Education

What to do with the results from the PCS


The Pain Catastrophising Scale is one of the more popular measures used in pain assessment. It’s popular because catastrophising (thinking the worst) has been identified as an especially important risk factor for slow recovery from pain (Abbott, Tyni-Lenne & Hedlund, 2010), for reporting high levels of pain intensity (Langley, 2011), and for ongoing disability (Elfving, Andersoon & Grooten, 2007). I could have cited hundreds more references to support these claims, BTW.

The problem is, once the PCS is administered and scored: what then? What difference does it make in how we go about helping a person think a little more positively about their pain, do more and feel more confident?

If you haven’t seen my earlier posts about the PCS, take a look at this, this, and this for more details.

Anyway, so someone has high scores on rumination, helplessness and magnifying – what does this mean? Let’s say we have two people attending the clinic, one has really high scores on all three subscales, while the other has low or average scores. Both have grumbly old low back pain, both have had exercises in the past, both are finding it tough to do normal daily activities right now.

For a good, general pain management approach to low back pain, and once red flags are excluded (yes, the “bio” comes first!) this is what I do. I establish what the person thinks is going on and ask if it’s OK to talk about pain neurobiology. Together we’ll generate a pain formulation, which is really a spaghetti diagram showing the experience as described by the person (I used guided discovery to develop it). I then ask the person what they’d be doing if their pain wasn’t such a problem for them, perhaps what they’re finding the most frustrating thing about their situation at the moment. Often it will be sleep, or driving or cooking dinner, or perhaps even getting clothes on (shoes and socks!). I’ll then begin with helping the person develop good relaxed breathing (for using with painful movements), and start by encouraging movement into the painful zone while remaining relaxed, and tie this in with one of the common activities (occupations) the person needs or wants to do. For example, I’ll encourage bending forward to put shoes and socks on while breathing in a relaxed and calm way. I’ll be watching and also encourage relaxing the shoulders and any other tense parts of the body. For someone who is just generally sore but doesn’t report high pain catastrophising, I will also encourage some daily movements doing something they enjoy – it might be walking, yoga, dancing, gardening, whatever they enjoy and will do regularly every day for whatever they can manage. Sometimes people need to start small so 5 minutes might be enough. I suggest being consistent, doing some relaxation afterwards, and building up only once the person has maintained four or five days of consistent activity. And doing the activity the person has been finding difficult.

If the person I’m seeing has high scores on the PCS I’ll begin in a similar way, but I’ll teach a couple of additional things, and I’ll expect to set a much lower target – and probably provide far more support. Catastrophising is often associated with having trouble disengaging from thinking about pain (ruminating), so I’ll teach the person some ways to deal with persistent thoughts that hang around.

A couple to try: mindfulness, although this practice requires practice! It’s not intended to help the person become relaxed! It’s intended to help them discipline their mind to attend to one thing without judgement and to notice and be gentle with the mind when it gets off track, which it will. I ask people to practice this at least four times a day, or whenever they’re waiting for something – like the jug to boil, or while cleaning teeth, or perhaps waiting for a traffic light.

Another is to use a “15 minutes of worry” practice. I ask the person to set a time in the evening to sit down and worry, usually from 7.00 – 7.15pm. Throughout the day I ask the person to notice when they’re ruminating on their situation. I ask them to remind themselves that they’re going to worry about that tonight and deliberately put that worry aside until their appointment with worry. Then, at 7.00pm they are asked to get a piece of paper and write ALL their worries down for a solid 15 minutes. No stopping until 15 minutes is over! It’s really hard. Then when they go to sleep, I ask them to remind themselves that they’ve now worried all their worries, and they can gently set those thoughts aside because they won’t forget their worry, it’s written down (I think worry is one way a mind tries hard to stop you from forgetting to DO something about the worry!). People can throw the paper away in the morning because then it begins all over again.

Usually people who score high on the PCS also find it hard to be realistic about their pain, they’ll use words that are really emotive and often fail to notice parts of the body that aren’t in pain. By noticing the worst, they find it tough to notice the best.  I like to guide people to notice the unloved parts of their body, the bits that don’t hurt – like the earlobes, or the belly button. I’ll offer guidance as to what to notice while we’re doing things, in particular, I like to guide people to notice those parts of the body that are moving smoothly, comfortably and that look relaxed. This is intended to support selective attention to good things – rather than only noticing pain.

