Theory and really practical clinical reasoning
I’ve been mulling over my delight and joy in theory, and wondering whether this turns people off reading my blog.  So today I thought I’d draw a link between theory and everyday work in pain management.

Theory and models really matter!  They form the organisational framework for the data we collect (ie the things we look for when we assess people), from the models we use, we develop hypotheses, or potential explanations for the way the person presents.

It’s these hypotheses we test when we actually carry out therapy: to confirm our predictions.  If our predictions don’t hold, we’ve probably got the wrong explanation and need to look for another one, if they do hold, we can probably work with the underlying theory or model to develop other hypotheses or interventions to predict.

It’s important then, that we have knowledge of a good number of theories or options to have as alternatives when we start gathering information/assessing a person’s presentation.  If we only know a couple of theories (eg we only know about biomechanical models, or psychodynamic explanations, or even cognitive behavioural models) we’re going to be really limited in terms of looking for appropriate information to notice – and it will be hard to organise information that doesn’t fit with our pre-existing model.

For a really practical application of theory to pain management, we don’t need to look too much further than Fordyce.  I’m quoting directly from Dunn and Elliott’s paper on ‘The Place and Promise of Theory in Rehabilitation Psychology Research’ (Dunn & Elliott, 2008).

‘Fordyce effectively developed ideas derived from operant conditioning and principles of reinforcement (e.g., Fordyce, 1971) to motivate clients undergoing rehabilitation. Fordyce (1976) specifically focused on how individuals with acquired disabilities understood and responded to their environments, the people within them, and the contingencies and secondary gains associated with them. As Fordyce (1971) wrote:

The development of an effective treatment relationship with a client or patient . . . . can be enhanced considerably by the professional’s awareness of his client’s [verbal or nonverbal feelings]. What is suggested here is that a more expeditious way to help the disabled person is to focus in helping him to change his behavior. It is quite possible that feelings will follow rather than lead these behavior changes. (pp. 77)

This landmark work initiated an appreciation for operant principles in the development and reinforcement of disabling behaviors, and for use of operant approaches to facilitate and reward healthier, adaptive behavior (Patterson, 2005)’

We have much to thank Fordyce for in our modern pain management approach – applying theory from operant conditioning to a real-life clinical situation offers us as clinicians new opportunities to help people live well.

Similarly, The idea that people are more than their disabilities comes directly from social psychology, where the relationship between the individual and the society or community is the focus. The concept of disability as a communal problem rather than an individual problem, and that disability can motivate people to develop awareness of previously under-used aspects of their abilities has lead to the strengths-based approach in rehabilitation. Tamara Dembo (1969) is cited in Dunn and Elliott’s paper as identifying the view that ‘outsiders assume a disability is all-encompassing so that insiders must always be preoccupied with their physical or mental states; the idea of living a normal and fulfilling life is rejected by these observers. Preferring to focus on their abilities, however, insiders affirm that disability is independent of identity.’ This view comes directly from social psychology.

Many research questions within rehabilitation are identified in response to a gap in knowledge, often clinically related knowledge. This knowledge gap is ‘the psychological distance between what is known and what knowledge is needed’. Typically in rehabilitation we’re trying to solve a problem. When existing information doesn’t ‘solve the problem’ – it’s time to start searching for more information!

I suppose what I’m trying to say is that most of the time we work in a clinical framework where an individual comes to see us with a problem.

It might be a problem of pain itself, or it might be a problem of the effects of pain in some part of the person’s life. By carrying out a comprehensive assessment of the features of this person’s presentation we allow for lots of information to be available so we can sift through to find features that are stable:

  • this person mostly avoids doing certain movements;
  • this person takes three hours to get off to sleep and can’t stop his mind from racing;
  • this person is 12 years old and everyone runs around helping her because she’s using crutches

By referring to our theory-based (and our theories are developed from and are confirmed by good empirical evidence), we can decide which theory generates hypotheses that best fit the person’s presentation.

For example, one explanation for avoiding certain movements could be that this person believes her fusion means she will inevitably wear away the vertebrae above and below the fusion, and her surgeon told her immediately after surgery to ‘be careful about moving’, and everyone has told her not to slump because it’s ‘bad for your back’.

What are our clinical options?
provide information about degeneration in the vertebrae above and below a fusion site (and no, there isn’t much evidence that these vertebrae do degenerate more quickly than others)
– if she’s fearful because she thinks she might do further damage, and it’s simply about protecting her spine, this information should reduce her fear, and help her feel safer about moving.
– if we add in the suggestion that immediately postsurgery it makes sense to be a little careful, but now it’s 12 months later, so any healing that needs to occur has already, this may also help her revise her beliefs about harm from moving.
– and if we demonstrate that any body position becomes uncomfortable if you haven’t done it for a while, if you’re a bit worried about doing it because people have said it’s not good, and that lots of people do sit in very poor posture without any problem at all, then once again we might help her revise her beliefs, reduce her fear and help her feel more confident about moving.

At the same time we can draw from very robust evidence from anxiety management to suggest that

  • if we start her moving again using activities she’s not too worried about,
  • gradually progress towards more demanding activities;
  • we make an attempt to understand what she is worried about
  • demonstrate that these things don’t happen (using applied experiments),
  • help her develop ways of coping with any increased physiological arousal (based on our knowledge from anxiety disorders) –

once again we have an intervention that is really practical, based on theory.

And you thought theory was only for academics!

Dana S. Dunn, Timothy R. Elliott (2008). The place and promise of theory in rehabilitation psychology research. Rehabilitation Psychology, 53 (3), 254-267 DOI: 10.1037/a0012962

Dembo, T. (1969). Rehabilitation psychology and its immediate future: A
problem of utilization of psychological knowledge. Rehabilitation Psychology,
16, 63–72.

Fordyce, W. E. (1971). Behavioral methods in rehabilitation. In W. S. Neff
(Ed.), Rehabilitation psychology (pp. 74–108). Washington, DC: American
Psychological Association.
Fordyce, W. E. (1976). Behavioral methods in chronic pain and illness. St.
Louis, MO: Mosby.

Patterson, D. R. (2005). Behavioral methods for chronic pain and illness:
A reconsideration and appreciation. Rehabilitation Psychology, 50, 312–

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