Education

The know-do gap: does social media help change things?


This post is prompted by a Facebook post from Connor Gleadhill asking “in what way is SoMe contributing to knowledge translation (KT)? I’m interested in the experience of those tagged and if anyone is aware if it has been rigorously tested. As far as I’m aware it hasn’t. Is it simply a confirmation bias arena? We are humans after all, and we curate our experience on SoMe.”

Oh such a great question and one reason I still hang out on social media!

I’ve been blogging since 2007, two years before the famous Body in Mind (who have just announced they won’t post any more content). Over that time I’ve risen to the top of the blogs, then plummeted down to my current level. Yet I still have a passion for doing this (usually) weekly post.

One reason I post is in answer to Connor Gleadhill’s question: one method for translating knowledge from journals into clinical practice is through online content. Content that’s accessible (not behind a paywall). Content that offers an opinion. Content that (hopefully) translates a-contextual information into a context more familiar to clinicians.

Is there evidence that knowledge translation occurs in this space or is it all a vast echo chamber where we listen to ourselves and pretend that everyone who is anyone agrees?

Well, in the pursuit of understanding this phenomenon, I’ve been researching the research looking at the effectiveness of one form of social media: the community of practice. A community of practice is a concept developed by Wenger yet one that has (probably) existed since humans took up tools and started learning from each other. It’s a place where “groups of people … share a concern or a passion for something they do and learn how to do it better as they interact regularly.” Senior or recognised “expert” members of the group provide experiential knowledge to guide junior or “apprentice” members as they learn how to … the “how to” depends on the group. In my case, it’s a group devoted to learning how to apply a multifactorial model of pain into diverse areas of clinical practice.

The group I’m part of is unusual in that it has emerged organically, not having been established artificially for the purpose of studying it. I’ve written a paper on the findings from a study of this group, to be submitted shortly. So when I talk about “effectiveness” I have to refer to artificial studies where communities of practice have been examined. One integrative review by Rolls, Hansen, Jackson and Elliott (2016) found 77 studies consisting of 44 qualitative papers, 20 mixed methods studies, and 8 literature reviews. The range of social media used was wide and included Listservs (remember them?), Twitter, “general social media” (not sure what that really means!), discussion forums, Web 2.0, virtual communities of practice, wiki, and Facebook. The clinicians involved included medical practitioners, multidisciplinary specialty group, health care professional “in general”, midwifes, nurses, and allied health professionals. The study found that:

…social media use is mediated by an individual’s positive attitude toward and accessibility of the media, which is reinforced by credible peers. The most common reason to establish a virtual community was to create a forum where relevant specialty knowledge could be shared and professional issues discussed (n=17). Most members demonstrated low posting behaviors but more frequent reading or accessing behaviors. The most common Web-based activity was request for and supply of specialty-specific clinical information. This knowledge sharing is facilitated by a Web-based culture of collectivism, reciprocity, and a respectful noncompetitive environment. Findings suggest that health care professionals view virtual communities as valuable knowledge portals for sourcing clinically relevant and quality information that enables them to make more informed practice decisions.

Rolls, Kaye, Hansen, Margaret, Jackson, Debra, & Elliott, Doug. (2016). How Health Care Professionals Use Social Media to Create Virtual Communities: An Integrative Review. Journal of Medical Internet Research, 18(6), e166. doi: 10.2196/jmir.5312

Heidi Allen and colleagues (2013), from Body in Mind, found that by releasing papers on social media, there was an increase in dissemination of those papers. Chan and colleagues (2018) also identified that there was much “scholarly engagement” through online interactions. There are detailed analyses of the social construction of knowledge online (Gunawardena, Flor, Gomez & Sanchez, 2016), studies of how acceptable social media knowledge translation is amongst health researchers and clinicians (Tunnecliff, Illic, Morgan, Keating, Gaida, Clearihan et al 2015), and examination of patient’s use of social media (Antheunis, Tates & Nieboer, 2013).

Social media can “democratise” information. Because social media is readily accessible across so many forms and devices, and because there is greater opportunity to interact with authors, and the numbers of people seeking health info, social media allows more information flow than journal articles or conferences. There’s always a risk in that: loud voices, those with marketing smarts, those with a punchy delivery and especially those with a controversial message will attract more attention than, for example, my long form writing on complex topics.

