertently delay recovery if our focus is inappropriately on pain reduction. I say this because there is SUCH clear evidence that pain intensity is less of a factor in ongoing disability than unhelpful beliefs and avoidance (Froud, Patterson, Eldridge, Seale, Pincus, Rajendran et al, 2014; Shaw, Campbell, Nelson, Main & Linton, 2013; Wilkens, Scheel, Grundnes, Hellum & Storheim, 2013).

To conclude, it seems to me that it’s high time for health professionals to take a hard look at what they consider to be “their” domain of concern. Not only must we avoid “blaming” psychosocial factors for poor outcomes from treatments we provide, we also must begin to recognise our own biases as we work with people living with pain. One of these biases is the temptation to believe that we are not influenced by our own psychosocial factors. Another is to recognise that delicate moment when it’s time to take our attention away from reducing pain and towards reducing disability. We need to elevate the status of effective communication – not just “can I make myself understood” and “can I establish rapport”, but that much more nuanced scope of implementing reflective listening, truly hearing our clients, and responding in a way that upholds client choice and self efficacy. I think this belongs to all health professions, not simply those tasked with dealing with “psychosocial” factors.

 

Craig, K.D. (2015). Social communication model of pain. Pain, 156(7), 1198-1199.

Craig, K.D., Versloot, J., Goubert, L., Vervoort, T., & Crombez, G. (2010). Perceiving pain in others: Automatic and controlled mechanisms. The Journal of Pain, 11(2), 101-108. doi: http://dx.doi.org/10.1016/j.jpain.2009.08.008

De Ruddere, L., Goubert, L., Stevens, M.A.L., Deveugele, M., Craig, K.D., & Crombez, G. (2014). Health care professionals’ reactions to patient pain: Impact of knowledge about medical evidence and psychosocial influences. The Journal of Pain, 15(3), 262-270. doi: http://dx.doi.org/10.1016/j.jpain.2013.11.002

Froud, R., Patterson, S., Eldridge, S., Seale, C., Pincus, T., Rajendran, D., . . . Underwood, M. (2014). A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskeletal Disorders, 15, 50.

Shaw, W.S., Campbell, P., Nelson, C.C., Main, C.J., & Linton, S.J. (2013). Effects of workplace, family and cultural influences on low back pain: What opportunities exist to address social factors in general consultations? Best Practice & Research in Clinical Rheumatology, 27(5), 637-648.

Wilkens, P., Scheel, I.B., Grundnes, O., Hellum, C., & Storheim, K. (2013). Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: A cohort study. Spine, 38(1), 65-74.

forest walk

Life seems but a succession of busy nothings – Jane Austin


We hold some very contradictory opinions about being busy. On the one hand, Socrates is reported to have said “Beware the barrenness of a busy life”, and on the other Dale Carnegie is quoted as saying “Inaction breeds doubt and fear. Action breeds confidence and courage. If you want to conquer fear, do not sit home and think about it. Go out and get busy.”

Pacing, one of the cornerstones of “traditional” pain management, is intended to moderate both under-activity (avoidance) and over-activity so that important things can get done without running out of puff – or having an enormous flare-up of pain with subsequent crash into a jellied lump. Yet people who cope well with pain, and ourselves if we’re honest, are often guilty of doing more when we are highly  motivated to do something (or want to achieve a specific goal), and doing less afterwards so we can recuperate.

What is an optimal level of activity for a person living with chronic pain and why might this be important?

I’ll address the second question first. Fatigue is experienced by many people living with chronic pain. Fatigue is a term “used to describe a period of extreme tiredness, as a result of emotional strain, physical exertion, boredom or a general lack of rest and sleep” (Psychology dictionary) People living with chronic pain often develop a sense of fatigue as part of their pain, and some authors believe that not only is it because of disruption to the delta sleep phase (the deepest sleep we achieve), but also because some brain activity continues all the time as the neuromatrix processes potential threat from the painful parts of the body. This activity may result in changes to brain structure, although brain structures may actually cause some of this effect (Baliki, Geha, Apkarian & Chialvo, 2008; Wiech, Ploner & Tracey, 2008). The practical impact of experiencing fatigue is to reduce cognitive efficiency: it takes longer to solve problems, and even boring tasks can feel very difficult.

