Motivation

“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

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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.

 

How does chronic pain management work? A self concept hypothesis


In my previous post looking at how chronic pain management works, I put forward the hypothesis that

“What DOES change is [people’s] self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.”

Later in the comments I mentioned the idea of renegotiating self concept – that part of learning to live well with chronic pain is the process of integrating the reality of on-going pain and associated limitations within their “understanding of how he or she responds in situations and the roles he or she expects to fulfil” (Baumeister, 1997; Christiansen, 1999).  Self-concept is a predictive process where the knowledge a person has about his or her personality traits, roles, and relationships guides their actions so that they present consistently across social and private contexts.

So self concept is “the person I am”. Several authors have described chronic pain as a “biographical disruption” that forces individuals to reconsider their past, present and future, often creating a discrepancy between the self-concept before pain and the current self (Asbring, 2001; Richardson, Ong, & Sim, 2006; Wilson, 2007). To accommodate chronic pain within the self concept means people need to incorporate an understanding of the new current self in a way that can retain as much of the past self as possible, without placing unsustainable demands on the future self. People who cope well with pain develop a self-concept in which the effect of pain is assimilated without compromising critical values in their lives, even though it may influence how these are enacted.

What this means is that people who cope well with pain identify the important values they hold (parts of self), let go of old parts of themselves they can’t continue to achieve, and find ways of ensuring the parts of themselves that they do value very highly can still be done.

John Quintner suggested that programmes that help people cope with their pain provide people with hope. I agree. I think that by helping people see that they can still retain essential parts of their concept of who they are, they can begin to see that life CAN continue to have some of the good things they really value.

Some of the mechanisms that I think might be involved in helping people renegotiate their self concept are:

  • engaging in occupations (activities, roles that are individual and unique to them) as part of learning to make sense of their pain
  • this helps to make their pain less threatening, more predictable
  • and thus they’re more able to account for the effects of pain on what they want to do

People don’t only learn by doing things themselves, they also learn by seeing other people do things. This means that when people see a famous athlete or actor identifying with something like depression, for example, people with depression can gain hope that they too can still achieve despite their depression. In chronic pain management, people attending a group programme watch one another do things that they have also struggled with – and this provides both a model as to how this can be done, but also something to aspire to. This increases self efficacy because instead of seeing how “experts” (ie professionals) suggest they do things, they see people “like me” doing things.

If learning to live well with pain is partly about developing a new sense of self, then acceptance also involves letting go of things that can no longer be sustained (the past self) while holding onto important aspects of this self that can continue in a sustainable way into the future. This is something we all need to learn to do as we grow older. Usually it’s a gradual process, and most of us are sad to recognise that we’re aging, but also positive in that we’re moving towards new things that continue to add to our self concept. For people who develop chronic pain, it can be a profound change.

Letting go of the desire to “go back to normal” is incredibly hard. It won’t happen if a new opportunity to “go back to normal” keeps on being offered. And this is the tragedy of repeated attempts to find a complete cure, because it stops people being able to let go of things that may be unsustainable, keeps them in a sort of stasis while their life is focused on pain. And for many types of pain, there is no complete cure – even very successful interventions rarely completely abolish pain.

Hope, for people with chronic pain, involves more than taking all the pain away. It needs also to restore their confidence that they can be the person they want to be, to fit their self concept.  This is why return to work for people with chronic pain needs to address issues of the person feeling unreliable (“how can I go to work if I can’t go every day because of my pain?” “who would employ me when I can’t work the way I used to?”), of being able to present themselves as an asset to an employer, where chronic pain isn’t a liability but can be an asset. Because most people want to be seen as competent, reliable, and contributing within a work environment – and until they can see how these things can be achieved despite their pain, it’s going to be hard for them to convince an employer.

I think that learning to be flexible in terms of how to go about achieving something important might be the biggest factor in how chronic pain management programmes work. And I think the process is about renegotiating a self concept that allows this flexibility to occur, and maybe by helping people identify the values that underpin important occupations we might be able to support them to find new ways to express those values.

Asbring, Pia. (2001). Chronic illness – a disruption in life: identity-transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing, 34(3), 312-319. doi: 10.1046/j.1365-2648.2001.01767.x

Baumeister, Roy F. (1997). Identity, self-concept, and self-esteem: The self lost and found. Hogan, Robert [Ed], 681-710.

Christiansen, C. H. (1999). Defining lives: occupation as identity: an essay on competence, coherence, and the creation of meaning. British Journal of Occupational Therapy, 53(6), 547-558.