Finally, I give more support to those who tend to be more worried about their pain than others. So I might set the goals a little lower – walking for five times a week, two days off for good behaviour rather than every day. Walking for five minutes rather than ten. And I’ll check in with them more often – by text, email or setting appointments closer together. It’s important for people who fear the worst to experience some success, so setting small goals that are achieved can build self efficacy – especially when I try hard to offer encouragement in terms of what the person has done despite the odds. So, if the person says they’ve had a real flare-up, I’ll try to boost confidence by acknowledging that they’ve come in to see me even though it’s a bad pain day, that they’ve tried to do something instead of nothing, that talking to me about the challenge shows guts and determination.

People who see the glass as half empty rather than half full are just people. Like you and I, they’re people who have a cognitive bias. With support, we can help people view their pain differently – and that process applies to all of us, not just those with high scores on the PCS.

 

Abbott, A. D., Tyni-Lenne, R., & Hedlund, R. (2010). The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy, 96(3), 213-221. doi:10.1016/j.physio.2009.11.013

Elfving, B., Andersson, T., & Grooten, W. J. (2007). Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing. Physiotherapy Research International, 12(1), 14-24.

Langley, P. C. (2011). The prevalence, correlates and treatment of pain in the european union. Curr Med Res Opin, 27(2), 463-480. doi:10.1185/03007995.2010.542136

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!

Book review: 2nd Edition of Pain: A textbook for health professionals


I’m an educator, and always on the lookout for a good textbook that summarises and presents up-to-date material in a format that’s easy to read and yet comprehensive. The first edition of this book was a great one and I’ve been hoping a new edition would come out – well, the wait was worth it!

Pain: A textbook for health professionals is edited by Hubert van Griensven, Jenny Strong and Anita M Unruh, published by Churchill Livingstone (Elsevier), and released in November 2013. It’s a whole lot of new material wrapped up in a shiny new cover, over 400 pages of fully-referenced patient-centred pain geekery.

What makes this book different from many is the focus on functional outcomes for people with pain, and on the patient’s voice. The book opens with a chapter on “what is pain” from the perspectives of the person, the interprofessional team, the physician, nurse, psychologist, physiotherapist and occupational therapist – and other providers. The “textbook” nature of the book means there are reflective exercises scattered throughout in which you are invited to reflect on your experiences and perspectives, also clear objectives for each chapter, and study questions at the end of many chapters. This is great, because it can be so easy to read with the head and not with the heart.

What’s in the book?

It opens with “what is pain”, the patient’s voice and social determinants of pain as the first three chapters. This is again unusual, because most texts open with neurobiology or models of pain, sometimes forgetting that it is people who experience pain, while neurobiology only transmits information.  It also reminds us that for us to know anything about what it is like to have pain, both the person with pain and the onlooker need to communicate – to encode, transmit and decode behavioural components to convey the pain experience to one another. And here is where so many problems begin! Because if either party fails to recognise the signals, communication is faulty and we have assumptions and opportunities for misinterpretation that can then lead to increased distress and disability.

The first section of the book then covers the psychology of pain, models of pain, neuroanatomy, and neurophysiology of pain. What I like about these chapters is their clarity and the level of detail which is not overwhelming but remains accurate (to the extent we can be!), and is well-illustrated for those of us who like pictures for learning.  The level at which it’s written is for those with a reasonable familiarity with anatomy and physiology, but it’s not dumbed down, and quickly gets into the level of detail needed to understand many of the latest publications in the area.

The second section relates to assessment and management, and its in this section (which has 10 chapters) that this book really shines. It incorporates biomedical, psychological, functional and complementary modalities, including manual therapy and workplace rehabilitation. Not something you’ll often see in a textbook on pain! I particularly enjoyed the chapter on neuropathic pain and complex regional pain syndrome, and it’s great to see discussion of newer modalities like mirror therapy, laterality training and graded motor imagery.