Some interesting facts: the effect of fatigue on performance differs depending on an individual’s beliefs about fatigue – there is a thing called “fatigue catastrophising” which, like pain catastrophising, means individuals unduly and negatively assess the effect of fatigue on their ability to do things. Being fatigued influences the ability to switch tasks from one task to another, fatigue reduces the ability to ‘change tack’. Interestingly, being bored increases the likelihood of experiencing fatigue. There is an optimal level of stimulation in which we operate. Stress, while initially increasing alertness, over time results in increased fatigue.

So in terms of the importance of identifying and developing an optimal level of activity, it seems that for people living with chronic pain, there might be a need to carefully work out just what level of activity is sufficient to avoid boredom but not so much as to stimulate unhealthy levels of fatigue.

And now, what is an optimal level of activity for a person living with chronic pain?

This question is a much more difficult question to answer, not only because “optimal” will depend a great deal on an individual’s satisfaction with his or her activity level, but also because it’s difficult to measure, definitions about activity level are unclear, and because there are many assumptions about activity levels that have been retained since the early operant conditioning model of pain was proposed by Fordyce. In this model, avoidance develops by reducing activity levels as a way to reduce pain (or prevent it from increasing), while over-activity is thought to occur when activity increases pain resulting in avoidance. Some research suggests that over-activity is an ongoing habit used by individuals who have always tended to be those that work long hours and remain highly engaged in activities they value.

There has been a lot of interest in the notion of over-activity, in part because of the recent interest in “pacing”, but also because people who “over-do” exhibit some features inconsistent with the old avoidance model. For some reason people who over-do engage in activity that will increase their pain – and yet they continue doing so, despite the need to “recover” or do less on the days following their high activity days. Something is overriding the (expected or usual) sense of concern about experiencing pain at the time of their over-activity.

A study by Andrews, Strong and Meredith (in press) looks at activity patterns and particularly over-activity and avoidance patterns and has been able to validate the construct of “over-activity” as a pattern of activity that increases pain – but inconsistent findings relating to avoidance and over-activity. While pain is known to increase, the effect of this on future activity levels is not yet known.

What I wonder is whether these patterns relate to contextual aspects of activity carried out by people living lives. We all know that we push ourselves some days and chill out a little on others. We know that sometimes we’ll do things that will be either fatiguing or actually generate pain (like when you need to move house, dig the garden in spring, do a fun run, have a Christmas dinner at our place), and for most of us this is something we accommodate by being a little less busy for a couple of days afterwards. If we take actigraph recordings over a week or two (Jawbone anyone?), I’m sure it will also show a pattern of high activity and then lower activity, so that over time the activity levels probably flatten out around a mean level of activity. When we do something we value very much, the perceived sense of effort (fatigue) may be lower – we feel energised and enthused although we are tired. When we do something we don’t value (for me it has to be vacuuming!), it feels more tiring and time goes very slowly.

I wonder if people living with pain need additional time to “recover” because of both increased pain, and also the feeling of fatigue. And whether perhaps we need to also study what it is about the tasks being undertaken that is valued rather than simply the task activity level. Busyness may depend on the value of what is being done.

 

Andrews, N.E., Strong, J., & Meredith, P.J. Overactivity in chronic pain: Is it a valid construct? Pain.

Baliki, M.N., Geha, P.Y., Apkarian, A., & Chialvo, D.R. (2008). Beyond feeling: Chronic pain hurts the brain, disrupting the default-mode network dynamics. The Journal of Neuroscience, 28(6), 1398-1403. doi: http://dx.doi.org/10.1523/JNEUROSCI.4123-07.2008

Wiech, K., Ploner, M., & Tracey, I. (2008). Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8), 306-313. doi: doi:10.1016/j.tics.2008.05.005

summer

Those who expect moments of change to be comfortable and free of conflict have not learned their history ~ Joan Wallach Scott


I’ve been touring North America – Chicago, Toronto, Edmonton and Vancouver. As I’ve toured I’ve been listening to the stories of change and insight as different professions review their contributions to effective pain treatment. Some things change, some things stay the same – but as the quote above indicates, change isn’t comfortable nor free of conflict.

