Motivation

Exercise? Who me? Yoga or physiotherapy or education…


Exercise, while one of The Most Important self management approaches for persistent pain, is not an easy sell to someone who is experiencing pain. Especially not if that exercise looks like huffing and puffing, hauling on bits of metal in a gym, or wearing lycra. Not to mention the “sports drinks”…  Those things aside, exercising is a good thing. You heard it from me, and I have declared my body an exercise free zone! The thing is, what kind of exercise, for what purpose, and how to get introduced to it.

Personally I’m a fan of exercise that achieves something else other than “getting fit”. I like gardening, I love dancing, I enjoy cycling (especially to the store to get a GREAT coffee!). Walking the dog is fun. Swimming (especially snorkeling) is awesome! I like my exercise to do more than bring on the endorphins, especially as I don’t get much of that post-exertional analgesia that many people do – and believe me, they do (Ellinson, Stegner, Schwabacher, Koltyn & Cook, 2016). I like my exercise to look like the things I need or want to do, so that when I need to do ’em, I’m in fit state to get on and do ’em.

So what kind of exercise works best? One sage told me “the exercise the person does!” and there is some truth to that, so when I begin talking to someone about exercise, I’m looking for something they can do regularly, that fits into their lifestyle, that makes them feel good, and has some other benefit to them. That benefit might be the social thing – going to a box-fit class with a group of others all bent on getting their fix of play-fighting. It might be the solitary thing – long walks along the beach with the dog for company. It might be the music – in my case, it’s belly dance (and I dare anyone to do a 5 minute shimmy drill while keeping an isolated upper body, a loose shimmy and smile!).

I like the idea of having variety – who says we need to do the same kind of exercise every day? So it’s a wet day and I don’t fancy taking my bike out in the rain, I can turn to my dance practice, or do the dusting, or vacuum the floors. It’s a frosty day and I can go for a brisk walk and take photographs of gorgeous sparkly frosty droplets while Sheba-the-wonderdog huffs steam and sniffs at the local scents. If it’s a warm day, why not head to the pool for a lap or two? If it’s a busy day and I don’t have time, what about some “exercise snacks”? Five minutes of exercise every 25 minutes adds some pretty quickly, so it’s lunges and chair dips and wall presses and shimmy practice in between writing.

Over time we’re seeing more research looking particularly at yoga for persistent pain of all kinds. Yoga comes in many different forms, and in this case I’m guessing the more extreme forms of hot yoga and contortion is not being studied. Some of the studies are appearing in rather eminent journals, like this one from the Annals of Internal Medicine and authored by a very large team including Saper, Lemaster, Delitto and colleagues (2017).

This study is a “non-inferiority” study, looking to establish whether yoga or physiotherapy, or indeed education, can help people living with chronic low back pain. Now I’m not going to do a blow-by-blow analysis of the study, that’s for you to do. What I am going to do is look at what the yoga consisted of – and see why, perhaps, yoga is getting so much research interest. BTW, yoga was found to be non-inferior to physiotherapy, and both yoga and PT were more likely than education to have a clinically meaningful response, although neither yoga nor PT were superior to education.

This is the basic format of the yoga class: Each class began with relaxation and meditation exercises, yoga breathing, and yoga philosophy. It continued with yoga poses and
concluded with relaxation. Pose variations and aids (such as chair, strap, and blocks) accommodated various abilities. Thirty minutes of daily home practice, facilitated by a DVD, a manual, and take-home yoga supplies, was strongly encouraged.

Yoga appeals to many because it seems to begin where people are at – it’s not huffy-puffy, things don’t jiggle, and generally the classes begin and end with the ritual of breathing and meditation. I like the idea of yoga (and yes, I’ve done a class or two!), because it doesn’t involve a lot of gadgets, you can do it alone or in a group, and it feels good. What I don’t like about yoga is the need to get effective and consistent feedback about how well you’re performing the poses, especially in the beginning, which means it can be difficult to do on your own without a teacher.

For people who find exercising both difficult and painful, yoga is a good place to start. I think attending classes is crucial (or at least having an instructor and a mirror!). Learning to use the meditation and breathing is integral to the exercise – and it’s this that I think makes yoga an effective addition to the exercise toolkit. What I’m less sure of is whether it’s better than any other form of exercise – or, in my case, the many different types of movements that I use in my weekly routine. And there’s the rub. As an occupational therapist, exercise is something people choose to do as a form of occupation (valued and meaningful activity). I also enjoy a bunch of other movement-based occupations, and to me these are as valid as yoga or the PT exercises included in this study. What my approach lacks, however, is a researched basis for it.

But here’s the thing: to date the research supporting exercise for people with persistent pain shows modest effects. And those effects are completely lost if the person doesn’t do the exercise. So why not have a wide range of whole-body movement practices to draw on, allowing the person to pick and choose and get out and do something every day, even if it doesn’t fit with our modern notions of what exercise should be?

 

 

Ellingson, L. D., Stegner, A. J., Schwabacher, I. J., Koltyn, K. F., & Cook, D. B. (2016). Exercise Strengthens Central Nervous System Modulation of Pain in Fibromyalgia. Brain Sciences, 6(1), 8. http://doi.org/10.3390/brainsci6010008

Saper, R. B., Lemaster, C., Delitto, A., & et al. (2017). Yoga, physical therapy, or education for chronic low back pain: A randomized noninferiority trial. Annals of Internal Medicine. doi:10.7326/M16-2579

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Deconditioning? Or just not doing things any more?


For years there has been a general wisdom that people with chronic pain who gradually stop doing things “must” be deconditioned. That is, they must lose fitness, cardiovascular and musculoskeletal, and this is often used to explain low activity levels, high disability and the prescription of graded exercise.

While this explanation makes sense (remember what happens to limbs when they’re in plaster for six weeks? all skinny and wasted?) – it doesn’t inevitably hold, in my experience. I vividly recall a person who routinely swam 20 lengths of an Olympic pool in very fast time every day, yet could not, in his estimation, return to any kind of work, and who did not sit – for an entire three week programme. It’s always seemed a bit odd to me that even though people report they can’t do many everyday activities, they can complete a rigorous gym programme.

So, skeptical me was very pleased to see another paper by the wonderful Nicole Andrews, occupational therapist and PhD, and her colleagues Jenny Strong and Pamela Meredith. This one is about approach to activity engagement, certain aspects of physical function and pain duration and was published in Clinical Journal of Pain in January this year (reference at the bottom of the page). It’s an important paper because it challenges some of the assumptions often made about activity levels and “fitness”, as well as the use of an operant conditioning model for pacing – pacing involving working to a set quota, rather than letting pain be the guide. The concept of pacing has been woven into most pain management programmes since the early days of Fordyce, but more recently has been criticised for lacking a clear definition, and for very little in the way of empirical support as a stand-alone treatment.