Richardson, Jane C., Ong, Bie Nio, & Sim, Julius. (2006). Is chronic widespread pain biographically disruptive? Social Science & Medicine, 63(6), 1573-1585. doi: http://dx.doi.org/10.1016/j.socscimed.2006.03.040

Wilson, S. (2007). ‘When you have children, you’re obliged to live’1: motherhood, chronic illness and biographical disruption Sociology of Health & Illness, 29 (4), 610-626 DOI: 10.1111/j.1467-9566.2007.01008.x

The Graded Motor Imagery Handbook – a review


I love getting presents, and I love books, so what could be better than getting a book to review as a present!

Graded motor imagery (GMI) has become incredibly popular in pain management, especially for people with unilateral pain.  It’s a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence.  For those who don’t know – level B1 evidence means there are several RCT’s, and at least one meta-analysis showing support for this approach.

Back to the book.  Like all the NOI books it’s an unusual size, has groovy graphics and an easy-to-use layout. It’s a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes.  The illustrations and photographs are clear and provide excellent guidance for clinicians.  Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler’s favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment.   Each chapter can stand alone, and it’s not necessary to read from beginning to end – but of course, it does help!

This book isn’t for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain – and the translation into the “real world” – are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.

Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment.  GMI has best application in people with unilateral pain such as CRPS and phantom limb pain – although it has been extended to other pains.  These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.

Back to the book again!   I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI.  His writing is clear and provides an excellent scientific basis for the approach.  He doesn’t extend his writing into psychological aspects of pain beyond the concepts of what he calls “neurotags”, or “interconnected neurones … that produce an output”.  Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action).  I have learned these associations as just that – associations between various aspects of learning and anticipation, and have called them the neuromatrix – but NOI have used the term neurotag, and I guess it’s as good a name as any.

The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written.  While it’s possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer’s neuroscience, and Butler’s metaphors, it becomes far more flexible.  I like this.  It is a chapter that I think many clinicians will turn to regularly – but as is emphasised throughout this handbook, patients/participants should read this stuff too.

Worth getting? Yes, I think so. 

My caution lies in over-interpreting the application of GMI beyond the evidence-base.  If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her.  Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain.  Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world.  After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport – where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment.

Where to get it? Go here – and let ’em know I sent you.

How occupational engagement might work in pain management


ResearchBlogging.org
Intuitively, most of us know that when we’re actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst – or pain.  In the very early years of occupational therapy, this “distracting” factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars.  Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation’s sake was often left behind.

More recently we’ve begun to learn more about how occupation might be a good thing.  First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing.

Then we found that through positive psychology studies that the state of  “flow” popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance.

Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management.  This is interesting to me for several reasons – firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004).  Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual.

Let me explain: usually it’s recommended to maintain a consistent level of activity.  Sometimes this is called activity pacing.  Yet there are times when it’s appropriate to suspend the use of pacing – when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours).  We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam.

Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity.  Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues.  Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus.  Two different colours were used, one of which had been associated with a painful stimulus.  Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing.

To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud.  If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made.  This was the “nonpain task goal”, or activity/occupation.

The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted.  In other words, they were not as quick to respond to things that they had previously viewed as a potential threat.

This is a really interesting finding – while it’s a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat.

Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used.  Their findings were that “engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. ”

It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management.

Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025

Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227.

Bradshaw, D.,Chapman, CR., Jacobson, RC.,  and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain.

Seeing is believing?


ResearchBlogging.orgI am slowly wending my way through a long, complex and incredibly important article by a group of researchers and clinicians writing about the social element of pain.  The basic premise of this paper is that while pain is a private experience, we are social creatures.  As social creatures, we communicate about things that are important to survival – and because pain is one way for the brain to signal to an individual that “something dangerous or might be dangerous is happening”, once pain is experienced, for the most part we begin to signal this to others around us.

I haven’t a hope of trying to summarise this paper, and I urge you to read it for yourself  – it really is an important piece of work.  The reason it’s so important is that we don’t have any idea about someone else’s pain except as it is “displayed” or communicated to us.  This has far-reaching implications for any clinician working in the field of pain management, whether acute or chronic pain.

