You want a piece of me

Around and around and around we go – or…back to the beginning again


ResearchBlogging.orgIn the early days of non-medical chronic pain management, operant models of behavioural learning were used by Prof W Fordyce.  At the time, this was a revolutionary approach to helping people with chronic pain reduce their disability, distress and depression by altering the reinforcement schedules operating on pain behaviour.  It was such an innovation because it moved the focus from pain intensity to disability associated with pain, and in doing so, it offered hope to the many people who were otherwise thought unlikely to ever “get better”.

Operant models gradually fell out of favour as cognitive behavioural approaches for managing pain became popular over the 1990’s and later.  Refinements to behavioural approaches have been incorporated into ACT (Acceptance and Commitment Therapy) and graded exposure treatments for pain-related anxiety and avoidance – but this hasn’t been extended to operant conditioning.

What exactly is operant conditioning? The simplest way to think of it is to remember “operant” conditioning “operates” on the environment with behaviour maintained by what occurs afterward – so we need to think about rewards, punishments, and positive and negative conditioning.  In other words, the chance I’ll reach for a certain brand of chocolate bar will go UP if I receive some sort of reward for doing so, while the chance of my watching the Rugby World Cup will go DOWN if the people around me groan in unison whenever a game comes on the TV.  But this depends on whether I want the reward offered by the chocolate manufacturer – or I’m bothered by people groaning when I have the TV on!

In a really interesting study by researchers from Eastern Michigan University and University of Washington (Seattle), three hypotheses were tested: fear-avoidance, operant, and pain models, and their ability to predict activity levels.

To recap, the so-called fear-avoidant (pain-related anxiety and avoidance) model involves anticipatory anxiety, or specific fear of movement/reinjury and the resultant avoidance of activity and is usually associated with a classical conditioning process.  A person moves and simultaneously experiences pain or the fear of pain/reinjury, and therefore movement becomes associated with pain.  It doesn’t take long before the person avoids movement because it hurts, and because of the meaning of the hurt.

The operant model involves the person’s behaviour “operating on” the environment (usually involving people’s responses to the behaviour) which serves to increase or reduce the likelihood the person will do that particular behaviour again.  Think of someone coming home with a headache, looking poorly, maybe lying down, and the partner offering comfort – chances are, if the person liked this response, he or she will do the same thing next time a headache comes to visit!

In the pain model, it’s believed that the experience of pain itself dictates the degree of disability an individual has.  So, the person may have a neurobiological vulnerability leading to a greater sensitivity to painful input, and an augmented experience of pain.

In this experiment, 20 patients with chronic low back pain attending a tertiary pain management centre were asked to complete a range of questionnaires, and then were tested with a pressure algometer to determine the pressure at which they experienced pain.  This is thought to help identify the degree of “pain sensitivity” people may have and in this experiment was used to test the pain model.

Then patients were asked to wear an accelerometer to determine their activity level over five days – except when in water (showering, bathing, swimming).

Working some awesome statistical analyses (that, as usual, I won’t go into! Read the paper itself for more details), the researchers found that “the operant model emerged as the only model accounting for a statistically significant amount of the variance in physical activity”.  While the other two models were also relevant, and did contribute to the level of activity people carried out, family and/or spouse responses that were less solicitous, less punishing, and more distracting predicted higher activity levels.

The researchers concluded that“significant others’ responses account for a significant amount of the variance in physical activity, confirming that reinforcement of behavior is a powerful mechanism for behavior change”.  In a sense, this is not news – the response of family and others has always been thought to be important.  What is news is that when the other two models were tested concurrently, the factor that had the most impact on activity level was that of family and partners.

Here’s a question: how often do we

(a) assess the responses of these important people in behavioural terms?  While we might ask about the impact of pain on relationships, I think we need to examine what people do when the person is experiencing pain, and we also need to know how the person demonstrates or displays their pain – what the significant other is responding to, and

(b) specifically address how the person with pain can manage the responses of other people to their pain behaviour? Do we tell the person to communicate effectively about their pain to help them let other people know what they would like them to do when they’re sore?  It can be a very delicate process to negotiate how to ask the partner not to take over the activities the person with pain is beginning to do again! and finally

(c) include the family and partner in our treatments, goal setting and pain “education” so they are more fully informed about what their family member is trying to do, and so they can know what their best options for offering support might be?

It’s almost like deja vu – operant conditioning is coming back in from the cold.  I’d love to know your take on how we can do this within our usual practice. 

Alschuler, K., Hoodin, F., Murphy, S., Rice, J., & Geisser, M. (2011). Factors contributing to physical activity in a chronic low back pain clinical sample: A comprehensive analysis using continuous ambulatory monitoring PAIN DOI: 10.1016/j.pain.2011.07.017

2 comments

  1. First, listen, truly listen, to the heart and soul of what the patient is communicating and pay little attention to the “pain behaviors” as expressed in body language.

    Second, listen, truly listen, to the heart and soul of what the significant other is truly saying.

    Last and hopefully least, listen to the “medical practitioners and models” proposed by those who have not listened and likely have never know first hand the meaning of chronic intractable pain, especially if the practitioners are really injection technicians who stand to profit by quick fix, needle in needle out, on your way interventions.

    Chronic intractable pain is a devastating chronic disease. The patients know that but it is hard to accept when we keep seeking cures that don’t exist. The most we can offer are interventions that will improve function a bit. In that setting operant conditioning can help a sufferer learn the difference between pain that is a damn nuisance and pain that is a legitimate warning of harm. What I have seen over 25 years of practice is that pain sufferers are limited by their pain. If we find a way to relieve some of the pain, the activity increases to the point at which the pain again limits the activity. Patients are most grateful for improved activity and so are family members.; The pain with a higher activity level is far better for sufferer and family than pain with lesser activity.

    Just some off the top thoughts as I read this post….Excellent post and it raises some important issues

    1. Hi Doc, I think pain behaviours communicate just as much, if not more, than words alone. It’s the totality of the person’s experience – including the things they are not aware of – that help me as a clinician really help a person. I agree that simply reducing pain via injection or medication without understanding and helping the person interpret their experience and then gain confidence to DO things again isn’t especially helpful. It reduces the person to a collection of tissues and nerves without recognising that people interact with one another, live in a community, have beliefs and emotions and wants – and that’s not what my pain is all about.
      I don’t think you have to have chronic pain to help people with pain, although I have drawn on my own experience from time to time to remember what it can be like to feel fatigued, disheartened and stuck. Maybe it is more about listening with integrity, an open heart – and a keen intellect.
      thanks for your thoughts!
      cheers
      bronnie

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