In this study, Andrews and colleagues examined the relationship between certain activities and a “habitual” approach to activity engagement, and pain duration. This is a different approach to studying activity and over- or under- activity in that it examines specific activities rather than using a global measure of disability – and this is important because the people we work with do specific activities (or occupations as I’d call them) and it will be more important to be able to predict the types of activities people do, or not do, rather than simply using a general guide.

Andrews and colleagues used a tool I particularly like called the Pain and Activity Relations Questionnaire (McCracken & Samuel, 2007) – this is a 21-item measure that looks at how people approach their activities. It has three subscales – avoidance, confronting, and pacing. Confronting measures “over”activity, while the other two are self explanatory.  They also used the Oswestry Disability Index, an old standard in measuring physical functioning.

The analysis was really interesting, and well-described for those who want to dig deeper into how this team found their results. I’ll cut to the chase and simply point out that they used the items rather than the overall score of the ODI, which allows for a more fine-grained analysis of the kinds of activities individuals engaged in, and how they approached those activities. This is the stuff occupational therapists and physiotherapists really want to get their teeth into!

So, what did they find?

Firstly, individuals who reported high levels of avoidance and low over-activity also reported significant restriction in personal care tasks, compared with those people who reported low levels of both avoidance and activity. There was no relationship between this item and pain duration, but there was a relationship between pain intensity and interference.

Lifting tolerance, however, was affected by pain duration and pain intensity rather than avoidance patterns. Walking tolerance wasn’t affected by approach to activity, or pain duration, but age and pain intensity were important factors. Sitting tolerance was not related to approach to activity, and only pain intensity was a contributor rather than pain duration. Finally, standing was also not associated with approach to activity and was only related to pain intensity.

Sleep was influenced by approach to activity engagement – and with pain duration. This means people with pain for one year and who were inclined to be “over” active and not avoidant, and those who were highly avoidant and highly “over”active were more likely to report problems with sleep than those with low avoidance and low “over” activity. (BTW I put the “over” in quotes because it could also be called “confronting” or “pushing” or “doing” – I think it’s weird term not yet well-defined). The group most likely to report poor sleep were those reporting high “over”activity and low avoidance who reported sleep problems 9.23 times more than those reporting low “over”activity and low avoidance. Once again, pain severity was the only other variable influencing reporting.

Sex life was not associated with approach to activity engagement, nor to pain duration. Social life, however, was associated with approach to activity engagement with those reporting high avoidance and “over”activity reporting more restrictions than those with low levels of both, along with similar results for those reporting high avoidance and low “over”activity – again, pain duration wasn’t associated, but pain intensity was.

Finally, travel was more likely to be reported a problem by all those compared with the low avoidance, low “over”activity group, with the high avoidance, low “over” activity group most likely to report problems.

What does all this mean?

Bearing in mind that the population from whom these participants were taken were attending a tertiary pain management centre programme, and that this is self-report, the findings from this study are really very exciting. As the authors point out, when the ODI is mapped on to the ICF (International Classification of Functioning, Disability and Health) the instrument covers sleep (body function), personal care, lifting, walking, sitting and standing (activity limitations), and social life and travel (participation restrictions). Activity limitations can also be divided into two domains – mobility and daily activities (basic and instrumental activities of daily life) – walking, standing and sitting are therefore “mobility”, while personal care and lifting are “daily activities”.

These findings show that mobility activities were not associated with an individual’s approach to activity engagement – they differ from the other items in that they’re performance skills, that is, they make up other activities can’t be reduced to a smaller component. The authors suggest that the responses to these items in this study may reflect the individual’s perceived capability to engage in daily activities, as opposed to their actual physical performance to engage in these tasks.

I think this means it’s important to ask about what people do in daily life, rather than rely simply on reported levels of walking or sitting. Tie self report into activities – for example, sitting tolerance might be best described in terms of whether a person can sit to watch a whole TV programme, or whether they need to get up during the ad breaks.  It’s important to note the relationship between approach to activity and poor sleep – sleep being one of those aspects of living with pain that people most want addressed. Perhaps by moderating the approach to activity we might be able to help people develop more effective sleep patterns. It also seems to me that we need to tie outcomes from pain management to real life activities in which an individual wants to participate – rather than a more “objective” measure such as the six minute walk test – which might satisfy our urge to measure things in a nice orderly way, but might not be relevant to an individual’s life.

Finally, this study shows that overactivity and avoidance patterns are not inevitably associated with reduced capacity over time. I think this is a “received wisdom” that needs to be unpackaged

 

 

Andrews, N. E., Strong, J., & Meredith, P. J. (2016). The relationship between approach to activity engagement, specific aspects of physical function, and pain duration in chronic pain. Clinical Journal of Pain, 32(1), 20-31

McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity patterns in chronic pain. Pain. 2007;130:119–125.

Pain Acceptance rather than Catastrophising influences work goal pursuit & achievement


We all know that having pain can act as a disincentive to doing things. What’s less clear is how, when a person is in chronic pain, life can continue. After all, life doesn’t stop just because pain is a daily companion. I’ve been interested in how people maintain living well despite their pain, because I think if we can work this out, some of the ongoing distress and despair experienced by people living with pain might be alleviated (while we wait for cures to appear).

The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption. Sophisticated mathematical procedures can now be used to model the effects of variations in individual’s experiences on factors that are important to an overall group. For example, if we track pain, fatigue and goals in a group of people, we can see that each person’s responses vary around their own personal “normal”. If we then add some additional factors, let’s say pain acceptance, or catastrophising, and look to see firstly how each individual’s “normal” varies with their own acceptance or catastrophising, then look at how overall grouped norms vary with these factors while controlling for the violation of usual assumptions in this kind of statistical analysis (like independence of each sample, for example), we can begin to examine the ways that pain, or goal pursuit vary depending on acceptance or catastrophising across time.

In the study I’m looking at today, this kind of multilevel modelling was used to examine the variability between pain intensity and positive and negative feelings and pain interference with goal pursuit and progress, as well as looking to see whether pain acceptance or catastrophising mediated the same outcomes.

variationsThe researchers found that pain intensity interfered with goal progress, but it didn’t do this directly. Instead, it did this via the individual’s perception of how much pain interfered with goal pursuit. In other words, when a person thinks that pain gets in the way of them doing things, this happens when they experience higher pain intensity that makes them feel that it’s hard to keep going with goals. Even if people feel OK in themselves, pain intensity makes it feel like it’s much harder to keep going.

But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.

The authors of this study point out that “not all individuals experience pain’s interference with goal pursuit to the same extent because interference is likely to depend on pain attitudes” (Mun, Karoly & Okun, 2015), and accepting pain seems to be one of the important factors that allow people to keep going. Catastrophising, as measured in this study, didn’t feature as a moderator, which is quite unusual, and the authors suggest that perhaps their using “trait” catastrophising instead of “state” catastrophising might have fuzzed this relationship, and that both forms of catastrophising should be measured in future.