What have I found in my travels?

There’s a great deal to be proud of in our approaches to helping people who live with pain. Allied health practitioners of various backgrounds have adopted and adapted to the discoveries about how people experience and deal with their experience of pain. There’s been enormous change in our views of pain as neither a form of mental illness (or malingering, or imagination, or even simply weakness of spirit), nor a lifelong static state. Allied health practitioners of every kind know that they can contribute to helping people make sense of their pain, perhaps change their experience and reduce the distress and disability that living with pain can bring.

Disturbingly, though, I heard the exact same issues as those I face in New Zealand, when it comes to unrest and disquiet about competence, scope, and funding for effective treatments.

Disquiet because some of the different professions lay claim to certain areas of practice as “theirs”. Disquiet because there are attempts to limit access to learning about aspects of pain that are integral to the experience and management of pain. Concerns that some clinicians might be overstepping their scope when they begin to develop skills in, most notably, psychosocial aspects of our experience of pain. And disproportionate funding given to short-term (primarily) biomedical interventions without a consistent or even logical argument for similar funding levels to be applied to allied health approaches. Or worse – funding given to those working in a single-discipline approach, and loss of funding (or funding not even considered for) approaches where teamwork is a critical part of the treatment.

As a somewhat renegade occupational therapist with a MSc in psychology, PhD in health sciences, and great interest in psychosocial aspects of pain, I know that I don’t sit especially comfortably in one little box. And it was SO refreshing to find that I’m not alone in this. As allied health professionals develop knowledge and skills in a biopsychosocial and neurobiologically sophisticated model of pain, it becomes increasingly difficult to distinguish between the practice of good occupational therapists, physiotherapists, massage therapists, psychologists, nurses and social workers when working with people who live with pain.

Our aims are the same: we want to help people live good lives despite experiencing pain. Some of the ways we ALL do this are to help people reconceptualise pain as something that is not fixed but can be influenced by reducing the threat value of the experience within the context of what we view as important.

We ALL draw on learning theories, influencing beliefs and attitudes, consider contingencies and work at reducing the relationship between experiencing something inherently unpleasant and avoiding that experience.

We ALL help people set goals, work hard to achieve them, use movement and activity to help pursue what is valued and deal effectively with what gets in the way of this.

We ALL use motivational approaches, we ALL consider personal values and choices, we ALL want the people we work with to have the freedom to choose personally-valued goals and outcomes.

We ALL draw freely on the published scientific literature across all the branches of pain research – biological, psychological, and to a lesser extent, sociological. (I’d love to see far more emphasis on the social as I’m sure regular readers know!).

It confuses and perplexes me that each one of our professional groups has, at times, criticised other professions for failing to address or consider the aspects of pain experience that our particular group sees as critical. But what really perplexes me is that once another profession begins to take up the challenge of adopting and integrating learning from “outside” their original knowledge base, some people turn right around and begin to criticise that group for “working out of scope”. It does not make sense.

A discussion that I think needs to begin is to consider the merit of a specialist “certification” if you like, for those people who have taken time to learn about pain in-depth, and who no longer fit as comfortably within their original profession as they once did. As I saw so often in my travels, when we get beyond the simplistic level of learning about pain as a biopsychosocial experience we begin to recognise that the way we work with people changes over time to become so much more similar than dissimilar that our professional disciplinary approaches seem to fade away.

I know that in the years since my original training and graduation as an occupational therapist (waaaay back in 1983) I’ve done so much more learning and development that what I do now is so very different from what I did then. I’m still essentially interested in helping people do what is important in their lives. Doing, or occupation, is integral to my practice. The ways I help people achieve this (thus reducing distress and disability) has changed but my “domain of concern” (old-fashioned language for “what I’m interested in”) is still occupation, or the things people want and need to do in daily life.