Reader beware must also be the motto. Info dumping a load of references tangential to the actual topic, along with little, if any, critical analysis of that material, can lead to what appears to be authoritative content, but may perpetuate unhelpful and outdated ideas.

I continue blogging because it helps me sort my ideas out. I find it helps me “construct” and assemble what I know into something I can then apply. It helps me sift through the overwhelming wealth of research pouring out of Universities and research groups everywhere around the world. As I look at the over 1100 posts I’ve written, I can see the issues I’ve pondered, and the stance I take on issues such as communication, respect, thinking before adopting a new treatment, clinical reasoning, collaboration. Many of these are attitudes towards people who live with pain.

The things I most appreciate about social media are that I have a network of people with whom I can nerd out. People who do “get it”. People who may not agree with me but who are willing to entertain alternative views. People who push me to learn about areas I wouldn’t normally. People who live with pain who inspire me. People for whom I have great compassion because of their personal stories. I have a sense of community. A real assemblage of people I can turn to when I have questions.

In answer to the question “Does social media contribute to knowledge translation?” I would say it is as effective as the readers and contributors make it, possibly more effective than attending a conference (the best part is always the social isn’t it?!), certainly more useful for generating clinical discussion than a publication locked up in a journal, and as long as conversations remain respectful and discuss ideas and not personalities, it’s an effective way for clinicians to construct knowledge for their practice setting. I’m still going to blog even if my average reader numbers in the last week were a measly 100 people.

Allen, Heidi G, Stanton, Tasha R, Di Pietro, Flavia, & Moseley, G Lorimer. (2013). Social media release increases dissemination of original articles in the clinical pain sciences. PloS one, 8(7), e68914.

Antheunis, Marjolijn L., Tates, Kiek, & Nieboer, Theodoor E. (2013). Patients’ and health professionals’ use of social media in health care: Motives, barriers and expectations. Patient Education and Counseling, 92(3), 426-431.

Chan, Teresa, Trueger, N Seth, Roland, Damian, & Thoma, Brent. (2018). Evidence-based medicine in the era of social media: Scholarly engagement through participation and online interaction. Canadian Journal of Emergency Medicine, 20(1), 3-8.

Gunawardena, Charlotte N, Flor, Nick V, Gómez, David, & Sánchez, Damien. (2016). Analyzing social construction of knowledge online by employing interaction analysis, learning analytics, and social network analysis. Quarterly Review of Distance Education, 17(3), 35.

Tunnecliff, Jacqueline, Ilic, Dragan, Morgan, Prue, Keating, Jennifer, Gaida, James E, Clearihan, Lynette, . . . Mohanty, Patitapaban. (2015). The acceptability among health researchers and clinicians of social media to translate research evidence to clinical practice: mixed-methods survey and interview study. Journal of medical Internet research, 17(5).

Informing — and knowing


Learning is perceived as a process of personal and social construction where people are actively involved in making sense of information they interact with, rather than passively receiving it (Kuhthau 2004). This cumulative and developmental process involves the whole person in thinking, acting, reflecting, discovering ideas, making connections, and transforming prior knowledge, skills, attitudes, and values into new knowledge (Dewey 1933).

I’m an educator for much of my time. When I think about it, I’ve been an educator for most of my clinical career – after all, when I helped people learn how to shower and dress again after a stroke, I was teaching. When I help someone work out how to organise their day to optimise energy levels, I’m teaching. And when I interact online in some of the Facebook groups I’m part of, I’m also teaching.

Teaching is the process of attending to people’s needs, experiences and feelings, and intervening so that they learn particular things, and go beyond the given.

http://infed.org/mobi/what-is-teaching/

When I look at what people do for continuing education, and also how we approach helping people with pain to understand something about how their nervous system works, I think we often do a fine job of providing information. “Information is to behaviour change as spaghetti is to a brick”, said Prof Bill Fordyce, father of behavioural approaches to pain management. As clinicians and educators we spend a great deal of time working out “what” people should/need to know. There’s talk of a “curriculum” for people living with pain so the basic concepts are provided. Information is the “what” – those facts, concepts and often context-free bites of data that are gathered together into information through analysing, cross-referencing, selecting, sorting, summarising or otherwise organising them (Stonier, 1997).