An important point when interpreting this study: acceptance does not mean “OMG I’m just going to ignore my pain” or “OMG I’m just going to distract myself”. Instead, acceptance means reducing unhelpful brooding on pain, or trying to control pain (which just doesn’t really work, does it). Acceptance also means “I’m going to get on with what makes me feel like me” even if my pain goes up because I do. The authors suggest that acceptance might reduce pain’s disruptive influence on cognitive processes, meaning there’s more brain space to focus on moving towards important goals.

In addition to the cool finding that acceptance influences how much pain interferes with moving towards important goals, this study also found that being positive, or feeling good also reduced pain interference. Now this is really cool because I’ve been arguing that having fun is one of the first things that people living with chronic pain lose. And it’s rarely, if ever, included in pain management or rehabilitation approaches. Maybe it’s time to recognise that people doing important and fun things that they value might actually be a motivating approach that could instill confidence and “stickability” when developing rehabilitation programmes.

Mun CJ, Karoly P, & Okun MA (2015). Effects of daily pain intensity, positive affect, and individual differences in pain acceptance on work goal interference and progress. Pain, 156 (11), 2276-85 PMID: 26469319

Using the Theory of Living Well with Chronic Pain


Last week I had the privilege to talk to a national gathering of occupational therapists, physiotherapists, nurses and educators from Arthritis NZ. I presented my Theory of Living Well with Chronic Pain which is the theory of re-occupying self to achieve self-coherence after developing chronic pain.

To give you a bit of background, in this theory which was developed using classical grounded theory, I identified that the thing that goes as soon as pain doesn’t fit the usual acute pattern is the sense of self-coherence – life doesn’t make sense any more. As so many people have said to me about their early experiences with chronic pain, “I don’t feel like myself any more”. The things we take for granted like our habits, routines, the things we can expect from ourselves (like how long it takes to do something, how much we can get through in a day) get scrambled by this invasive experience that takes over. In an effort to make life more coherent, many people stop doing things they enjoy so they can focus on just. keeping. going.

I identified that there are three important processes that help people when they’re making sense of their pain: the first is diagnostic clarity, then symptom understanding, and finally occupational existing. When these three processes are complete and in the presence of both a trustworthy clinician and occupational drive, people begin deciding – deciding whether to seek more treatment so they can return to the old normal, or take the bull by the horns and get on with life as it is. After deciding, people begin occupational engaging, using coping and they can finally begin future planning again.

I have a suspicion that if we asked a person who was living with chronic pain where they would put themselves in this process, we’d get a fairly accurate idea of what their clinical needs might be. Perhaps we’d understand what their focus is, and we’d be able to provide them with input targeting what they identify as important rather than what we think they need.

For example, if we look at the illustration below (andwhere are you“click” for a pdf copy of it), when someone is unsure of their diagnosis we might need to check their understanding of what the diagnosis means. Does it fit with their experience? What’s the prognosis and does the person understand this? Has that label been interpreted accurately? Does the person know that it’s chronic/ongoing and that the pain is now not a signal to stop? If not, we need to think about how to explain this, to help the person make sense of it, and this might be a good time to consider providing the person with information on what pain is.

If the person can’t yet answer the questions related to understanding symptoms, then our job might be to help guide them through the process of experimenting with different activities, noting changes and variations in pain intensity and quality, and fatigue, that occur. I think this is best carried out while doing the basics (or occupational existing).

Doing the basics refers to occupational existing, or just doing what’s necessary. NOT setting new goals, just simply keeping life ticking over. If the person is having trouble with sleep, mood, anxiety, keeping a normal routine going, we’re not going to have much luck in helping them focus on bigger or more valued goals, or getting them to add more obligations to the mix. I’ve indicated sleep and routines as the two areas for the person to think about, but it could be that asking the person “what have you stopped doing” is enough of a prompt – I’m just concerned that, at this stage, the person isn’t yet ready to look ahead, they might just need some breathing space before moving on to deciding.

If the person is currently in the process of deciding, they’re weighing up the costs of looking for more treatment (to help them return to “normal”, or how they were before their pain began). The longer it’s taken to get to this point, the less chance they have of getting back to normal in its entirety. At this point, I think our job is to help the person make this process explicit. Using a decisional balance  chart (similar to the one I’ve linked to, but you can change it), and reflecting on what’s important in the person’s life, we can help people resolve their ambivalence and make their own minds up as to whether they’re ready to get on with life, or carry on looking for treatments. Remember, every treatment carries the risk of failure: so even if you’ve got the newest, most groovy treatment ever, respect that many people would rather not go ahead with an uncertain outcome if they can instead return to doing something that’s really important to them. It’s just that making this decision explicit is rarely carried out.

Once someone’s finished deciding, they can begin doing what’s important or occupational engaging. To enter this process, the person needs to consider what occupations (activities to those of you who don’t use occupational therapy/occupational science language) are most highly valued, make them feel like themselves. While some people are very clear about what it is they want to do most, others might find this a bit of a struggle – especially if it’s been a long time, or if the thing they love the most is something other professionals have told them is “unrealistic”. Here’s my take on this: I think if a person wants something of value, they will find a way to do it. Who am I to disagree? My job is to help them develop ways of achieving it, or at least of achieving the value that this occupation expresses. Each occupation we do is underpinned by values, reasons we believe it’s important. It may not be the occupation itself, but instead may be how we do it that expresses an important value. Our job at this point is to help the person identify the values expressed within this important occupation, and help the person problem solve ways to express those values.

Then most people will begin developing coping skillsso they can do what’s important. Again, our job is to support the person to develop a range of ways to achieve or engage in valued occupations. There’s no “right” way or “wrong” way, there are simply ways to do things that work in that particular context. What’s important is that the person knows plenty of options, and can choose when they fit the context. Where we might need to help is in providing options for coping, and in helping the person develop flexibility in how they apply these strategies. Flexibility might need to come from helping the person think differently about their pain, or about using some of the strategies.

And finally, once a person is beginning to do what’s important and use coping strategies, then it’s time for them to begin future planning. This process (and the other two of occupational engaging and coping) are going to be relevant for the rest of the person’s life. Future planning needs to include setback planning, maintaining behaviour changes, thinking about other ways to keep expressing who the person really is. I think it’s an aspect of pain management that we rarely consider – having chronic pain can mean learning to grow, to keep developing, to become more resilient and allows us to develop different parts of ourselves. It’s more than just “returning to normal” because, after all, what’s normal?

Who are you? The effect of pain on self


My client, let’s call him Al, is a plumber. Or was a plumber. He sees himself as a hard-working, reliable guy who takes pride in doing a job once, doing it well, and not stopping until the job is finished. He’s worked for most of his adult life in his own plumbing business, something he’s very proud of. He’s supported his partner while she’s been at home caring for their two now adolescent boys. In his spare time he goes fishing, loves the outdoors and likes to wander the hills whenever he can.