The obstacles to participating in occupations might be addressed in slightly different ways, but I draw on the same fields of knowledge that I drew on in 1983. Just as I learned then that biomechanical, kinesiological, anatomical, biological, psychological, social, anthropological – and the rest – ways of understanding human behaviour informed the way I work with people, I STILL draw on those same fields of knowledge. The first three fields might have less influence now than I thought they did when I first started working in pain management, but they all contribute.

So here’s the thing: if there is so much our different professions have in common with one another, is it time for allied health professionals to work in a united way to demonstrate just how significant our contribution is to the health and wellbeing of people living with pain? Is it time to trust one another just a little more and stop the infighting as to who is working “in” or “out” of scope? Isn’t it time we looked to the people we work with and for, and focused a little more on sharing our expertise with one another? Shouldn’t we trust that if we’re interested in what works well for the people we want to help, we’ll develop effective knowledge and skills rather than thinking, like Gollum “It’s mine! It’s my preciousssssss!”

I truly thing we can do a much more effective job if we remember that while we let go of some things that we think of as “ours” we might have made just a little room to add some new skills to our own repertoire? And perhaps that change might happen more smoothly if we were more accepting of the need to let go some control and trust a little more.

Te kouka time traveller

When medication side effects get in the way of living life


There are very few people living with chronic pain who gleefully swallow a handful of pills and skip happily off for the day feeling chipper and bright as a button. For the most part, people living with chronic pain don’t seem to enjoy the need to take medications – I’ve heard some say they’re worried about “not being able to tell whether I’m doing damage” when they can’t feel their pain, others say they don’t think medications are very helpful, while still others complain about rattling when they walk. But by far the biggest complaint is the medications for chronic pain have unpleasant side effects – side effects so bad that for some people, it’s just not worth taking the pills at all.

Surprisingly, although there are many studies looking at the side effects of medications, and why they occur, the effect of side effects on doing everyday activities has seldom been examined. Thankfully a group of researchers from Harvard and Johns Hopkins have taken on this task, and we now have some information about just how much side effects can get in the way of life.

What side effects do people experience?

Nausea, dizziness, headaches, constipation, weakness, cognitive fogginess, excessive sleepiness, skin itchiness and rashes, muscle twitching – you get the drift!

Why do they happen?

Many medications for pain, and particularly medications for chronic pain, exert their influence on the central nervous system – where the receptors for neurochemicals important in modulating our experience of pain are found. It would be fabulous if there were some separate receptors that only dealt with “unhelpful” pain that could be targeted, but because pain is an adaptive response designed to protect us – and because in evolutionary terms experiencing pain is crucial to our survival and has been present from early on in our evolutionary development – receptors targeted by many pain medications are found throughout the body. And particularly in the brain – hence the fogginess, sleepiness, and headaches.

What does this mean?

When prescribing medications for chronic pain, clinicians and their patients ultimately go through a process of empirical study. What this means is that because we don’t know which type of medication is most likely to help an individual, each one needs to be tried out. And the trial and error process involves establishing the balance between helpful effects – yes, pain reduction, perhaps some help with sleep – and unhelpful effects – those side effects. The process of deciding which particular combination of medications to take is absolutely personal – only the person with pain can possibly determine whether they find the balance of helpful vs unhelpful effects tolerable.

What about this study?

In this study, Martel, Finan, Dolman and colleagues (2015) sampled a group of 111 people living with chronic musculoskeletal pain. The participants were asked to report once a month, for six months, on their medication use, side effects, and pain and activity levels.  Interestingly, the group selected had to have been prescribed opioids because the larger study of which this one was a small part, was designed to establish ways to improve adherence to medication taking. In addition, this group of people were considered to be at risk of prescription opioid misuse based on an assessment for this problem, but those with a current or past substance abuse problem within the past 12 months. What this means is that while the study has some interesting findings, they will not be representative of all people living with chronic pain, and results need to be interpreted in this light.

OK, OK, I’ll get on with it!

