Over the past little while I’ve been writing about how a comprehensive pain assessment can be carried out. Today it’s time to pull that information together to develop a formulation, or set of possible explanations for why this person presents in this way at this time – at least for one or two aspects of his presentation.
For example, if the person’s pain is low back pain, where surgery has failed to improve the person’s pain, but he has maintained working in a teaching job where physical demands are reasonably light, but is having trouble with sleep, feels irritable, can’t manage things like mowing lawns, and is very careful not to bend because he was advised after surgery to avoid bending because it may affect healing. Limited forward flexion, side bending, back extension, cardiovascular tolerance moderate on step test, reports fatigue getting worse through course of week. Guarding noted, rubbing back, grimacing, would not complete box lift test from floor, or box to top shelf (no weight in either situation) due to concerns about increased pain and potential harm.
Each of the underlined phrases represents a finding that needs to be put together with the information from questionnaires and clinical examination/observations from the team to form a set of hypotheses that can be tested within therapy to (a) establish whether they hold true and (b) help to ameliorate the pain, distress and/or disability the person is experiencing.
What do you think is going on for the person described above?
Remember that the people I see have chronic pain, most of them have had this for many years, and most of our treatments reduce pain by maybe 30%.
From a biomedical perspective, if it’s established that surgery has been ineffective, one of the most likely diagnoses is ‘chronic low back pain with central sensitisation’. This diagnosis can’t be confirmed with any specific test, but is most likely if the person describes multiple persistent pains, possibly migraine, often highly sensitive to side effects from medication, low mood, irritable bowel and, in women, pelvic pain especially that associated with menstruation.
The main management from a medical perspective is a tricyclic antidepressant, if that’s ineffective something like gabapentin or pregabalin, failing that, and atypical SNRI or similar, and often a combination of these medications. In some people there is a nice response – pain is alleviated, sleep is improved, and the person feels much better. In most people, the response is somewhat more muted, and in some there is no improvement at all. Even the best response is not often more than a 30% reduction in pain. At least in our experience. At this point I’ll remind everyone that I’m not a doctor, this is not medical advice, and this is what is carried out in the center in which I work. For more references on central sensitisation, you can’t go beyond papers by Prof Clifford Woolf, this one is from 2007 and is full text, online.
Unfortunately, having a diagnosis, as you can see, doesn’t really help us with the management of our man’s disability and distress. Even if his pain reduces by our mystical 30%, he still avoids a lot of movements, his sleep pattern is poor, and he believes his back may be damaged if he does movements that bring on his pain.
And even if we’re very good at giving him ‘education’ about his pain – as I’ve said before, quoting Bill Fordyce, ‘Information is to behaviour change as spaghetti is to a brick.’ Information or education alone is often/usually insufficient for someone who is stuck in a pattern of avoidance and disability – after all, a spider phobic in New Zealand knows there are very rarely any poisonous spiders here, but is still fearful! (I know because I was one).
Let’s take a look at one of the psychosocial and functional strengths this man brings to his situation: He’s maintained working as a teacher, despite poor sleep, and lots of functional limitations. We can ask some questions of the information we’ve assembled about how he’s able to do this – what are his values? what routines support his getting out to teach every day? what strategies does he use to maintain standing, walking, sitting – and concentrating, remaining calm despite feeling irritable – as he teaches?
At the same time, we can ask similar questions of his functional limitations: what factors contribute to his difficulty bending? What are his beliefs about bending? What maintains this behaviour – internally (he may get a stab of pain when he bends, or he may anticipate that he will get pain when he bends, or he may get pain that starts after he’s done some bending – hardly an incentive to bend!), and externally (what do people around him say when he bends and grimaces? what do important/powerful people say about bending? eg his surgeon), what muscle groups are working over-time to maintain his guarded posture – and so contribute to his pain and subsequent avoidance?