Al isn’t very happy. He’s been told that his back pain, which he’s had for six months now, is not likely to go away. He’s been having treatments from physiotherapy, had a return to work programme developed by an occupational therapist, tried medications and injections but nothing has taken his pain away. He’s slowly stopped seeing his mates, isn’t sleeping well, hasn’t been out fishing in months, and he’s even had trouble keeping from shouting at his boys.

Al doesn’t sound all that different from many of the men I’ve seen in pain management. Some people call him “unmotivated” because he’s stopped thinking about goals for the future, and does his exercises in a half-hearted sort of way. He doesn’t always attend his appointments. It’s hard to know whether he’s actually doing his home exercise programme. A far cry from the “hard-working, reliable” man who runs his own business.

What’s going on? We could say he’s depressed, and maybe he is. But more importantly, why is he depressed? He doesn’t describe his pain as anything more than a 5/10 where 10 is the most extreme pain he can imagine. He’s still getting an income from his worker’s compensation, he’s still in a loving relationship and in their own home. But he’s not a happy man.

We’ve all met an Al, I’m sure. Superficially he looks fine, but a throwaway comment nails it: “I’m just not myself any more, I want things to be normal”.

Self-concept

All of us have an idea of who we are. A self-concept is a set of representations about who we are, what we do, how we do it, and why we do it. We all have several self-concepts – the “actual” self, the “ideal” self (who we would like to be), the “ought” self (the person others think we should be), the “feared” self (the person we really don’t want to be) and so on (Higgins, 1999; Markus & Nurius, 1986). Our sense of self is based on a collection of memories, a pattern of behaviours that we’ve developed and continue to develop as we aim to be the person we want to be.  Our sense of self guides our choices and the way we do things.

What happens when we can’t do things the way we think we “should”, or the way our sense of self would guide us to? Let’s think about this for a minute.

Al is used to getting up early in the morning, usually about 6.00, so he can get out to the site he’s working on that day and begin work by about 7.30. He prides himself on being at work, ready to go, before his apprentice gets there. He’s always organised, got his gear ready and in the truck with a cup of tea all sorted so he can plan his day.

Since he developed his back pain, Al’s had trouble getting out of bed before 8.00. He’s always tired. He’s not sleeping. He’s the last one in the house to get up, and he can’t even get to the work site until 9.00 because his body is sore and he can’t seem to wake up. He’s getting picked up by his apprentice who keeps giving him grief over not having his gear ready in time. He’s not the man he used to be, in fact, he’s become the man he swore he’d never be, a compensation bludger. He doesn’t like who he’s become. He feels lazy and useless.

Achieving self-coherence by re-occupying self

One of the neglected aspects of pain management is how to help someone deal with the changes to his or her sense of self. Life becomes chaotic when assumptions we make about the world no longer apply. The main concern of someone who is learning to deal with chronic pain is how to make life and self make sense again, to regain some coherence.  When they successfully solve this problem, it’s like all the various aspects of “self” have been reassembled. This is usually a new “self”, one that incorporates pain and the things that need to be done to accommodate pain while still expressing important aspects of “who” he or she is.

The process of learning to live comfortably with a new self is, I believe, a process of re-occupying self. Making a new self that feels recognisably “me”, doing the things that make “me” feel like myself, including some of “my” usual standards and attitudes and interests.

Yet what do we so often do when we doing pain management? We tell people like Al to “relax” and “pace” (Al learned as a child that you don’t stop until the job is done). We tell him he needs to move in certain ways (as a plumber? under buildings, in roof cavities, hauling gear out of the truck, carrying it over building sites). We suggest he needs to not do some things (work for the whole day without a break), but ask him to do other things (carry out a set of exercises three times a day). We say he needs to be back at work, but he doesn’t feel he’s pulling his weight.

What can we do?

I think we need to take some time to understand Al and what’s important to him. Not just the occupations (activities) but also the way he does them, and why he does them. How do they contribute to his sense of self? And then we need to work with him to give himself “permission” to do things differently – for a while. It’s like putting on a temporary “self”, a “rehabilitation” self. We can revisit this “rehabilitation” self as time goes on, and help him identify important values and occupations so he can begin to feel more like himself. Perhaps help him develop a new self that lets go of the old “normal” but includes some of the most important values expressed differently. I call this flexibly persisting – as Antony Robbins says, “staying committed to your decisions, but staying flexible in your approach”.

BTW – if you’d like to help me share this concept, you can! The idea of re-occupying self emerged from my PhD studies, and I want to present this at the Pain Science in Motion Colloquium in Brussels at the end of March. If you’d like to help me raise the airfare to get there (and back!), go to Give a Little and my page “Live well with pain”. Every little bit counts! I’ve had some wonderful people help me get almost half the money I need – will you help me get the rest? Thank you!!

 

Beekman, Claire E., Axtell, Lois, Noland, Kathy S., & West, Jaime Y. (1985). Self-concept: An outcome of a program for spinal pain. Pain, 22(1), 59-66. doi: http://dx.doi.org/10.1016/0304-3959%2885%2990148-4

Charmaz, K. (2002). The self as habit: The reconstruction of self in chronic illness. Occupational Therapy Journal of Research, 22(Suppl1), 31S-41S. doi: dx.doi.org/10.1177/15394492020220S105

Hellstrom, Christina. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology & Health, 16(1), 111-124. doi: http://dx.doi.org/10.1080/08870440108405493

Higgins, E. Tory. (1999). Self-discrepency: A theory relating self and affect The self in social psychology (pp. 150-181). New York, NY: Psychology Press; US.

Markus, Hazel, & Nurius, Paula. (1986). Possible Selves. American Psychologist, 41(9), 954-969. doi: dx.doi.org/10.1037//0003-066X.41.9.954

Being: or doing?


I’ve posted a couple of times on goal-setting here and here and here.

You might get the message that I spend my time bimbling along without focusing on anything in particular. That’s just so not true! I definitely have things I want to achieve – and I achieve them (mostly – I never did learn German except to decipher my Burda pattern instructions!). It’s just that I think health professionals can use goals to clobber people with, and I don’t think that helps anyone, least of all the person in the middle.

Here are some more good reasons not to focus on goals:

  1. Goals can make all our efforts focused on the goal, and when the goal’s complete the actions stop. Goals can make daily actions things we do as a means to an end rather than something we do because we think they have value. Goals can make those actions temporary, a chore.
  2. Goals are external outcomes we want to achieve. That means achieving them is often out of our control. If I want to get a new job there are things I can do but in the end an employer must want to hire me. There’s nothing I can do to get a particular job if the employer just doesn’t want to employ me.
  3. When a goal takes a long time to reach, we can lose interest and give up. Then all that work is lost.