The findings

There were no differences between men and women in terms of pain intensity, mood or pain-related activity interference but women were more likely to describe side effects due to medication. Reports of side effects were no different between those taking opioid medications as well as other pain medications such as antidepressants, anticonvulsants or NSAIDs.

Now for some expected findings: people reporting greater pain-related interference were less likely to be employed, while changes in pain intensity were related to pain-related interference, and similarly, changes in mood were also associated with greater pain related interference.

After some statistical magic (multilevel modeling is horrendously complex!), these researchers examined the unique contribution of medication side effects on pain-related activity interference. What they found was that side effects contributed a unique amount to interference even after controlling for gender, pain intensity and negative mood, and even taking into account individual differences between people.

Now this is important. Medications are prescribed for pain for two reasons: to reduce pain (obviously) and it’s assumed that because pain is then lower, pain-related interference will also be lower. In other words, people will feel less pain and do more things they want to do. What this study suggests is that the burden of side effects from medications can actually ADD to the burden of disability experienced by people living with pain. Now, one way to deal with this is to reduce the number of medications a person takes. That would take care of the side effect burden – but it would also increase the pain. Both distress and disability may then increase. An alternative is to treat the side effects with something else – a bit like taking something to stop constipation when being prescribed opioids. But that in itself can create problems – because, as many people I’ve talked to mention, they really don’t want to rattle like a pill bottle from all the medications they have to swallow.

I think there are two more alternatives. One is to look at the timing of medication taking. I’ve seen many people prescribed gabapentin three times a day – but gabapentin is sedating, and people complain of the effects on driving and on concentrating at work. An alternative, and one that I’ve seen carried out very successfully for years at Burwood Pain Management Centre in Christchurch, NZ, is prescribing the same dose of gabapentin, but taking it once a day at night. A good night’s sleep is had, and the hangover effect during the day is minimised. But this requires a change in how the doctor prescribes – and some confidence to fiddle about with the timing of the dose. It also suggests that the person living with pain, his or her doctor and probably the pharmacist need to work together to develop a plan that maximises the effectiveness of medication administration.

The second is to look at reducing reliance on medication as the primary form of coping strategy for chronic pain. This solution is a vexed one. Many people living with chronic pain are afraid to reduce their use of medication. Many doctors are unaware of alternative ways of coping even though it’s evident that as many as three people in four will not obtain any benefit from medication.  Worse still, many communities have few treatment providers available to help people develop nonpharmacological ways of living well with pain. I think that’s a tragedy and I think it’s time that changed.
Martel MO, Finan PH, Dolman AJ, Subramanian S, Edwards RR, Wasan AD, & Jamison RN (2015). Self-reports of medication side effects and pain-related activity interference in patients with chronic pain: a longitudinal cohort study. Pain, 156 (6), 1092-100 PMID: 25782367

headlands

“Failed back surgery” syndrome – who or what failed?


It’s a term I thought had died a natural death. Failed back surgery syndrome. I used to hear it in the late 1980’s when people with low back pain often had five or six surgeries to try to “fix” whatever wasn’t working in the back. I hadn’t heard it for a while and I really thought it had gone the way it should have – into that great rubbish bin diagnosis pile in the sky, along with “somatisation” and “functional pain” and trigger points. But, to my astonishment, there it is, now a separate MeSH title when you search through Ovid or Medline.

The question I always ask is “Who or what has failed?”

Is it the patient who dares to carry on saying that they have pain, sometimes even more pain than before surgery?

Is it the surgeon for choosing the wrong surgery, or perhaps for doing surgery at all?

Is it the nervous system, already sensitised, now subject to more sensitisation through the planned trauma of the surgical scalpel?

Is it the system for funding surgery?

In a paper written by Shapiro (2015), the rate of “failed back surgery syndrome” is reported as being between 10 – 40%. It seems to increase when the surgery is complex, and it hasn’t improved despite developing less invasive surgical techniques.  Shapiro goes so far as to define FBSS as  “a multidimensional chronic pain syndrome that has significant myofascial and psychosocial components that are directly related to the high incidence of lumbar surgeries in the United States.” Sorry to say, but it’s not just present in the US.