The third section is called “special issues” and has chapters on pain education for health professionals, pain in childhood and older adults, cancer pain and spinal pain, and then turns to some rather neglected issues: rehabilitation and ICF, life role participation, the law, psychiatric problems, and acute pain.  These are remarkable because they consider the impact of having pain on the individual’s identity and life even if the pain subsides. The focus of management is not simply on pain reduction, but on how an individual becomes well again.

What I like about this book:

It’s comprehensive, written by experts in the field, clearly written, and considers the person with pain and the effect pain has on identity and engaging in occupation. The index and referencing is great, nice clear illustrations, lots of aids to learning including the reflections and end of chapter study questions. The price is reasonable and I could see this book being used as a textbook in pain courses (I may even adopt it for my students!).

What I like less about this book:

For a textbook, the cover (I have a soft cover) is a bit light, and I am worried about the spine breaking down if it’s used the way I use textbooks – opened out, copied so I can highlight pages, pages marked with post-it notes, and used in a busy office space where someone else could “borrow” it! It’s definitely covetable, and that’s always a problem for me (I never remember to get them back!).

The price in New Zealand was about $85.00. I think that’s pretty good given the cost of many other textbooks. This book would sit well on anyone’s shelf, but especially for people wanting a good overview of pain and pain management, and anyone entering pain management practice.

Overall:

A very useable, readable textbook on pain for clinicians who want a thorough introduction to pain management, or to refresh and update knowledge without wading through all the journals.

And for people who would like a patient-oriented book: I’ve reviewed Dr Steven Richeimer’s book Confronting chronic pain in my Healthskills4Pain blog

Not just neural plasticity – health system plasticity


ResearchBlogging.orgIn chronic pain management there seems to be a pretty consistent pathway for people to finally get to interdisciplinary treatment.  First a referral from the primary care physician or GP to one or more specialist medical people – maybe an orthopaedic surgeon, or a rheumatologist, or a psychiatrist, or a neurologist.  This person will carry out investigations, get the results, make a determination that the problem is “not theirs” – and suggest some kind of management, or a referral to another kind of orthopaedic surgeon, or a rheumatologist, or a psychiatrist, or a neurologist… who will repeat the same.

Finally, after many investigations and referrals and consultations, around 3 years later, the person makes it to a chronic pain management centre.  (btw I am using those specialties as indicative only – could be other types of specialties too).

Once the person makes it to a pain management centre, there again is a kind of process that typically involves a medical assessment and possibly some intervention (injections, medications), and often a psychosocial and functional assessment.

Finally … the person begins self management. If they’re willing and not searching for another option or “cure”. (Remember, patients have been well-trained by this stage to hope there is something else out there to fix their problem completely.)

Now what if our health system became as plastic as our neurobiological system? What if, as evidence mounts, the pathways to management of chronic pain could change?  What if people with pain were given information so they could be informed about chronic pain – and then choose their own “next best step”?

In our own small way, a colleague and I developed a different pathway for people referred to our Centre.  We, like so many tertiary pain management centres, have a waiting list.  Some people can’t be seen within the Government-determined timeframe of six months and are sent back to their GP.  We decided to identify those people and invite them to participate in a new form of programme.  Here’s what we did:

  • Sent an invitation to attend a chronic pain seminar
  • We made it clear there would be no medical management and no individual treatment
  • At the seminar, we had a talk by one of our pain physician’s who pointed out the limited options available from a medical point of view, and outlined that chronic pain is a disorder of the nervous system, that there are different kinds of chronic pain, and that hurting doesn’t mean there is ongoing damage.
  • We then invited participants to consider attending a six week, two hours a week, group programme
  • The programme included all the usual pain management information and strategies but was delivered in a mini-lecture format, with a workbook that included home learning activities each week.
  • The programme was conducted by two occupational therapists and one physiotherapist, with the doctors involvement only at the seminar.

The numbers attending this pilot approach were quite low – a combination of winter, earthquakes, and the usual problems people with chronic pain have with transport, readiness to change, and self regulation.  It is, however, a different way of thinking about delivering pain management, and could be one way to help people access self management for their pain.  Because otherwise? They could very well continue the cycle of referral to one or more specialist medical people, more investigations, more inconclusive results, more decisions that the problem is “not theirs” – and more referrals… All the while that person and the person’s family are living in limbo.