So, if I don’t just bimble along, randomly doing whatever takes my fancy, and I don’t set goals, what do I do?

I read a fabulous post by Nadira Jamal, The Belly Dance Geek

In it she’s looking at building a daily dance practice. Dancers need to practice, but many amateur dancers do a boom and bust approach to dance practice. “There’s a performance coming up – must practice! must practice!” Then once that performance is over, dance practice stops. Only to begin again once there’s another performance! No wonder some of us never get beyond struggling with hip drops. Nadira’s reasoning is that when we focus on “achieving the goal”, practice is a means to an end, not a means in itself.  Now the reason I want to dance is that it’s part of who I am, an expression of myself. So, you might wonder, why on earth don’t I practice as often as I can?  Well, it seems too hard to fit it in, I get bored, there are other people around, it’s too hot, it’s too cold, I’m still in my pj’s, I’ve had my shower already and don’t want to get all sticky…

People we work with have similarly good reasons for not doing those exercises we’ve recommended.

Instead, Nadira recommends using themes in dance practice. Picking some areas of dance to work on and working on them – selecting from a theme gives more variety for practice, they become a focus but not a prescription, and we choose them. A theme might be arms – and thinking of all the different ways I could improve my arms in dance. Pick a couple of activities, use these as a “menu”, then when you begin to practice, choose the one or ones that appeal that day.

Translating this into pain management, a theme might be “ways to down-regulate my sensitive nervous system”. The are a heap of ways to do this: mindfulness, yoga, walking in the garden, reading a good book, stretching, self-hypnosis. What a range of things I can choose from each day! I can write them all down, then depending on how I’m feeling that day I can choose the one that suits me the most.

I think it’s good to begin the day by reviewing my diary – and that when I plan my actions. I’ve decided, after listening to Nadira, to practice every morning. It’s easy because I just have to get out of bed five minutes earlier than normal. And yes, I’m only doing 5 minutes at the moment. For those who don’t know, I am NOT a morning person. And 5 minutes means I KNOW I can do it, even when I’m feeling sluggish. And it’s tied to getting up – usually I read, so I just finish reading 5 minutes early. I know the things that are likely to derail me from doing the practice, so I have my music ready, stay in my pj’s to do it (a vision that is not a sight for sore eyes), and go straight to the shower after. I’ve chosen themes for practice, and I focus on those.

With a client, I might look at “exercise” and consider all the activities that could be included in “exercise”. Not just the gym, but also gardening, vacuum-cleaning, dancing, walking along the beach, taking Sheba-the-wonderdog for a walk, throwing a stick for her. So flexible I can pick something to do each day.

The key, I think, is looking at why we think someone “should” do whatever it is we want them to do. Why should someone do exercises? Is it to be able to do something else? Yes? Then choose a number of activities that will contribute to doing that thing. Let the person decide exactly what to do each day.

Here’s an example: if we want someone to get fitter because this will help them return to work, list all the ways we (and the person) can think to get a bit of exercise into their day.

  1. Park the car a bit further away from home today, and walk to the park.
  2. Use the stairs instead of the lift.
  3. Take a bike ride around the blog.
  4. Take the dog for a walk.
  5. Walk along the beach with your partner.
  6. Build 5 minute exercise “snacks” throughout the day (I use Pomodoro technique to do this)

While these aren’t earth-shattering in intensity, for someone who is just not that into exercising, this might be a good beginning. And it allows for variety, builds on existing habits (daisy-chaining) Beginning where we are, allowing for variety and interest, and focusing on actions rather than goals gives us pleasure in the doing.

If we can’t say why we think they need to, for example, increase single leg standing balance, then seriously folks, why are we getting them to do it? If we don’t know why someone should sweat it out on a bike at a gym, then why do we think it’s a good thing? Is a spin class just for the thrill of the spin? If so, does the person enjoy it? Yes? Then fine, go for it. No? If it’s to be fit enough for something else – what other ways could that person “get fit enough”?

There is always more than one way to skin a cat, as they say. Don’t get trapped into getting your patients hooked into doing The One Exercise just because you think it’s a good thing. I’m pretty confident that this is the best way to lose people. Let’s instead focus on being, and the doing will happen in a myriad different ways.

One gap to fill in pain management


There have been some great gains in pain neuroscience over the past few years – we know more about mirror neurones, cortical smudging, “placebo” and how cognitive behavioural therapy changes the brain. It’s sexy. There are also some rather unsexy areas of pain management, and one of these is about how people learn about their chronic pain.

It takes most people several years to get a definitive diagnosis for even well-known inflammatory problems like ankylosing spondylitis (Salvadorini, Bandinelli, Delle Sedie, Riente et al, 2012) – nine years is a long time to have mysterious pain that no-one seems to have a handle on. We also know that people with pain want some very specific things from their consultations: a definite diagnosis, acknowledgment of pain, acknowledgement of expert knowledge from the person with pain, to be seen as an individual rather than a diagnosis (Haugli, Strand & Finset, 2004).

My research looked at the ways to cope used by people who live well despite their pain. The first part of living well involves making sense of what is going on.

When a person first experiences pain, mostly it’s thought of as a typical acute pain problem. When the pain doesn’t settle down, or if it feels different from other experiences of pain, people will begin searching for information. Eventually, and this can take a long time (years), there’s a match between “what I feel”, “what I’ve learned” and “a label”. The label represents a lot to people living with pain. It means validation (I’m not going crazy, I’m not imagining it, I’m not being weak), it means the problem is understandable, and it means someone knows what is going on.

At the same time as getting external validation for the problem, people are trying to work out what their pain does on a day-to-day basis. Where do I hurt? What does it feel like? What’s normal? Over the past few years as apps for our devices have been developed, these are useful tools people can use to track their pain from day-to-day.  I’ve seen incredibly detailed diaries where people have written down their pain intensity, and what they’ve done for months and months in an attempt to get symptom understanding.

And then there’s the need to predict the effect of chronic pain on what needs to be done in life. And this is a gap I think we need to fill.

When people are busy learning about their pain, and at least until they have diagnostic clarity, life seems to get put on hold. It’s a recognised feature of this phase of having pain, life can become “a viscous long-lasting now”, with temporal disorganisation (Hellstrom & Carlsson, 1996; Hellstrom, 2001).  In other words, people’s sense of the future and moving towards this gets disorganised because the world that used to be predictable has become chaotic.  They’ve lost the ability to dream about what might be there for the future, because now dominates everything.

This occurs because humans make plans based on a sense of self, of who we are, what we do, our contributions and roles. When chronic pain is present, people’s sense of self (the collection of knowledge about what-it-feels-like-to-be-me) is disturbed because all the everyday things they need to do are more difficult. Pain intrudes.