These are the psychosocial risk factors, as identified by Chan and Peng :

  • significant levels of depression,
  • anxiety,
  • poor coping,
  • somatisation
  • hypochondriasis

To be honest, I think these indications would be risk factors for ANY surgery (and probably ANY invasive procedure, including dry needling). But there’s more than this – preoperative risks such as having had prior surgery (spinal instability seems to become worse with repeated revisions); surgery carried out when imaging results suggest there may be good reason, but there is no corresponding clinical correlation; nonsurgical cases of radiculopathy and neuropathy (eg diabetes, viruses, inflammation, vascular disease). And intra-operative risks such as difficult radiographic imaging, inadequate decompression – this paper uses the term “pain generator” for the potential source of nociception, but you and I know that pain only occurs as an output of the brain within a biopsychosocial system; lots of other surgical issues including bleeding, fragments of tissue, “battered root syndrome” (!) where the nerve root is damaged during discectomy; and finally, there are a load of post-operative issues as well – such as haematoma, pseudoarthritis, fibrosis, irritation of the nerve roots, spinal instability, loss of disc height and the list goes on.

Shapiro suggests that some types of ongoing pain after surgery are misdiagnosed myofascial pain, stirring up or producing trigger points. He does add that central sensitisation in the dorsal horn could also play a part, expanding receptive fields in the spinal cord and amplifying “perception” (once again, think of this as amplifying nociceptive input reaching the brain). He also favours the notion of motor control problems following surgery, again compounding the problems that occur with movement after surgery and feeding back into the ongoing pain experienced by the individual.

Shapiro also goes on to suggest various ways the problems could be ameliorated, primarily through careful imaging and then possible surgical management.  The overall management, however, he argues should be pharmacological, “with the goal of increasing physical activity and community involvement”.  Interestingly, Shapiro says “FBSS patients are often pushed aside and told that their surgeons have little to offer them after their surgeries were unsuccessful. These patients are generally managed by community-based physicians, including primary care physicians, anesthesiologists, physiatrists, and neurologists.”  He goes on to say “Treatment of FBSS demands recognition that it is a chronic pain syndrome. One reason that FBSS is a difficult-to-treat syndrome and a public health problem is that the antecedent back pain did not respond to intervention and was often augmented with additional pain complaints caused by the surgery. The psychosocial burden for individuals is huge, especially if there is job loss or loss of function physically. Many of the immediate postoperative pharmacologic strategies complicate the situation further by altering the patient sensorium, mood, affect, and even libido. Opioid-induced hyperalgesia is probably under-recognized and under-reported.”

What does this mean to me?

It must be terribly distressing to be offered a treatment for low back pain and leg pain that is both invasive and expensive – only to find that it hasn’t helped one bit. And even more distressing to then be advised that “there is nothing more I can do, it’s a risk of having surgery”. Worse, then to be advised that the options for managing this pain are quite limited – and for many people, means repeated surgery, perhaps even to the point of having a spinal cord stimulator implanted (with all the known complications of this kind of intervention). Shapiro describes people being offered facet joint radiofrequency neurotomy, but even he acknowledges that “it does not offer a permanent fix to facet-mediated pain, which should raise concern with regard to overutilisation”.

What astonishes me, but probably shouldn’t, is that interdisciplinary pain management approaches continue to be seen as costly, yet there is ample research showing these programmes achieve clinical and cost-effective improvements in patient function.  I’ll let you draw your own conclusions from the following paragraph snipped from Shapiro’s paper:

The cost for this individually tailored 20-day outpatient program, including physical therapy, occupational therapy, and psychological support, is approximately $15,000 (Pain SolutionsNetwork, personal communication, 2013). This is similar to the cost for a single-level laminectomy not requiring a hospital stay and is substantially less costly than the direct costs for lumbar fusion when hospital, hardware, surgeon, and anesthesia costs are added up. [and I’d go even further to add that the 30% risk of a poor outcome is even more expensive…]

I think the health system has failed the people who undergo surgery for low back pain. With a failure rate quoted by Shapiro as approximately 30%, and an increase in epidural injections and facet joint injections of over 250% without any similar improvement in health status, something is going wrong. Very wrong.