Perhaps where we’re less capable is in supporting people in the process of turning information into knowledge. Knowledge is about integrating information into meaning. It’s magic to see someone have that lightbulb moment when suddenly one bit of information connects with something else the person knows and it begins to make sense!

With CPD I wonder how many of us go to a course, then walk away with our heads jam-packed with new information – then when we walk into clinic we get caught up in the everyday of clinical life, and promptly forget how that new information we’ve stored relates to what we do.

I think the same when I listen to patients talk about what they’ve been told, perhaps about pain, or perhaps about ways they might do things – and they talk of these information bites as disconnected from their daily reality.

To me, the process of developing knowledge involves processing information into personal relevance. It means that, as we learn a new piece of information, we sift through what we already know and establish how the new information might be similar to or different from what we already know. We might ponder when, where, and how this new information can apply. We try using the new information to test its utility. We talk about “what does this mean” with other people as we do this.

A community of practice (Wenger) is a “group of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly”. In a community of practice, people who have become expert or more experienced in doing this activity share their expertise and “knacks of knowing” – novices spend time absorbing what the experts say and do, and ultimately learn to become expert themselves. Communities of practice are everywhere and in our internet and social media-based lives, communities of practice exist virtually as well.

Clinicians often turn to online discussions to carry out their process of turning information into knowledge. Through the debates and discussions (yes, and arguments and flame wars) clinicians become familiar with new information and discuss the implications for practice. It’s common to see clinicians use Instagram, Twitter, Facebook, blogging (yes!) as ways to not only produce information but to also make sense of it.

But when I think of comparable and positive opportunities for people living with pain who are also trying to make sense of the many different bites of information they’re provided with, I’m less certain there is a good place to go to be supported in this process. Much of our clinical treatment is carried out individually, one-to-one with patient. Because pain is invisible and so many people are hopeful the experience will be temporary, meeting with and discussing information about pain and ways to live with pain are rare. In fact, there’s plenty of evidence from research showing that people living with pain feel isolated, abandoned and judged (Cagle & Bunting, 2017; Collier, 2018; Wilbers, 2015). Not the best place to be when trying to put pieces of information together.

While as clinicians, we can offer much information – how good are we at helping people connect that information with what that person already knows? How can we – especially if we don’t experience pain? What would we know of the process of going to various therapists, being told many different things, of the highs and lows of benefits and failures?

I run a group programme called Springboard. It’s a six-week programme, one session a week, with home-based “missions” people can do over the week. I’ve always thought the magic happens not when I give out information, but when participants return with their experiences and share what they’ve learned with one another. I don’t the group is simply bridging a feeling of loneliness or stigma, although it certainly seems to do that. I think the magic happens because participants share what this information means to them, when participants help one another connect a new piece of information to what they already know. Because no-one knows better what the meaning of a new understanding is than people living with pain.

So I question us all. Clinicians – do we help people connect with others who are in the same boat to learn from one another? To make sense of what we try to tell them? People living with pain, do you have ways of sifting through new information so you can work out its relevance to you? Can we bring people together – experts in living well with pain and novices learning how this information might apply?

Cagle, J., & Bunting, M. (2017). Patient reluctance to discuss pain: understanding stoicism, stigma, and other contributing factors. Journal of social work in end-of-life & palliative care, 13(1), 27-43.

Collier, R. (2018). “Complainers, malingerers and drug-seekers”—the stigma of living with chronic pain. In: Can Med Assoc.

Dewey, J. (1933). How we think. a restatement of the relation of reflective thinking to the educative process (Rev. ed.), Boston, MA: D. C. Heath.

Kuhlthau, C.C. (2004). Seeking meaning: a process approach to library and
information services. (2nd ed.). Westport, CT: Libraries Unlimited.

Stonier, T. (1997). Information and meaning—An evolutionary perspective.
Berlin: Springer.