I’ve looked for any systematic tools to give people so they can learn how to predict the effect of their pain on daily activities (occupations, to use the language of occupational science and occupational therapy).  I haven’t found anything yet.

The whole idea that someone might want to, or need to, develop this kind of “somatic awareness” is counterintuitive. I mean, most programmes ask people to complete questionnaires that are used by clinicians to identify their problems and what therapy should target. Much of therapy is intended to extend what people can do, to help them go beyond their existing beliefs and limitations. We do this by engaging people in physical activities such as a circuit gym or a set of exercises that gradually gets increased over time.

BUT How does knowledge drawn from a set of exercises, or a circuit gym, transfer to the daily life patterns of a 34 year old builder? Or a 28 year old bank clerk? Or a teacher? Or a retired merchant navalman?

“Somatic awareness” as a clinical need in people with chronic pain is not a new idea. Strong and Large (1995), and Large and Strong (1997) identified that people who were not seeking treatment for their low back pain used “somatic awareness” to titrate their activity levels, and this formed a large part of their coping approach. Crowe, Whitehead, Gagan, Baxter, Pankhurst and Valledor (2010) also found that people “listen to their body” so they can adjust what they expect from themselves. Fisher, Emerson, Firpo, Ptak, Wonn and Bartolacci (2007) identified that by understanding the variability of pain, people could modify their occupational engagement, as did Persson, Andersson & Eklund (2011).   There are many more.

I think an obstacle to developing this aspect of self-management might be our fear that by asking people to notice what is going on in their bodies, we are reinforcing “pain behaviour”. I’m not sure that this is in fact what happens, but it’s an area for future research. The behavioural paradigm still has a strong influence on how we think about attention and pain. And we’ve all probably seen those people who fixate on pain fluctuations to the point of obsession, and usually because they’re keen to do whatever it takes to reduce the pain.

Somatic awareness, making sense, symptom understanding and occupational existing are tools used by people who are naive to pain management. Maybe in our efforts to help those who have a great deal of trouble with their pain, we’ve forgotten to build on the strengths used by those who cope well.

 

Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. doi: http://dx.doi.org/10.1093/fampra/cmq063

Crowe, M., Whitehead, L., Gagan, M. J., Baxter, G. D., Pankhurst, A., & Valledor, V. (2010). Listening to the body and talking to myself – the impact of chronic lower back pain: a qualitative study. International Journal of Nursing Studies, 47(5), 586-592. doi: 10.1016/j.ijnurstu.2009.09.012

Fisher, G. S., Emerson, L., Firpo, C., Ptak, J., Wonn, J., & Bartolacci, G. (2007). Chronic pain and occupation: an exploration of the lived experience. American Journal of Occupational Therapy, 61(3), 290-302.

Haugli, Liv, Strand, Elin, & Finset, Arnstein. (2004). How do patients with rheumatic disease experience their relationship with their doctors? A qualitative study of experiences of stress and support in the doctor-patient relationship. Patient Education and Counseling, 52(2), 169-174. doi: http://dx.doi.org/10.1016/S0738-3991%2803%2900023-5

Hellstrom, Christina. (2001). Affecting the future: Chronic pain and perceived agency in a clinical setting. Time & Society, 10(1), 77-92. doi: http://dx.doi.org/10.1177/0961463X01010001005

Hellstrom, Christina, & Carlsson, Sven G. (1996). The long-lasting now: Disorganization in subjective time in long-standing pain. Scandinavian Journal of Psychology, 37(4), 416-423. doi: 10.1111/j.1467-9450.1996.tb00673.x

Large, Robert, & Strong, Jenny. (1997). The personal constructs of coping with chronic low back pain: is coping a necessary evil? Pain, 73(2), 245-252. doi: http://dx.doi.org/10.1016/S0304-3959(97)00100-0

Persson, Dennis, Andersson, Ingemar, & Eklund, Mona. (2011). Defying aches and revaluating daily doing: occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188-197. doi: http://dx.doi.org/10.3109/11038128.2010.509810

Salvadorini, G., Bandinelli, F., Delle Sedie, A., Riente, L., Candelieri, A., Generini, S., . . . Matucci-Cerinic, M. (2012). Ankylosing spondylitis: how diagnostic and therapeutic delay have changed over the last six decades. Clinical & Experimental Rheumatology, 30(4), 561-565.

Strong, J., & Large, R. (1995). Coping with Chronic Low Back Pain: An Idiographic Exploration Through Focus Groups. The International Journal of Psychiatry in Medicine, 25(4), 371-387. doi: 10.2190/H4P9-U5NB-2KJU-4TBN

Goals? I loathe them: What to do instead


I dislike that acronym “SMART” goals. I can never decide whether it’s meant to mean “Specific, measurable, achievable, realistic and time-bound” or “specific, manageable, active, realistic and timed” And if it’s either of those, what’s the difference between achievable and realistic? Or is it meant to be “relevant”?

In previous posts I’ve established good reasons to have a focus for therapy. Unless the focus is something valued by the client, it’s either unlikely to get done or it’s not their goal and they’re going along with it to keep you happy. Goals, targets or focus are useful, and the logic goes that unless you have them you won’t know where you’re going or when you’ve got there.

I’m not going to argue against the idea of having a focus to therapy. I just think there are risks in having goals, like some sort of checklist that says “If you achieve this, you’re all good”.

Seriously, that doesn’t work in real life. That’s the same kind of logic that says “if I just buy enough things I’ll be happy”, “if I just earn a bit more I’ll be happy”. While there’s a bottom line below which it’s hard to think beyond survival, above that line, having stuff, and even doing things as an end in themselves doesn’t fulfill for long.

What gives forward momentum, enrichment, fulfillment and can’t be ticked off like some shopping list is recognising that life is actually a whole series of actions and events that, when we think back on them, make up a good life. The richer events and experiences and actions feel good and fulfilling. The empty routine and humdrum things feel deadly dull and empty.

When I think about the purpose of therapy my focus is helping people to live the kind of life they value, doing the things they believe are important. Given I don’t want to be a long-term feature in a client’s life (for all I love them, I’d rather they were doing it themselves), my focus is on helping them work out what makes a rich, fulfilled life they can look back on and feel satisfied. My job is to help them develop skills and strategies to carry out the actions needed to live a life aligned with what they value.

Let me unpack this a little.

Many people I see place value on being a good parent, a loving partner, a reliable employee. When I see them, their pain has interfered with doing the things they believe demonstrate “being a good parent” or “being reliable”. Pain has moved in to their lives, and come and sat on their laps right in front of their face so that all they can see is pain.  If I ask someone in this state to “set goals” they laugh, rather sarcastically sometimes, and say they don’t have goals, they can’t think of anything and what’s the point anyway. Perhaps not in those words, but the meaning is clear.