Allied health professionals can and do provide cost-effective interdisciplinary pain management for people living with so-called “failed” back surgery syndrome. I think it’s time for allied health professionals to begin agitating, and perhaps even advertising direct to people who have pain – we can help. Our treatments don’t have the risks of invasive procedures. We are focused on helping you DO despite your pain. And what we do can hardly make your pain worse – unlike some of the very sad stories I’ve read.

 

 

Chan C, Peng P. (2011). Failed back surgery syndrome. Pain Medicine 12:577–606.

Shapiro, C.M. (2014). The failed back surgery syndrome: Pitfalls surrounding evaluation and treatment. Physical Medicine & Rehabilitation Clinics of North America, 25(2), 319-340.

Rhodin, A. (2014). A case of severe low back pain after surgery. Journal of Pain & Palliative Care Pharmacotherapy, 28(2), 167-168; discussion 168-169.

tanglewood

Central sensitisation – can a questionnaire help find out who is, and who isn’t?


My orthopaedic colleagues have been asking for a way to identify which surgical candidate is unlikely to have a good outcome after major joint surgery. They know that between 10 – 50% of people undergoing surgery will have chronic pain.  5 – 10% of those people experiencing pain that’s rated >5/10 on a numeric rating scale where 0 = no pain, and 10 = most severe pain you can imagine ( Kehlet, Jensen, & Woolf, 2006). The people with severe pain are the kind of people who hear “well the surgery I did went well…” and can be left wondering why they ever decided to go ahead with their surgery.

Two main factors seem to be important in postsurgical chronic pain: the presence of central sensitisation (usually indicated by reporting chronic pain in at least two other areas of the body) and catastrophising. I’ve discussed catastrophising a great deal here and here .

What I haven’t talked about is central sensitisation. Now, the idea that people can experience chronic pain associated with changes in the way the nervous system responds to stimuli isn’t new, but the neurobiology of it is still slowly being unravelled.  I’m not going to get into definitions or whether having changes in the nervous system equates with “chronic pain” (because pain is an experience and the neurobiology is just the scaffolding that seems present, the two are not equivalent). I want to talk about the measurement of this “sensitisation” and whether a pen and paper tool might be one way of screening people who are at greatest risk of developing problems if they proceed with surgery.

First of all, what symptoms come under this broad heading of “response to an abnormally sensitised nervous system”? Well, Yunus (2007) proposed that because there are similarities between several so-called “medically unexplained symptoms” such as fibromyalgia, chronic fatigue, irritable bowel disorder and so on, perhaps there is a common aetiology for them. Based on evidence that central sensitisation involves enhanced processing of many sensory experiences, Yunus proposed the term “central sensitivity syndrome” – basically a disorder of the nociceptive system. Obviously it’s pretty complicated, but various researchers have proposed that “dysregulation in both ascending and descending central nervous system pathways as a result of physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system, as a result of physical trauma or viral infection… including a dysfunction of the stress system, including the hypothalamic–pituitary–adrenal axis (Mayer, Neblett, Cohen, Howard, Choi et al, 2012, p. 277)”. (what are “pain impulses”?!)

By proposing this mechanism, various researchers have been able to pull together a number of symptoms that people experience, and their premise is that the more symptoms individuals endorse, the more likely it is that they have an underlying central sensitisation disorder.

The authors completed a literature review to identify symptoms and comorbidities associated with fibromyalgia and the other disorders they believe indicate a sensitised central nervous system. they then develop a self-report instrument and asked people with these problems to complete it, and compared their results with a group of people who wouldn’t usually be thought to have any sensitisation problems (students and staff at a University – we could argue this, but let’s not!).