Wilbers, L. E. (2015). She has a pain problem, not a pill problem: Chronic pain management, stigma, and the family—An autoethnography. Humanity & Society, 39(1), 86-111.

Pain science is not a thing


Today’s post is occasioned by reading several discussions on various forums where the term “pain science” and various adjectives to describe this kind of practice. For those who don’t want to read the rest of my ramblings: no, it’s not a thing, science is an approach to understanding phenomena, and I would have thought all health professionals would use a science-based approach to treatment.

I went on to Google, as you do, to find out when this term began its rise in popularity. Google wasn’t particularly helpful but did show that it’s been around since 2004 at least, and seems to have been centred around the US, UK and Australia in roughly May 2004. I can’t grab data from earlier than this, sadly, but I think it’s interesting to take a look at the popularity peaks and troughs…

So, what does “pain science” mean to commentators? I haven’t delved in too deeply to the social media use of the term, but given I’m a social animal and have written my blog since 2007 (which is mainly on “pain science”) I’ve encountered it many times. It seems to be related to using a neurobiological explanation for pain as an experience (referring to the phenomenon and the underlying biological processes involved) rather than focusing purely on biomechanics or tissue damage/nociception as the key force. And it does seem to tie in with the emergence of “Explain pain” as one way of helping people reconceptualise their experience as something they can influence rather than something other people need to “fix”.

Commentators who aren’t in love with the “explain pain” thing have said things like “the pain science camp” or as one person put it “There’s your manual PTs, your pain science PTs, and your just load it PTs etc”

I went on to Twitter and the hashtag #painscience was paired with #BPSModel and #PT and #physicaltherapy (or variations), #chronicpain #exercise #lowbackpain – and so on.

So what do I think pain science means if it’s not a neurobiological approach to pain management? Well – pain science is a lot like cardio-respiratory science, and neurological science, and psychological science – it’s about applying a scientific approach to understanding pain. Science has been defined as “the intellectual and practical activity encompassing the systematic study of the structure and behaviour of the physical and natural world through observation and experiment.” In this instance, Google is your friend. So science is about systematically studying phenomena through observation and experimenting. If we apply this to pain – it’s the systematic study of structure and behaviour of the phenomenon we call ‘pain’ through observation and experiment. For what it’s worth, scientific study of pain has been going on since… oh at least Descartes, but probably much earlier given that pain is a ubiquitous and essential part of human experience.

To me, understanding pain involves multiple disciplines: yes to biology, and especially neurobiology because the experience (as we understand it now) involves neurobiological processing. But it’s also about psychology
the scientific study of the human mind and its functions, especially those affecting behaviour in a given context; sociology – the study of the development, structure, and functioning of human society; the humanities – the study of how people process and document the human experience; politics – the activities associated with the governance of a country or area, especially the debate between parties having power; and Anthropology –  the study of humans and human behavior and societies in the past and present. Social anthropology and cultural anthropology study the norms and values of societies. Linguistic anthropology studies how language affects social life.

So to describe an entire approach to understanding a phenomenon as if it’s a “movement” or “camp” or “dogma” or even “tribe” suggests serious  misunderstanding of both science and of an intervention.

What is “explain pain” then, or pain neurobiology education? – it’s an explanation of some of the biological elements of our nociceptive system as they combine to produce the experience we know as pain. For some people it’s the first time anyone took the trouble to explain why the pain of a papercut feels so bad compared with, for example, the pain of a sprained ankle; and why they still experience pain despite having no “damage” as visible on imaging. It’s an attempt to give people a frame of reference from which to understand their own journey towards recovering from a painful injury/disease/problem. In itself it’s not new: explanations for pain have been used in pain management programmes since the 1970’s (and earlier, if we consider that Fordyce used explanations in his behavioural approaches to pain management), and have routinely drawn on current pain research to help provide explanations that make sense to both the person and the clinician. The distinction between earlier explanations which drew heavily on the gate control theory, and this latest iteration is that the explanations are more complex, pain is considered to be an “output” that emerges from multiple interactions between brain and body, and that’s about it. Oh and it’s been picked up and enthusiastically used by physiotherapists (and other primarily body therapists) around the world.