What does it imply? Clinically, it means that if I am working with someone who has pain, all my personal beliefs and ability to interpret the verbal and nonverbal behaviours of that person come into play.  So if I’m having a bad day, perhaps I’m not attending to what the person is and isn’t saying, my interpretation can be “off”.  Similarly, if I have beliefs about what constitutes “normal” pain behaviour, and the person I’m seeing doesn’t exhibit this kind of behaviour, I can easily misinterpret this, maybe even convey skepticism or disbelief.

Included in this paper is a great discussion of social context – after all, we don’t live in isolation! And even if we did, this too would constitute a social context.  People who have pain and exhibit illness behaviour will have an effect on others around them.  We know that relationships can be negatively influenced by alterations in roles, but we also know that illness behaviour and distress can elicit additional attention and caring from others – at least in the short term.

One social context in which pain communication has a profound effect is in healthcare.  There can be an assumption or belief that we as health professionals have a neutrality about the way we view pain behaviour, yet we are not immune to our own beliefs or biases.  And we can misinterpret the behaviour of another in some rather alarming ways.

Here’s an example: a client has complex regional pain syndrome of his hand.  He has all the typical features of CRPS in that he has swelling, colour change, temperature change and so on.  He is also a guy who loves to work and is very distressed that because of his hand pain, he can no longer work, in fact for months he had to have someone else help him wash and dress because of allodynia along his whole arm – so bad that he couldn’t bear the shower water running on his arm.

Not only was this man able to show some concrete evidence that he does have “something wrong” with his hand, he was also articulate, and he wasn’t afraid to go after what he wanted.  He has been to numerous treatment providers, attended the Emergency Department and After Hours Clinics almost every week, and in his distress, he was known to sit, weeping, in the entrance foyer of the ED, refusing to leave until “someone” did “something”.

He has had over 30 anaesthetic procedures to his arm, with concurrent physiotherapy. He has been prescribed multiple medications. He has done “everything” asked of him in terms of his rehab. His functional status has not changed. And he has never been seen by a psychosocial clinician.

When I asked why he hadn’t been seen by an interdisciplinary team, the reply from one of the attending clinicians was that his pain was “genuine”, and “really severe”, and “he has always participated in his rehab” – the implication being that he didn’t need to see an interdisciplinary team because of his “motivation”.

By stark contrast, another client I’m seeing is very reticent about his pain. He doesn’t like to talk about it, he generally looks well although he moves a little cautiously.  His pain is back pain. While he’s had surgery, it’s been unsuccessful.  This client doesn’t use medication (he says because none of them help without giving him significant side effects). He is very apprehensive about seeing health professionals. He’s reluctant to participate in rehab – his view is that if he does, it increases his pain, if his pain increases, life isn’t enjoyable. He’s worried about his pain and doesn’t know what to do to move on.

This man has been seen by some of the same clinicians as the previous man – but viewed completely differently. With more than a dollop of skepticism. He doesn’t engage in the behaviour that is acceptable for a patient. Oh, and he’s been referred to an interdisciplinary team to address his “motivation”.

On the face of it, these two men both have pain, both haven’t responded to biomedical intervention, and both are significantly disabled by their pain. The one has had numerous interventions and is viewed as having “genuine” pain, while the other is seen as maybe “playing on” his pain.

I have two take-home points:

  1. Both men are demonstrating pain behaviour, but how we as health professionals respond to them has been quite different and tells us more about our beliefs and attitudes than it does their “genuineness”.  Let’s think about the judgements we make about our patients.
  2. Psychosocial and interdisciplinary pain management is needed by both men. It shouldn’t depend on how we view their motivation. Psychosocial input helps with distress management (the first man) as well as goal setting and anxiety management (the second man). Let’s make sure we view all pain with biopsychosocial lenses on.

 

Hadjistavropoulos, T., Craig, K., Duck, S., Cano, A., Goubert, L., Jackson, P., Mogil, J., Rainville, P., Sullivan, M., de C. Williams, A., Vervoort, T., & Fitzgerald, T. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin DOI: 10.1037/a0023876

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

Friday Meditation


As you know, Friday is about getting ready for the weekend.  Today I decided not to pass on some of the horrendous puns shared with me by one of my esteemed colleagues (although I may drop just one in because I can!).  Instead I thought this poem is a chance to consider being ‘in the now’, something clinicians working in pain management really need.

Salutation To The Dawn

Look to this day!

For it is life, the very life of life.

In its brief course

Lie all the verities and realities of your existence:

The bliss of growth,

The glory of action,

The splendor of achievement,

For yesterday is but a dream

And tomorrow is just a vision,

And today well lived makes every yesterday a dream of happiness

And every tomorrow a vision of hope.