In the space of a few minutes, I’ve started to put together some areas to flesh out the simple picture we get from just knowing his diagnosis. Now let’s start to draw in what else we know from theory and clinical experience.
Hypothesis one: because this man holds strong values about following through on a commitment, he may be mindful of his pain while teaching, but is able to put this aside in the classroom. Theory base? If I used ACT as a framework, values are ‘chosen qualities of purposive action’, in other words, they’re what lies beneath committed actions. One way this man could be maintaining this action could be because he has developed an awareness that his thoughts are not him. So he can experience pain, but allow this awareness to flow past him as he continues teaching.
We could to test this hypothesis by asking him about his values and his awareness of his thoughts about pain while teaching, and we could see if he uses this same approach in another activity that he also feels is aligned to an important value.
Hypothesis two: he avoids bending because of several things – he believes he may harm himself, this was initially reinforced by advice from his surgeon post-operatively, and later by the images he has in his mind of his vertebrae ‘above and below the fusion taking more of the strain’. Additionally, he experienced pain on several occasions when he inadvertently leaned down to pull his socks on after surgery, and he is fearful of having that pain again because it gave him a fright and reminded him of the pain he had before his surgery. Finally, his partner reminds him to ‘be careful when you’re moving, dear’ because she’s heard him groaning when getting in and out of bed during the night.
To test this set of hypotheses we can provide him with good information about his back, we can remind him that the surgeon was talking about immediate post-operative care, we can show him his X-rays and we can tell him about the studies that show degeneration of vertebrae above and below a fusion is no worse than if his back hadn’t been fused. If his anxiety reduces, and he is more able/ready to approach doing those movements, our hypothesis is confirmed to a degree.
Then we’ll need to use graded exposure to help him work out that bending doesn’t inevitably lead to an increase in pain – and more importantly, even if he does experience an increase in pain, this doesn’t mean he ‘can’t cope’ with it, or that he will end up needing further surgery. We can help him deal effectively with any increase in pain by using breathing, mindfulness, positive coping statements, and ensuring our graded exposure has been developed appropriately.
If, by following this process, he begins to reduce his avoidance and he reports that his anxiety is reduced (and we could even monitor this using biofeedback), our hypothesis is confirmed, again to a certain degree.
The final thing we might do is ensure his partner is involved in the initial explanation and reasoning for these approaches so she is reassured, and help her develop some coping strategies for her own distress at seeing her partner sore – perhaps by helping her say something encouraging like ‘good to see you have a go at that’, or breathing techniques, or a coping statement like ‘he’s learning how to do things again, this is a good part of his recovery.’
If, by his partner responding more positively to his attempts at doing things he has previously avoided, our patient starts to do more while in her presence, again our hypothesis is confirmed and we have done the right thing.
Some references for these types of approach? Your wish is my command.
Vowles, K. E., Wetherell, J. L., & Sorrell, J. T. (2009). Targeting acceptance, mindfulness, and values-based action in chronic pain: Findings of two preliminary trials of an outpatient group-based intervention. Cognitive and Behavioral Practice, 16(1), 49-58.
van Wilgen, C. P., Dijkstra, P. U., Versteegen, G. J., Fleuren, M. J., Stewart, R., van Wijhe, M., et al. (2009). Chronic pain and severe disuse syndrome: long-term outcome of an inpatient multidisciplinary cognitive behavioural programme. Journal of Rehabilitation Medicine, 41(3), 122-128.
Slade, S. C., Molloy, E., & Keating, J. L. (2009). ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23(3), 270-280.
Quartana, P. J., Campbell, C. M., Edwards, R. R., Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics, 9(5), 745-758.
de Jong, J ; Vangronsveld, K ; Peters, M ; Goossens, M ; Onghena, P ; Bulte, I ; Vlaeyen, J. (2008) Reduction of pain-related fear and disability in post-traumatic neck pain: A replicated single-case experimental study of exposure in vivo. The Journal of Pain. Vol.9(12), pp 1123-1134.