What’s the evidence for this approach? Well, IMHO it’s not intended to be a stand-alone “treatment” for most people experiencing pain. I see giving an explanation as integral to usual practice, just as we do when we explain why it’s not a good idea to go running on a newly sprained ankle or why we’re suggesting a mindfulness to someone with a panic disorder. So far there have been a lot of studies examining variants of “explaining pain” alone or in combination with a number of other treatments including exercise. A recent systematic review and meta-analsyis of “pain neuroscience education” for chronic low back pain found eight papers (with 615 participants) showing that in the short-term, this kind of education reduces disability (by 2.28 points on the Roland-Morris Disability Questionnaire which is a 24 point scale) in the short-term and a slightly lesser effect in the long-term  (2.18). There were greater effects when this was combined with physiotherapy, though we often don’t know exactly what is included in “physiotherapy”.  There was some evidence that this kind of education helps reduce pain scores (by 1.32) but only in combination with other physiotherapy interventions. The authors pointed out that the strength of evidence for education on pain in the short term was low to moderate, but that it doesn’t have much of an impact on pain-related fear and avoidance, or on pain catastrophising (Wood & Hendrick, in press).

To compare this with another active treatment, exposure therapy for fear of movement/reinjury in chronic low back pain, de Jong, Vlaeyen, Onghena, Goossens, Geilen & Mulder (2005) performed a careful study of six individuals, using a single case experimental design. (If you’re not familiar with this approach to research – it’s extremely rigorous and useful in a clinical setting, this link takes you to a chapter discussing its use).  The aim was to establish which part of treatment “did the work” to change behaviour, but also measured pain intensity, and fear of pain and movement.  The treatments were information about pain and mechanisms, and the activities were those the person particularly wanted to be able to do. Their findings identified that explanations do little to pain intensity, avoidance or fear – but what actually worked was doing graded exposure. In other words, experiencing something different, DOING that something different in the real world, was more effective than talking about why someone shouldn’t be afraid. A much more recent replication of this study was conducted by Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski (2018) and shows the same result: doing trumps talking about doing.

When we sit down and take a cold hard look at what we do in pain management we can see that the field has to draw on a huge range of disciplines and fields of study to understand the problems people experiencing pain have. This is, in fact, why Bonica and colleagues first established the International Association for the Study of Pain, and why multidisciplinary (and now interprofessional) pain management teams and approaches were established. None of us can possibly hold all the knowledge needed to work effectively in the area. At the same time, as health professionals working with people, we do need to have some foundation knowledge about biology, disease, illness, psychology, sociology and anthropology. These areas of study inform us as we work hard to help people get their heads around their pain. Do we need to be experts in all of these fields? Yes – if you work completely in isolation. No – if you work within an extended team (whether co-located or otherwise). Pain research will continue to push our understanding ahead – and to be responsible health professionals, we must incorporate new understandings into our practice or we risk being unprofessional and irrelevant. I would go as far as to say we’re irresponsible and harming patients if we fail to incorporate what is known about pain as a multidimensional experience. It’s time to back away from temporary guruism and move towards a far more nuanced, and perhaps less flighty approach to understanding pain.

Pain science. No, it’s not a thing. Pain being examined through multiple scientific lenses: definitely a thing.

NB for the avoidance of doubt: pain is never a “thing” but examining pain through multiple scientific lenses involves many “things”. (Merriam-Webster – click)


de Jong, J. R. M., Vlaeyen, J. W. S. P., Onghena, P. P., Goossens, M. E. J. B. P., Geilen, M. P. T., & Mulder, H. O. T. (2005). Fear of Movement/(Re)injury in Chronic Low Back Pain: Education or Exposure In Vivo as Mediator to Fear Reduction? [Article]. Clinical Journal of Pain Special Topic Series: Cognitive Behavioral Treatment for Chronic Pain January/February, 21(1), 9-17.