What they found, after much statistical analysis, is a four factor measure:

Factor 1 – Physical Symptoms (30.9%)
Factor 2 – Emotional Distress (7.2%)
Factor 3 – Headache/Jaw Symptoms (10.1%)
Factor 4 – Urological Symptoms (5.2%)

Test-retest reliability was established, and because the questionnaire could discriminate between those who reported widespread pain (aka fibromyalgia) and those who had no pain, it’s thought to have discriminant validity as well. (BTW a copy of this measure is included in the appendix of the Mayer, Neblett, Cohen, Howard, Choi, Williams et al (2012) paper – go get it!)

The researchers then went on to look at some norms for the measure and found that amongst people with chronic pain, referred to an outpatient multidisciplinary pain centre, those with more diagnosed “central sensitisation syndromes” scored more highly on this measure, and that a score of 40 on the measure was able to discriminate between those who didn’t have sensitisation and those who did (Neblett, Cohen, Choi, Hartzell, Williams, Mayer & Gatchel, 2013).

Well and good. What does it actually mean?

This is where I think this measure can come unstuck. I like the idea of people being asked about their pain and associated symptoms. We often don’t have time in a clinical interview to ask about the enormous range of symptoms people experience, so being able to get people to fill out a pen and paper measure to take stock of the different things people know about themselves is a good thing.

What this measure doesn’t yet do is indicate whether there is any underlying common causal link between these experiences. It’s tautological to list the symptoms people might experience with central sensitisation based on the literature, then ask them to indicate which ones they experience and then conclude “oh yes! this means they have central sensitisation!” All it means is that these people report similar symptoms.

What needs to happen, and is now beginning to occur, are studies examining central nervous system processing and the scores individuals obtain on this measure. That, and establishing whether, by completing this questionnaire, it is possible to predict who is more or less likely to develop things like post-surgical chronic pain. Now that would be a really good measure, and very likely to be used by my orthopaedic colleagues.

In the meantime, whatever this measure indicates, it seems to be able to differentiate between people who are more likely to report “medically unexplained symptoms” and people who don’t. This might be useful as we begin to look at targeting treatment to suit different types of persistent pain. At this point in time, though, I think this measure is more useful in research than clinical practice.

 

Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–1625

Mayer, T.G., Neblett, R., Cohen, H., Howard, K.J., Choi, Y.H., Williams, M.J., . . . Gatchel, R.J. (2012). The development and psychometric validation of the central sensitization inventory. Pain Practice, 12(4), 276-285. doi: 10.1111/j.1533-2500.2011.00493.x

Neblett, R., Cohen, H., Choi, Y., Hartzell, M.M., Williams, M., Mayer, T.G., & Gatchel, R.J. (2013). The central sensitization inventory (csi): Establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. The Journal of Pain, 14(5), 438-445. doi: http://dx.doi.org/10.1016/j.jpain.2012.11.012

Roussel, N.A., Nijs, J., Meeus, M., Mylius, V., Fayt, C., & Oostendorp, R. (2013). Central sensitization and altered central pain processing in chronic low back pain: Fact or myth? Clin J Pain, 29, 625-638. doi: 10.1097/AJP.0b013e31826f9a71

Van Oosterwijck, J., Nijs, J., Meeus, M., & Paul, L. (2013). Evidence for central sensitization in chronic whiplash: A systematic literature review. European Journal of Pain, 17(3), 299-312. doi: 10.1002/j.1532-2149.2012.00193.x

Yunus, M.B. (2007). Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis & Rheumatism, 36(6), 339-356.

BFT poster

My North American Tour!! #Bronnie2015


It’s fast coming up – my wonderful North American tour!! Thanks to some amazing friends who have organised the details, I’m going to be in North America from the end of May to mid-June at the following places:

11 June – one day workshop on graded exposure!
13/14 June
What am I doing?
This is a two-day workshop on integrating biopsychosocial factors into clinical assessment, clinical reasoning and treatment planning. It’s about taking pain management from the clinic into the real world. It’s a time to learn more about the practical aspects of integrating these messy concepts – without breaching your scope of practice!
By the end of the two days you’ll have some tools you can use on Monday, gained confidence and had fun.
Come and join me and the fabulous team who have done all the arranging for these workshops!