It’s a little radical – changing the way we deliver health to side-step the wait to access self management. But what we tried to do is not the first, nor the only way to do this.

Davies, Quintner and colleagues (2011), in Western Australia, have published this study examining the effects of a brief, group-based self management programme, delivered to people before they see a specialist, with any ongoing consultation initiated by the patient. Wow! Now that’s different.

Their programme was only slightly different to ours: six-session program run over 2 days led by clinical psychologists, an occupational therapist, a physical therapist, and pain medicine physicians to impart their knowledge and to share skills.

Their aims were: (i) a reduced demand for individual new case outpatient appointments; (ii) reduced clinic waiting times; (iii) increased efficiency of clinic utilization with reduced unit costs; and (iv) improved patient outcomes and satisfaction.

Is this what they achieved? In their own words: preclinic group education for patients with persistent pain attending our Pain Medicine Unit reduced the overall unit cost per new patient and decreased the new to follow-up ratio of  attendances, reflecting the increased number of new patients appointed and reduced need for follow-up appointments. This resulted in significantly reduced waiting times for new patients to access the pain units while increasing the total number of individual patients seen.

Working in a large, tertiary pain management service within a large health service organisation can mean change is S L O W! Organisations just don’t change that fast, health delivery culture is conservative at best and stagnant at worst, and there still is a focus on a biomedical model in many centres.  This can get in the way of responding quickly to emerging needs, or thinking about different ways to conduct business.  Innovation is not always supported.

While our small project was too small to indicate whether it would be helpful or not, this one in Western Australia supports our approach.  And, for what it’s worth, I’m not sure that the specific clinicians delivering it, or the timeframe it was delivered in, are particularly significant.  It’s the concept of offering self management before medical management, and patient-initiated appointments for any further input.  Now that’s responding to need – a health system with plasticity!
Davies S, Quintner J, Parsons R, Parkitny L, Knight P, Forrester E, Roberts M, Graham C, Visser E, Antill T, Packer T, & Schug SA (2011). Preclinic group education sessions reduce waiting times and costs at public pain medicine units. Pain medicine (Malden, Mass.), 12 (1), 59-71 PMID: 21087401

Information is to behaviour change as spaghetti is to a brick


ResearchBlogging.org
I’m a great fan of books like ‘Explain Pain’.
This delightful publication by David Butler and Lorimer Moseley gives accurate information about pain, particularly chronic pain, in an accessible format for both patients and clinicians, and I’ve used it often with people I’m seeing. I’m also a fan of helping people to understand what we do (and don’t) know about pain to give them more awareness of their ability to influence their own body.

But as anyone who has worked in chronic pain management knows, telling someone something doesn’t always make an enormous difference – and here’s a case in point.  Before I go on, any cases I refer to on this blog are a compilation of several people and details are altered to protect confidentiality.

Yesterday I met with a person who has had chronic back pain for about four years.  She has had a discectomy for what the notes stated was a ‘large disc prolapse compressing the nerve root with neurological signs’, so a good candidate for this procedure.  The operation was a success four years ago – but, as is common in spinal surgery, she was left with persistent low back pain.  Her surgeon told her to ‘be careful of heavy lifting, twisting and bending’ and she had taken this to mean she shouldn’t do things like carry a full washing basket of clothes to the clothesline, do the vacuum cleaning (I can understand this decision!), load the back of her car up with groceries, mow lawns, or even play golf. Ooops, I’m not sure the surgeon meant ALL of these things, but you never know.

We met with one of the doctors I work with to review her clinical chart and to talk about her back pain because she was very wary of doing any of these movements even under clinical supervision.  The problem being that her surgeon, four years ago, had said she ‘shouldn’t’.

I want to add at this point that she was seeing us because of another, unrelated pain problem that was responding well to input although the pain from this other problem was not resolving.  The other pain problem was in her knee, and it had stopped her from walking comfortably and had also lead to her stopping work.  I also want to add that the doctor she was seeing with me is one of the best physicians I know for explaining medical investigations and treatment in a way that patients understand.