Look well, therefore to this day!

Such is the salutation to the dawn.

Kalidasa

 

Oh, a pun?  As you read this, remember I have to work with the person who passed it on…sigh…

She was only a whiskey maker, but he loved her still.

A rubber band pistol was confiscated from algebra class, because it
was a weapon of math disruption.

No matter how much you push the envelope, it’ll still be
stationery.

A dog gave birth to puppies near the road and was arrested for
littering.

I wondered why the baseball kept getting bigger.  Then it hit me.

Two fish swim into a concrete wall.  One turns to the other and says
‘Dam!’

CBT approach in the real world


ResearchBlogging.org

While there are many papers published about the outcomes from using a cognitive behavioural approach, there are very few describing the process ‘in the real world’. This leaves a gap for many clinicians who may read about it, maybe have training in delivering this type of intervention, or work in a team where it’s an integral part of practice – but who may not know how it ‘works’ except as it’s delivered in a pen-and-paper, sitting-in-a-clinic-room kind of way.

Today I’m describing one way I go about integrating a CBT approach into my work.    This case study is a compilation of several people I’ve worked with, in order to protect patient privacy.

Simone has neuropathic pain in her dominant hand. She’s a tough cookie who worked in a shearing gang. She’s tiny, has a command of the cussing vocabulary that has to be heard to be believed, and she’s very reluctant to use her hand although she has really good movement.

Simone’s always been a physical kind of person and loved riding motorbikes, rock climbing and gardening. She doesn’t think any of these things are manageable now, and so she spends most of the day ‘pottering’ in the garden or with friends or, as she puts it ‘death by DVD’.

Her goals are to get fit again, to decide on her ‘next best steps’ for returning to work, and to feel more confident about using her hand BUT she’s made it very clear that she’s not going to do ‘pretend’ activities like handcrafts or ‘just holding the bike throttle’ – she wants to start doing proper things again.

Oh my, where do we start!

We’ve started by reviewing what she knows about pain management – naming all the different types of strategy that can be used, and ranking them in order of priority for review. Simone said she needs to ‘get fit again’ and sees exercise as a big part of this; she also recognises that she can be quite inconsistent in her activity patterns, and although she knows about activity pacing, she doesn’t like doing it.

I asked her about her daily routine and she laughed saying that she just ‘does’ and hates planning, so instead I gave her 12 cards representing the amount of energy she has to ‘spend’ over the course of a day. I asked her to allocate her cards into three areas of living: self care, fun and work. She divided the cards quite evenly, so I then asked her whether this was how she wanted to spend her energy. She said no and that it was very different from her pre-accident pattern, so I asked her to show me what that looked like. She pushed almost all of the cards into the ‘work’ pile, and kept only one for self care and two for fun.

I asked her what was different about her self care now compared with before, and she described the process of showering – and while she talked, I was able to identify her automatic thoughts about each task. She said she always thought it should be enjoyable but now it just felt hard. She said she didn’t think she should have to ‘think’ about how she undressed, washed herself, dried herself, and got dressed again. Now she felt her body was skinny and ugly and her arms ‘wouldn’t work properly‘, and so she avoided looking at it, and didn’t use moisturizer and didn’t shave her legs any more.

She was very articulate about the automatic thoughts and images that she had while showering and we were also able to identify some of the emotions that were generated by these thoughts, and how this affected what she did.

I used a whiteboard to jot down the situation, her thoughts, linking to her feelings and on to her actions, and Simone was quick to say that these thoughts weren’t helping her.  NB all the underlined phrases above refer to automatic thoughts she was having.

We haven’t yet explored these thoughts nor tried to do anything with them (maybe we won’t do anything, just notice and do what is important?) – but part of understanding her situation is about listening to her thoughts as I’ve outlined above. This is Simone’s ‘lived experience’, but it’s absolutely possible for her to evaluate her situation differently and come to a different conclusion about them.

For a very quick example, I might ask her what does it mean to ‘have’ to think about each movement she does?  What does it say about her? What does it mean to have a rule that says showering ‘should’ be easy – when clearly, showering for her is not. If she says she feels ‘dumb’ or ‘useless’, I may explore other situations in her daily life now where she feels ‘dumb’ or ‘useless’ – and help her notice her emotional response to this.  What effect does having this emotion have on her actions? On what she does and how she goes about it?