Instead, I ask them “what would you be doing if your pain was less of a problem for you?” Sometimes I’ll even hand over a plastic fairy wand I have, and suggest they dream a little. It’s then that the passion takes over – they’ll say “I’d be out working, having fun with my friends, caring for my family” – and the list goes on! If I stopped there, though, I’d be holding a tantalising dream just out of reach, which is cruel, so I don’t. Instead I ask why these things are important.

That’s how I find out that “family is everything”, “I just love creating”, “I need my friends”.

Then I switch tack for a moment and ask them “How well is what you’re doing to deal with your pain right now working to help you be the kind of person for whom family is everything? How well is what you’re doing with you pain helping you create?”

The reason for this tactic is to help generate what Acceptance and Commitment therapists (ACT) call “creative hopelessness“. Because motivation to change comes from inside – that it’s important enough, and the person is confident that change can happen.

I then suggest two things: 

  1. Is keeping pain happy more important than family ?(and yes, I know I’m personalising and objectifying pain here, and yes it’s an experience not a thing, but it works OK!)
  2. What would happen if you made a little room for pain to be there while you’re doing things that contribute to you being the kind of parent you want to be?

What I mean by this last statement is that pain can interfere with doing that things that help you feel you’re being a good parent. And that can lead to either completely abandoning those activities, or doing them while clutching resentfully to “the pain that interferes”. What if you attended to the value or importance of being the kind of person who is a good parent instead of focusing on the irritation, frustration and anger of having to bring pain along for the ride?

  • For many people, the things they believe contribute to “being a good parent” far exceed what they can currently achieve. So they give up and get demoralised. They both have their pain AND they don’t manage the very things they most value.

Now it’s here that I could begin to “set goals” and suggest we work towards them using all the traditional elements of goal setting. And that probably has excellent value. But here’s the catch: often we hold very strong internal rules about how these things should be done so that unless we can do them exactly the way we think they should be done, we’re not satisfied. And for many people this fails to recognise that as time goes on, life too goes on, and we change the way we do things to accommodate new habits or capabilities. So I try to begin a process of developing flexibility – and using the values a person identifies as a compass rather than a checklist.

What would happen if we thought a little about the range of things people might do to convey “being a good parent”? Maybe it would mean going to the children’s sports games and being a spectator. Maybe it would mean making lunches, helping to do homework. Maybe it would include listening while a kid tells you about his or her day. Many of these things can be done with pain present. Many might require altering how they’re done to accommodate having pain present but provided that they express the underlying value of being a good parent, can be fulfilling.

What’s important is less about the what a person does, and a whole lot more about why and how they do it.  When “being a good parent” becomes the direction we live (because we can never tick the box that says “being a good parent” is complete), then we focus on why and how we do it. Attention goes away from “but pain stops me”, and towards discovering all the ways “being a good parent” can be lived.

Often it’s through doing this that people seek new coping strategies so they can extend what they do. People may “set goals” or future actions they want to take but instead of feeling frustrated and dissatisfied, they begin to to take actions that bring them closer and closer to living the life they want to live. And that, my friends, is what I think “goal setting” is about.

This festive season is a good time to consider what’s important in your life. What actions are you taking to live a value-filled life?

“I don’t know what I want to do” – Silent copers?


One of my friends on Facebook said it’s difficult working with someone who doesn’t come up with a goal, or a new direction in pain management, even when they accept that their pain isn’t a threat (it’s hurt, not harm). It sure is! So I thought today I’d review some of the factors that might maintain someone in this “limbo land” where, as a therapist, it feels like you’re doing all the work.

Firstly, let’s distinguish between having pain and being disabled by it. Pain is an experience that people have. It doesn’t live outside a person’s narrative of their life. It always has some meaning in some way, and this meaning makes it pain rather than any other experience.  To quote Joanna Bourke “Being-in-pain is a multifaceted sensory, cognitive, affective, motivational, and temporal phenomenon… people perceive pain through the prism of the entirety of their lived experiences, including their sensual physiologies, emotional states, cognitive beliefs and relational standing in various communities.” (Bourke, 2014, p. 13).

Being disabled by pain involves being unable to do things as a result of pain; the experience and meaning of that experience interfering with participating in daily life. Being disabled can emerge from physiological responses to pain, cognitions about the meaning of pain, reinforcement for behaviour arising from contextual features, and emotional responses to all of the above. In chronic pain, where pain intensity is difficult to reduce (if it can be at all), my main focus is on how I can help a person be less disabled by their experience of pain.

When someone looks for help for their pain, Ferreira, Machado, Latimer, Maher, Ferreira and Smeets (2010) found that the primary reason was associated with how much pain interfered with life. Disability rather than pain intensity is a strong motivator for help-seeking. This suggests to me that we should be able to identify what it is that a person can’t do and use this as a motivating factor for change. But of course it’s not quite as simple as that.

Reasons for not having goals

  • One reason is that people coming for help with chronic pain may have been waiting a very long time to be seen. For example, in Christchurch, last time I reviewed the data around referrals to the tertiary pain management service, the average pain duration before being referred (not even being seen) was four years. Imagine how that might affect someone. Four years of “I don’t know what’s wrong with you”, or “I’m sorry but you don’t seem to be responding well”, or “The surgery went well, I don’t understand why you’re still feeling pain” – it might make you feel slightly demoralised, perhaps a little hopeless. Remember that most people with chronic pain don’t know the point at which they shift from an acute pain problem which should resolve, to a chronic pain problem that, by definition almost, is going to persist. Pain like that just doesn’t make sense. It can be very frightening.

As a result, some people lose hope and feel that they must live very, very carefully in case they do something to increase their pain, or make their problem worse.

  • Another reason can be because of the messages people can be given. Mixed messages usually, and by anyone  – “Be careful, you don’t want to overdo it”, “last time you did that, it took you days to get over it”, “You have wear and tear in your joint [oh, does that mean I should stop so I don’t wear the joint away completely?]”, “don’t have flare-ups”, “you need to let your body/brain settle down”, “pace yourself”.

Some of these messages are ones we give – even enlightened people coming from a Therapeutic Neuroscience (TNE) perspective can inadvertently suggest a person should “take it easy” and “be kind to your sensitive nervous system” – which is all very well, except when the “take it easy” message is never reviewed, and the person learns that a painful flare-up means they’ve been “too hard” on their nervous system. Like the paced activity approach, both of these messages need to be reviewed so the person learns how to deal with a flare-up then resumes gradual increases in activity level. Erroneous messages from the media (yes! that “text-neck” meme that’s going around!), medical professionals, family and friends can all maintain avoidance, even in the face of TNE that reaches the head but not the heart.