The consultation took about 45 minutes – so definitely not a quick’n’dirty consultation.  Together we reviewed all the clinical information including medical notes from the surgery.  We looked at a model of the spine and my patient was shown exactly what the surgical procedure was – she had no idea of what had actually been done to her vertebra or disc, and had visions of large chunks of bone being removed leaving a weak and vulnerable vertebra and disc that had lost most of its height.

We talked about the risk factors associated with having had one disc prolapse – that the risk of having other prolapses, and particularly another one in that disc, were somewhat higher than before her first disc prolapse.  We talked about the relationship between disc changes and pain (which is not entirely straightforward).  We discussed the signs and symptoms of a return of her original problem, and that her current back pain was quite different from the original leg pain.

And you know what?

Even though we followed best practice and used the kind of information that Lorimer Moseley describes in the paper I’ve linked this post to, and this woman has had this information given to her in several different ways by different clinicians in the Centre I work in, she is not convinced.  To her, having pain in her back inevitably means her surgeon was quite correct to tell her to avoid bending, twisting and lifting, and that unless she is very careful she risks needing the much more significant surgery of a spinal fusion.

The power of a surgeon who, with a few words, has helped this woman become trapped into no longer doing what she used to love.

What’s worse – her GP has said that she should ‘think of doing another job because it’s clear this one isn’t going to be good for your back’ – she’s a taxi driver.  So after the whole of her adult working life in the driving industry, at 52 she believes she needs to think of doing another job – even though she and her husband drive off in their motorhome every weekend, and she loved being a cabbie.

What to do, what to do.  Information alone in these cases doesn’t help this person feel confident enough to contradict the explicit instructions of her surgeon, nor the advice of her GP, nor her behaviour over the past four years.

It was Bill Fordyce who apparently coined the phrase ‘Information is to behaviour change as spaghetti is to a brick’.  While sometimes simply helping people to understand more about their body and what pain is and is not, can be enough for people to take their own steps towards changing their behaviour, for many others – and particularly people who are anxious about their health – it takes more.  That’s because knowing in the ‘I can tell you about it’ way is not the same as knowing in the ‘I really understand it’ way.

At heart, I’m a behaviourist I think.  While I know the value of working with thoughts and beliefs, and I thoroughly enjoy this part of my work, it makes very little difference to someone’s life if, after all our work together, they carry on doing what they’ve always been doing.  That’s one definition of insanity – doing the same thing again and again and hoping for a different result.  Something needs to change.

For me, with this person, I hope to start working using an exposure-based treatment.  Graded exposure, by identifying the movements she’s currently not happy to do, developing a hierarchy of avoided movements, and starting to help her recognise that the relationship between what she thinks is going to happen and what actually does happen is not the same, is one strategy that can help.  Underneath her almost religious adherence to this one surgeon’s advice is a potent fear that (a) she is going to do harm and (b) that she won’t cope with the changes in her pain if she disobeys his instructions.

Trying to convince her or to give her more information – even the very best information along the lines of Lorimer’s paper – isn’t, on its own, going to change her willingness to put her body on the line.  Successfully encountering movements and doing them without the scary consequences is probably the only way to help her gain confidence that she can manage it – and return to her normal work.

A pox on people who work with people who have pain and haven’t yet got up to speed with modern scientific knowledge about pain mechanisms.  And a bouquet to people like Bill Fordyce and Lorimer Moseley and David Butler and Nick Kendall who have, over the years, contributed so much to scientific and clinical knowledge about the biopsychosocial nature of pain and pain management.

Moseley, G. (2007). Reconceptualising pain according to modern pain science Physical Therapy Reviews, 12 (3), 169-178 DOI: 10.1179/108331907X223010

Health literacy: if you can’t read it, you don’t get it


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For a long time I’ve been a fan of ‘plainspeak’ or eliminating gobbledegook.  I know my writing is often quite complex, but I try to write as if I’m talking directly to someone – and yes, I do use all those complicated words in real life!