Schemer, L., Vlaeyen, J. W., Doerr, J. M., Skoluda, N., Nater, U. M., Rief, W., & Glombiewski, J. A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Wood, L., & Hendrick, P. A. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. European Journal of Pain, 0(0). doi:doi:10.1002/ejp.1314


Occupational therapists’ knowledge of pain


I am mightily bothered by health professionals’ lack of knowledge about pain. Perhaps it’s my “teacher” orientation, but it seems to me that if we work in an area, we should grab as much information about that area as possible – and pain and pain management is such an important part of practice for every health professional that I wonder why it’s so often neglected. So, to begin exploring this, I completed a search looking at occupational therapists’ knowledge of pain – and struck gold,  kinda.

Angelica Reyes and Cary Brown conducted a survey of Canadian occupational therapists, to explore how well occupational therapists knew their stuff.

Members of the Canadian Association of Occupational Therapists were asked to participate and a total of 354 therapists (mainly from Ontario, Alberta and Nova Scotia) took part. Curious that few were from British Columbia where I know of quite a few occupational therapists working in the area, but there you have it.  Over half of the respondents had 10 years or less experience – so they were fairly recent graduates and should reflect a “current” educational bias. Only 5% of the total number of members of CAOT responded, so this is a fraction of the occupational therapists working in Canada – but you’d think the motivated (ie knowledgeable) would be more likely to respond than those who don’t work in the area….

What they found was consistent with previous studies (prior to 2000) showing that these respondents, who were surveyed using the City of Boston’s Rehabilitation Professionals’ Knowledge and Attitude Survey (Rochman & Herbert, 2015), had disturbing “potential knowledge gaps” in the following areas:

  • children’s ability to feel pain;
  • use of analgesics in orthopedic pain
  • use of nondrug treatments
  • thermal modalities
  • prevalence of malingering
  • impact of therapists’ values on assessment of veracity
  • mind/body dualism in chronic pain
  • measurement of pain intensity
  • effect of under-treatment on chronicity
  • prevalence of patients who over-report pain
  • prevalence ofpatients who are likely to become addicted if treated with opioids.

Of particular concerns was 45.7% of participants believed that malingering is common; 38% believed that pain intensity can be objectively measured, 39.7% believed people with pain over-report their pain, and 59.8% believed that opioid addiction is likely to occur in more than 5% of the patient population.

OUCH!

So, it seems that these occupational therapists had some very outdated ideas about pain, and in particular, seem to have missed the point that because pain is a biopsychosocial experience, we have no way to determine whether someone is “faking” – or malingering.

Now, I will lay good money on a bet that if we were to carry out this very same survey amongst any other health profession, we’d still arrive at these rather unsavoury findings. Folks, I live in a pain nerd bubble and I still hear these kinds of discussions amongst knowledgeable health professionals, so it’s unsurprising that so many people hold these beliefs. Beliefs that will hamper developing good relationships with the people we want to help, and beliefs that fly in the face of what we know about pain.

I am SO not pointing the finger at Canadian occupational therapists, neither am I pointing the finger at my profession alone. I think this lack of understanding reflects many things:

  1. Pain is a complex experience, and the legacies of ancient models lingers everywhere (dualism, medical model, reductionism, etc);
  2. We devote very little time in our professional training to learning about pain – and often, it’s limited to “here is the nociceptive system”;
  3. The research around pain has exploded over the last 15 years – it’s hard to keep up, which is why I blog;
  4. The problem of persistent pain is under-estimated, so if a person works in paediatrics, older person’s health, neurology, brain injury, spinal cord injury – it’s quite probable that pain is almost completely ignored, because “it’s not relevant”. After all, pain is something for specialist pain services, yes? NO
  5. Prevailing attitudes within the healthcare community are that pain is a difficult area to understand – and “should” be treated with medication or surgery otherwise….

You can see that this year’s IASP Global Year for Excellence in Pain Education has much to do.

Did you know that IASP have produced NINE comprehensive curricula – including occupational therapy  (thank you to Emeritus Professor Jenny Strong, Professor Cary Brown and Dr Derek Jones for developing this wonderful resource). This means there is no reason for us not to begin integrating this import area of practice into our undergraduate training.