  • Some people can find it very hard to think of goals because they’ve never learned about goal-setting. Goal-setting is a learned behaviour, something that health professionals learn how to do, business people learn how to do – but it doesn’t always transfer into daily life. Some people live in the flow of life, going with whatever happens, responding to situations rather than setting out with a purpose. Sometimes this happens because they live in poverty and can’t think beyond today. Sometimes it arises because they’ve had so many negative experiences when they have tried to move in a particular direction that they’ve given up. Sometimes it’s part of a family context, perhaps a cultural context. I suspect goals and achievement are a very eurocentric phenomenon, and if you’re from a different culture, perhaps this doesn’t make sense – because family or group goals are far more meaningful.
  • Some people may have contexts in which making change is extraordinarily difficult. A scenario I’ve met before: the person with pain who hasn’t worked for some years; the two parents – one has a long-term disability, the other is unemployed, the sibling who is on a sickness benefit. No-one gets up before 11.00, no-one works, and there’s little or no support for the person with pain to make any changes within the situation. Even if pain is reduced, it’s going to be difficult for a person to do anything differently because others in the family are also stuck.
  • Some contexts are actively punitive when a person begins to make changes. When another family member needs the person to “be cared for” because it meets his or her needs, it’s going to be hard for anyone to make a change.
  • Some people hold strong ideas about their performance, perhaps holding up an idealised vision of who they were before this all happened – now, even beginning to think about making a change highlights the discrepancy between who they are now and who they used to be, not exactly a great way to encourage change.

I haven’t started looking at what you can do to help someone step out of the glue that these factors can be. Don’t worry – that’s next week’s post! But in the meantime, here are some of my older posts that might be useful:

Individualising explanations with case formulation Coping with pain: A motivational perspective goals-values-and-motivation

Bourke, Joanna. (2014). The story of pain: from prayer to painkillers: Oxford University Press.

Ferreira, Manuela L., Machado, Gustavo, Latimer, Jane, Maher, Christopher, Ferreira, Paulo H., & Smeets, Rob J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. doi: http://dx.doi.org/10.1016/j.ejpain.2009.11.005

Over or under activity in people with chronic pain


There is plenty of research showing that the relationship between pain intensity and limitations in daily life is unclear. There is also ample evidence showing that the relationship between tissue damage and pain is unclear. Add all three components together and it’s easy to see that trying to work out whether a person is unable to do something, or is simply unwilling to do something is complicated. It’s also important.

When we look at activity patterns across a day or week, each one of us has a different “typical” profile. Some of us are morning people (I’m not), with higher levels of activity in the morning, tailing off to less over the day. Some are night owls and peak activity might be at night. Different types of work also shape our activity profile – if you’re a business person you may spend a great deal of the day sitting in a desk, getting physically active only when going out for a fitness activity while there are plenty of tradespeople who work very hard throughout the day, but spend the evening in front of the telly. And of course shiftwork, days off from paid work, and home responsibilities like cooking meals, cleaning the house, caring for children, doing the garden also contribute to the variability in a person’s daily activities.

So it’s difficult to tell what activity profile is “normal”. How on earth do we tell whether someone is able to do more? And how do we define “over activity” or “persistence” and “under activity” or “avoidance”?

Activity management is coming under scrutiny more and more. Pacing, or ““the active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities” (Jamieson-Lega, Berry, & Brown. 2013, p. 207) is routinely used in pain management programmes to help people gain more capacity to do what is important in their lives. To use pacing effectively people living with pain need to estimate what they’re currently doing – are they pushing, or overdoing, then busting or avoiding?

In the current discussion, Van Damme and Kindermans (in press) present a self-regulation perspective on activity patterns. Within this model, behaviour, or what we do, emerges from a range of motivational factors or goals. We change our behaviour to better achieve valued goals, and adjust according to an internal “standard” we develop. Van Damme and Kindermans argue that, within this model, avoidance and persistence are not so much about how pain is interpreted, but more related to regulating the actions we take in relation to important goals. They review a number of theories relevant to self regulation, including self-identity such that avoidance and persistence can be seen as ways individuals try to restore a sense of “normal” self by reducing the discrepancy between what they think they should be achieving (and how), and what they can achieve.  They go on to look at “affective-motivational” theory in which over-activity might be associated with feeling positive, feeling good results in doing “too much”, subsequently leading to stopping when mood drops as pain increases. This model is also associated with the intrinsic value the person places on the activity – if the focus is on “I’m going to do as much as I can”, satisfaction rests on how much progress towards the end point is achieved, while “I’ll do as much until I feel like stopping” means the focus is on enjoyment levels in the tasks.

Van Damme and Kindermans also discuss goal cognition, or that people have a “mind model” of how they typically go about achieving a goal. People living with pain may develop a new model of the effect of pain on the ways they go about achieving goals, and this may influence how a person responds to pain fluctuations. Their final model is coping, in which they describe either an assimilating process, where efforts focus on changing factors getting in the way of the goal or by working harder so it can be achieved, or an accommodating process where goals are reappraised and adapted to accommodate the current situation.

So much for theory. There are a couple of main points I want to make.

Our baseline level of activity varies a whole lot. Even within the course of a week we can go from days where we do a lot, to days where we chill. This means that determining what is an appropriate level of activity needs to be context specific. The level of activity we engage in (and the pattern) can be intentionally changed. What this means is we can all choose (or be constrained) to do more, or less, depending on the situation and the goal. And what’s more, we do this all the time. We can intentionally grind up a hill, increasing our pain, so we can get to the top. We can also decide not to do the vacuum cleaning today because we’re too sore, or because we judge that it’s not as much of a priority as remaining calm while making dinner.

We, and people with pain, make decisions about what we will and won’t do on the basis of a whole lot of different factors, and we do this fluidly throughout the day, every day.

What seems important to me is that we help people living with pain establish flexibility in the ways they go about doing things. We need to help people make choices rather than feeling pushed into overdoing, or underdoing. It’s that knowledge that we can choose to push to the top of the hill (and pay the consequences in feeling out of breath), or we can choose not vacuum the floor today (and live with the dirt and dog hair a day longer). It’s also about knowing that we can be flexible and use different ways of achieving these outcomes depending on our values, energy, people around us, and other priorities.

I’m not sure this has been entirely factored into Van Damme and Kinderman’s proposal, but I do agree with them that we need to pay more attention to context and intention when we look at the ways people go about daily life.

 

Jamieson-Lega, K., Berry, R., & Brown, C. A. (2013). Pacing: a concept analysis of the chronic pain intervention. Pain Res Manag, 18(4), 207-213.

Van Damme, Stefaan , & Kindermans, Hanne A Self-Regulation Perspective on Avoidance and Persistence Behaviour in Chronic Pain: New Theories, New Challenges? Clinical Journal of Pain.

Van Damme, Stefaan Avoidance and Persistence: Capacity or Motivation? Clinical Journal of Pain.

Andrews, Nicole E., Strong, Jenny , & Meredith, Pamela J. . Avoidance or Incapacitation: A Discussion on Definition and Validity of Objective Measures of Avoidance, Persistence and Overactivity. Clinical Journal of Pain.