But after working in pain management for a while certain themes keep coming up, and one of them is the large number of people who don’t read and write well.  I value the concept of multiple intelligences, and some people are simply ‘practical’ and hands-on, and don’t like books much – but to actually not be able to read and write well enough to understand common labels and warnings and instructions, that is an incredible handicap.

I have just been reading a paper by Don Nutbeam called ‘The evolving concept of health literacy’ in which he discusses the concept of poor health literacy as a risk factor for poor health status, and conversely, the idea that by improving health literacy it can become an asset to enable people to take control over their health and the factors that shape their health.

Poor health literacy is associated with lower socioeconomic status, reduced use of health resources and information, poorer adherence to treatments and higher drop-out rates.  It’s easy to see why both direct and indirect effects of not being able to make sense of written information might have an effect on health.

Nutbeam’s paper makes the point that decisions about health are made in a context, part of which is the ability of the individual to make their way through the health care system.  This system inevitably involves negotiating paperwork, being aware of pre-requisites for care, being able to clearly state what is needed – and to the right person. More than that, it’s being able to retain the complex information that a health care decision is based on, and maintain that working knowledge to understand why certain actions need to be taken at certain times.  It’s clearly not just about an individual being able to read – its about an interaction between health care systems and individuals, and it includes, according to Nutbeam, three critical points at which literacy directly influences health – access (who do I see? where do I go?), the interaction between the person and the provider (how does the provider ensure the person understands and retains the information?) and self-care (how does the person continue to take best care without directly drawing on the ‘system’).

The alternative view of health literacy as an asset suggests that by improving literacy, it becomes integral to empowering the person to carry out self care – and to receive appropriately tailored information so they can engage in activities that increase wellbeing.

That’s a big ask for a health care system that often does view health as ‘the absense of disease’.

What can you and I do?  Check with our patients whether they can read the information we provide – write simply in bullet point, avoid jargon, make sure patients have time to absorb information before making a decision, and in the end – listening, listening, listening.

D NUTBEAM (2008). The evolving concept of health literacy☆ Social Science & Medicine DOI: 10.1016/j.socscimed.2008.09.050

Explaining pain to people with chronic pain


One of the most challenging jobs we do in chronic pain management is help people get their heads around what chronic pain is…without giving them the idea that we think they’re imagining it, they’re mentally unwell, they’re ‘pretending’, ‘malingering’ or otherwise ‘not coping’.

While I can’t say I’ve got the answer, after explaining what pain is for a few years (not telling how many!), there are some things I find work better than others…

The first thing is to have a bunch of examples of everyday pain (mainly acute pain) to act as examples – mine include getting a flu jab, sunburn, a stubbed toe, sports bruises, and shark bites!  This helps people understand that pain is a normal, everyday experience that is understable.  Challenging, but understandable!

I use two different models of pain to help give people a bit of an understanding of their pain.  The first is a biopsychosocial model – so I have three circles, and while I’m talking with the person and getting them to tell me what their pain is like and how it’s affecting them.  The three circles are the ‘bio’ or biophysical factors, ‘psycho’ or psychological factors, and ‘social’ which includes social and cultural factors.

I find that working from what people already agree about (ie what they identify for themselves) and working with that to develop an explanation using a framework, like the one above, avoids saying which comes first (the pain or the irritability), and helps people acknowledge that each part influences the other.

Another option is to use Loeser’s ‘onion rings’ model.  This is a model that helps place the pain experience in context – it helps put the biophysical factors in the centre (whether as initiator or maintainer of the pain), while ensuring that the other aspects of pain such as the behaviour and context are also in place.

At the centre of the ‘onion’ is nociception – today we might instead think about neuromatrix dysfunction – which initiates and probably maintains the biophysical aspects of the pain experience.  But without the next few components, the pain experience does not actually exist.  We need to attend to or judge the meaning of the information being transmitted to the brain before it can be experienced…

So the next part is the actual quality or experience of pain – this is the part we can’t share with another, no matter how much we want to.  This is directly influenced by the nociception/neuromatrix part, but is also influenced by the next layer – which is our judgement of the meaning of that experience.  Loeser describes this as ‘suffering’ – but while experiencing pain may not be optional, suffering certainly is!