Simone has described patterns of thoughts that are very judgmental about her capabilities.  While a psychologist may explore some of the origins of this, and the effect on her mood and especially her vulnerability to depression, what I’m inclined to explore is how her automatic thoughts and underlying ‘rules’ are affecting her willingness to engage in activities that she previously enjoyed – like having a shower – and both be aware of this vulnerability in terms of goal setting (she’s not keen on doing this!), and help her generate some more positive self statements she can make when trying a different approach. I’ll also ensure the goals are achievable but also ones she really values.  If they’re ‘too easy’, she’ll judge them as not worth the effort while if they’re too difficult and she can’t see why she should persevere (ie they’re not important to her), she may give up.

I’ve suggested already that she treat each new method as an experiment.  We don’t fail at experiments – we can learn from each attempt. When she tries a new approach, we’ll go through the things that worked well, and the things that she would do differently.  I’ll also use motivational approaches to encourage her to recall why she used to enjoy showering – she loved it because she felt energised, she could pamper herself (remember that Simone was working in a very masculine environment), and she was able to take some time out.  These are important things she can focus on as she develops strategies to return to this very important activity.

Shannon, E. (2002). Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA Australian Occupational Therapy Journal, 49 (1), 48-52 DOI: 10.1046/j.0045-0766.2002.00291.x

Strong, J. (1998). Incorporating cognitive-behavioral therapy with occupational therapy: a comparative study with patients with low back pain. Journal of Occupational Rehabilitation, 8(1), 61-71.

A year in review


This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too.

What has been the same this year is the endless need to repeat to all and sundry the following:

  • All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand.
  • All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model.
  • Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological response to that nociception – because the two are indivisible.  Our brains are not just ‘waiting for’ peripheral events to reach them – the brain is not a blank slate, it’s actively involved in determining which aspects of our experience ‘we’ will experience.
  • There is not a lot new under the sun in pain management really.  Not a lot of new drugs (mostly they’re derivatives of opium, or they’re old drugs that have been adopted for new uses), and not a lot of new procedures, and no, not even a lot of new psychosocial/nonpharmacological treatments.  With, perhaps, the exception of brain retraining a la Moseley, and the introduction of acceptance and mindfulness based treatments.

What has been different this year?

  • More discussion across ‘Web 2.0’, or the medium of the internet – Facebook, Twitter, blogging and email.
  • More detail of the aspects of the cognitive behavioural approach to pain management that is influential to change, and along with that, more recognition that one size does not fit all.
  • More detail of what works for whom and when.
  • More need to not only assess – but also treat people!
  • More recognition that people with pain live in a network of relationships with other people, within communities and sociopolitical systems including legislation, and that all of these have an influence on the person’s ability to cope.
  • Increasing recognition that the health provider relationship has as much influence on the individual as his or her own beliefs.  Yes folks, what we say and how we say it does have an effect! Maybe not quite what we had expected, but definitely we have an effect.
  • More awareness that it’s not so much WHO delivers self management, but that self management IS delivered that is important!

In Christchurch, we’ve had the momentous earthquake and the aftermath.  Internationally we have had wars, rumours of wars, pestilence and plague – and yes we’ve even had locusts (in parts of Australia!).  Once again I’ve made friends with people from all around the world, all sorts of professional backgrounds, all sorts of interests in pain and pain management.  And I’ve continued to learn – from fellow clinicians, colleagues, patients, the journals I’ve read, the blogs I’ve read, the discussions (and maybe even arguments!) I’ve had – all have prompted me to think and learn and question.

And once again, I reflect on the incredible nature of science and the way in which I, as a clinician, ‘stand on the shoulders of giants’ to learn more.  To know that no ‘fact’ is sacred – that if there is evidence there to challenge a ‘received’ view, even a view that I’ve cherished, then it’s my duty to look at that evidence in the face and check it out.  There is no need to resort to mysticism, nor to hold to magical beliefs, or sacred texts.  Research is there for us all to learn from, and it’s my privilege to help share it to people who may not have the time or access to the information I do, and by doing this I might have a chance to help people live lives that are a bit better in quality than if I had written nothing.  At least that’s what I hope happens!

I’m incredibly thankful to the people who take time to comment and question me.  I’m not a guru, I’m definitely blinkered in my own perception of what I see, and I admit to being somewhat biased.  That’s another reason for writing – by putting my thoughts out to the interweb, hopefully people can bounce ideas off what I write – and then ask me questions!  And in doing that, I learn too.

2011.  Who knows what it will bring.  I expect (and yes, hope) it will bring even more questions!  Do ya feel like coming along for the ride?!