Research examining occupational therapy’s contribution within pain management is in its infancy – but oh how my occupational therapy heart went pit-a-pat when, at the Australian and New Zealand Pain Society Scientific Meeting I presented alongside two other occupational therapists with PhD’s (or nearly there!) to a room full of clinicians, not just occupational therapists. While we have little specifically occupational therapy research, occupational therapists have been and are continuing to be part of research efforts around the world. And what clinicians do is apply what is learned into the daily lives of the people we work with. That, friends, is what occupational therapy is about – helping people live full, rich lives doing what’s important to them.

Reyes, A. N., & Brown, C. A. (2016). Occupational therapists’ pain knowledge: A national survey. Disability and Rehabilitation: An International, Multidisciplinary Journal, 38(13), 1309-1317.

Rochman D, Herbert P. Rehabilitation professionals knowledge and attitudes regarding pain (COBS). Accessed 18 March 2015. Available from: http://prc.coh.org/html/rehab_professionals.htm.

Back to basics about psychosocial factors and pain – iii


Last week I discussed some of the areas in the brain, and basic principles, that are currently thought to influence our pain experience. This week I thought I’d introduce one of my favourite ways of considering pain mechanisms, mainly because it helps me think through the four main kinds of mechanisms, and can influence our treatment approach. At this stage I want to raise my hand to acknowledge the following:

  • My gratitude to Dr John Alchin, longtime friend and colleague, who first pointed this paper out to me and has shared it with hundreds of people who go to see him at the local tertiary pain management centre.
  • We know this is a simplified, under-developed approach to mechanisms underpinning pain, but it’s helpful nevertheless.
  • Most of our patients will have a combination of mechanisms involved in their experience, not just one.
  • This approach to mechanisms doesn’t include the psychological or social – just the primary biological processes.
  • Throughout this blog, when I use the word “pain” I mean the experience we have once whatever mechanisms involved filter up through to our awareness. So while I talk about peripheral mechanisms, they’re only experienced as pain once we become aware of them – and that process involves a whole lot of what I discussed in my last post .

Clifford Woolf wrote this paper in 2010, and although the research into mechanisms has continued unabated, I think it provides clinicians with a reasonable guide to considering how best to tackle treatment. He begins by dividing the mechanisms into “useful” and “useless” pain – ie pain that is useful for adaptation, survival, warning, alerts. Just as it’s possible to have dysfunction or disease of our cardiac, pulmonary, gastro-intestinal, and skeletal systems, I think it’s just as plausible that we can have something go wrong with our nociceptive system. In fact, because of its complexity, it seems probable to me at least that there are many different ways this system can fail to work properly. But more about that shortly! Let’s begin with the useful pain.

Nociceptive pain – is considered to be pain that is, as Woolf puts it, our “early-warning physiological protective system”. When we touch something super cold, super hot, or a chemical that can harm us (think chilli pepper!), or meet a mechanical force that activates mechano receptors, our high threshold nociceptors are activated – well in advance of tissue damage, I quickly add. This process activates withdrawal – even in simple single-celled animals – and saves us from harm. When combined with behavioural responses including vocalisation, grimaces and other pain behaviours, we signal to everyone around us that we’re in danger, and others shouldn’t do what we’ve just done (Melzack, Dennis, Kosterlitz & Terenius, 1980).  For me, the cool thing about nociceptive pain is that once you’ve removed that stimulus (got rid of the chilli on your lips, let go of the ice-cube or the hot mug of coffee, or shifted in your seat to relieve your butt) the pain simply goes away. Just like that. How cool?!

Inflammatory pain – is also a useful pain to have. Unlike nociceptive pain, inflammation involves disruption to the tissues, triggering a release of a whole bunch of neurochemicals and cells that quickly lower the point at which nociceptors will fire (making you much more sensitive to mechanical, chemical and temperature input), and increasing the blood supply to allow foreign material, dead cells and spent neurochemicals to be whisked away. Inflammation is reasonably easy to see in the periphery (though not so easy in the internal organs because the innervation is more diffuse) and you’ll all have had it – think sunburn (I know you’re not meant to, but everyone gets sunburned at least once, especially in our NZ sun). With sunburn you’re red, hot and often swollen, and you really know it when you step into the shower! That experience of ouch! to your usual shower temperature (and the ouch! when you towel down) is allodynia, or the experience of pain when a usually comfortable stimulus is applied. You’ll experience hyperalgesia if your mate comes along and slaps you on your sunburned shoulders!

