On a similar theme from my post ‘Pain management can’t be cloned’, I want to post about the need to tailor therapy to suit the person. Pain management does not follow a recipe – principles yes, protocols … not quite so sure.
What do I mean by this? Well let’s take two people with back pain that is making it difficult for them to work. Both have trouble bending forward, sitting, walking and sleeping. Both are male, mid-30’s, hard workers in manual labouring jobs. Same date of onset, same reported pain intensity. Neither man responding very well to NSAIDs with gastric problems and now taking regular paracetamol but no other medications. ‘Objective’ measures of forward flexion, straight leg raising, lower limb strength are only slightly limited, and neurological testing is normal, and both present with paravertebral spasm, localised tenderness to palpation over L4/5, and localised pain over the central low back. There are no changes on X-ray, and MRI/CT is not indicated.
Robbie is a surfer in his spare time, hasn’t been surfing recently but has been swimming, and until now had back pain intermittently but had never stopped working. He comes from a family where pain has been ‘toughed out’, and he expects that this episode will eventually settle too. He is surprised that his back pain hasn’t settled, but is carrying on with regular walking and intends to return to work as soon as he is able. His main concern is that he finds during exacerbations of his pain, he has trouble settling his body down – his breathing changes, he feels nauseous, giddy, his heart rate rapidly increases, he becomes sweaty and quite distressed. He has difficulty getting off to sleep and his sleep is interrupted. He is typically active when his pain is settled, but then experiences a long period of intense discomfort (boom and bust pattern of activity). He is quite careful with his movements, and in particular takes care not to move into certain positions that he has found have been associated with pain.
Andrew is a motorcyclist and is continuing with recreational motorcycling despite having had what he calls ‘grumbling’ back pain for most of his adult life. His back pain hasn’t really settled completely, and this episode has got him quite worried because it is more intense than ever before. His family are becoming quite irritated with the ongoing saga of his back – and want him to ‘get on with it’. He has stopped walking, going to the gym and doesn’t like swimming. He stays fit by using an exercycle, but doesn’t enjoy it. His main concern is his lack of energy, and his increasing need for sleep. He does have trouble getting off to sleep on occasion, and goes to bed quite early because he is fatigued, but wakes regularly through the night and about an hour earlier than he would really like to. He has even had an occasional afternoon nap. He doesn’t really avoid movements that increase his pain – but has reduced his overall activity level because of his fatigue. He notices that he has gained weight because he is not doing very much.
Sound familiar? Clients like both of these men often attend pain management centres – and often they receive exactly the same treatment. Lots of ‘core stability’, fitness training, daily scheduling, relaxation training and a graded return to work programme. And these probably help in some way… but let’s take a closer look at what might be a more targeted and individualised strategy.
Robbie may have pain-related anxiety and avoidance. He describes increased physiological arousal and has learned that certain movements are best avoided. He’s not deactivated or unfit – his cardiovascular fitness as measured by a 3-minute step test has remained high. Treatment should probably focus on helping him develop skills to manage his physiological arousal (eg biofeedback, relaxation training, cognitive behavioural therapy to help identify automatic thoughts and replace with more helpful thoughts and behaviours), alongside graded exposure to those movements and activities that he finds concerning. Sleep management would focus on strategies to improve sleep hygiene, reduction of unhelpful rumination as he goes off to sleep, and possibly sleep restriction. A graded return to work would have a greater chance of success if he develops strategies to work to quota, and addresses his automatic thoughts and beliefs about needing to get everything done very fast (and very well). He can probably return to work quite quickly once he has overcome his concerns about activities such as lifting and bending.
Andrew on the other hand, has lost fitness and lacks energy to increase his activity level. He is assessed as being depressed and is treated with a combination of both antidepressant medication and cognitive therapy for this. His family need to be brought into his treatment and it would help if he developed ways of communicating with them. He needs to develop a daily activity plan with a schedule for both active and pleasurable activities. Because he normally attends the gym and walks, his programme needs to be developed around this – swimming or hydrotherapy probably won’t be helpful. He may need some help with ‘efficient’ ways for relaxing through the day, but doesn’t have the need for specific methods to reduce physiological arousal that Robbie does. He may need to have a similar programme of sleep hygiene and sleep restriction, but because worry isn’t a problem for him, he may not need to focus on ways to address this before sleep. His ‘pacing’ will need to focus on gradual increases in activity – and increases set by his fitness level. Graded return to work will need to be progressed according to his cardiovascular fitness and fatigue/depression levels rather than avoided activities.
In effect, the two men have quite different treatment programmes despite experiencing very similar functional limitations. This is why it’s so important to assess their presentation very carefully and develop hypotheses about what might be perpetuating their problems. Any ‘protocol’ should ensure that the following principles are followed:
- good assessment
- generation of a number of competing hypotheses about cause and maintenance of the problems
- interventions designed to confirm or disconfirm the hypotheses or based on a confirmed hypothesis
- pre and post as well as follow-up outcome measures
A protocol may be less effective when it specifies the content of each session or the processes used to facilitate learning. People learn at different rates, have different learning styles, varying automatic thoughts and underlying beliefs and attitudes, and live in different environments.
Health professionals have skills in applying concepts to specific situations. This is why people are professionals, not computers or robots.
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