Suffering is all about how we interpret the sensations we become aware of, arising from the neuromatrix or nociceptors.  Suffering includes our predictions of the implications of the pain, what we think the pain means (something serious? something that will mean we can avoid something unpleasant? something to worry about…).  Some pain we can interpret as good – the pain after exercising, or the pain of childbirth (really!), while other pain we are concerned about (is it cancer? am I dying?).

What we do about pain is action, or behaviour.  Pain behaviours are directly influenced by what we think is going on – we run away if we think it’s something harmful, if we think it’s helpful we’re more likely to tolerate it (think about the flu jab compared with being jabbed with a dirty syringe in a dark alley).  At the same time, pain behaviours are influenced by our social setting – we do different things depending on who is around us, and where we are!

So the final ring is the social context – where we are at the time, the response of other people, our culture and even the legislative setting in which we live and work – these all make a difference to our pain behaviour (think of the response to stubbing your toe in your garage compared with your response to stubbing your toe on a pew at a funeral).

Working from what the person tells us, to a framework or model, seems to help people understand that we know what’s going on for them, we understand they’re not going nuts, and that we do know what we’re talking about.  A bit of reflective listening doesn’t hurt either.

I’ve also attached this description if you want something more complex…simple-explanation-of-cp

I hope this post has helped – if you’ve enjoyed it, and want to see more, you can subscribe using the RSS feed above, or you can bookmark and visit again. I post most working days, and I do love comments! I usually reply asap, and if you think I haven’t seen your comment you can always email me.  Go to my ‘about’ page and you’ll find my contact email.  I hope to see you back again soon!

If you’re new to pain management


This is just a brief foray into thinking about what people new to pain management might need to know in the first few months.  I’m definitely not being academic about this, and I don’t have any references – it’s my reflections on seeing people starting in the field looking a bit like a possum in the headlights!  (For non-kiwi’s, the possum is high on cuteness, and more than high on destructiveness – and one of the best ways to catch a possum is to go spotlighting!)  (Photograph by PJWood, apologies for not crediting this before, this image is common on the internet).

(more…)

A week of self help books!


I hope to spend a little time reviewing self help books for chronic pain management – please note I don’t sell them, I just buy them! Anyone looking in my office will realise I spend wayyyy too much time in Amazon.com, and they make waaaayyyy too much money out of me!

Anyway, a quick review of one book today – more tomorrow.
This one is a bit of a standard, Manage your pain by Michael Nicholas, Allan Molloy, Lois Tonkin and Lee Beeston. It’s readily available, not overly expensive, and endorsed by Prof John Loeser, University of Washington, Seattle.

It’s designed to be complete, includes a lot of information, and for a self help book, spends quite a lot of time looking at investigations and treatments that may be used by medical professionals. Chapters include ‘What’s going on in your body when you have pain?’, ‘What X-rays, CT and MRI scans tell us’, ‘Working with your Doctor’, and ‘Treatments for chronic pain’. Then it starts in on the good stuff – Pacing, setting goals, recognising obstacles to change, stretching and exercising, challenging ways of thinking etc.

Three observations about this book –
1. On the helpful side, it’s Australasian, so for those of us from Down Under it refers to things quite familiar.
2. On the not so good side, I found it quite text-dense which could be off-putting for so many of the people I work with who have very limited literacy.
3. The other not so good aspect is that it doesn’t include worksheets or ways to personalise the application of strategies to an individual. I think it could be quite easy to glance through the book and just not use the very helpful information that is included.

I’d suggest this book is one you might provide as a supplement to individualised input by a health professional, and perhaps set individualised goals as you and the client work through the contents. Or it may be one that is held as a reference in a health centre, with certain chapters provided to the person with chronic pain as needed.

Oh, by the way – I hadn’t heard of Fishpond online bookstore in New Zealand until a couple of weeks ago – yet another place I’ll need to lock up my credit card from!!

Manage Your Pain
Practical and Positive Ways of Adapting to Chronic Pain
By Michael Nicholas, Allan Molloy, Lois Tonkin
Format: Paperback, 224 pages
Published In: United States, September 2006
Publisher: Souvenir Press
ISBN: 0285636790
EAN: 9780285636798