Now both of these mechanisms are useful because they alert us to threat, they make it more difficult to move around, and we often respond to them with changes in our behaviour that act as a signal to others around us. Let’s turn the attention to two mechanisms where there is something gone awry with the nervous system – in other words, useless pain.

Neuropathic pain – is defined by IASP as “pain caused by a lesion or disease of the somatosensory nervous system.” What this means is that there must be an identifiable lesion in the nervous system somewhere – something that can be imaged or tested to demonstrate damage. This could be in the periphery – think of radial nerve entrapment with its characteristic tingling, deep aching and burning over the distribution of the nerve. It could be in the spinal cord itself – think of a complete spinal cord injury where the person is unable to move from the lesion down, and who also gets the same tingling, aching, burning and electric shock pain over the same area. A simple example would be radicular pain where the nerve root is compressed – and this can be seen on imaging, and where the pain is experienced over the same nerve distribution. The final group in this nasty set of neuropathies is when someone has a stroke, where part of the brain is damaged leading to intractable, deep, aching pain with electric shock-like pain just to make it nastier. For a great paper reviewing neuropathic pain, Finnerup and colleagues wrote one published in 2016 (see below), describing a grading system to indicate possible, probable and confirmed neuropathic pain. The hallmark of this pain is that it doesn’t represent tissue damage except in the area of the nervous system where the lesion is located. In other words, that pain down the leg is not where the problem lies in radicular pain – it’s near the spinal cord. So this pain doesn’t have a function for survival – it’s just a horrid nuisance.

The final mechanism is poorly understood – even less well understood than neuropathic pain. This is where ostensibly the nervous system appears intact. The pain experience might be in multiple parts of the body, it could be just in the head (migraine, for example), or it could be just in the shoulder (frozen shoulder maybe?), or it might be everywhere (fibromyalgia). The name isn’t even completely determined – it’s called “dysfunctional” by Woolf, and he collapsed this and neuropathic pain into one mechanism, but I prefer to keep it separate because it’s more helpful for management especially when a neuropathy might be amenable to surgery. Another term, and one I like, is nociplastic – referring to the idea that it’s the unhelpful neuroplasticity of our nervous system that has over-responded to potential threat (Kosek, Cohen, Baron et al, 2016). Some would argue that this mechanism is partly a general tendency to a lower nociceptive threshold, maybe genetic, maybe behavioural (ie we’ve learned to monitor and respond to threat perhaps because of early life experiences), perhaps a diathesis-stress where the predisposition exists but it’s not brought into expression until a stressor, perhaps a virus or an injury, exerts an influence on homeostasis.

Ultimately, pain is an experience that we’ve all had, and one that has individual meaning for each of us based on our previous experiences, predictions for the future, current goals, culture and biology. What a mechanisms-based approach to pain management might mean is better and more accurate management for each one. So we’d be looking to remove that bunion so people can walk more easily; reduce the inflammation in an auto-immune disease; decompress a squished nerve in neuropathic pain and look to altering plasticity in nociplastic pain. But pain is weird and as I said at the very beginning, it’s entirely possible to have more than one mechanism involved – and because pain is not just biology, we’d be foolhardy to think that just by down-tuning the intensity, everyone so treated will go “back to normal”. More on that next week!

 

 

Finnerup NB, Haroutounian S, Kamerman P, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016;157(8):1599-1606. doi:10.1097/j.pain.0000000000000492.
Kosek, E., Cohen, M., Baron, R., Gebhart, G. F., Mico, J. A., Rice, A. S., … & Sluka, A. K. (2016). Do we need a third mechanistic descriptor for chronic pain states?. Pain, 157(7), 1382-1386.

Melzack, R., Dennis, S. G., Kosterlitz, H. W., & Terenius, L. Y. (1980). Phylogenetic evolution of pain-expression in animals. Pain and Society, 13-26.

Woolf CJ. What is this thing called pain? The Journal of Clinical Investigation. 2010;120(11):3742-3744. doi:10.1172/JCI45178.

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