Book reviews, site reviews

Live Plan Be

There are times in my work when I feel like I’m banging my head against a brick wall. Even though I’ve been saying most of what I write about on here since forever, it seems to take SUCH a long time for anything much to change! BUT then along comes something totally cool to brush my frustration away, and today I want to talk about Live Plan Be developed by Pain BC in Vancouver, Canada.

A couple of years ago I was given the privilege of being asked to prepare a document analysing the content and approach of self management programmes. I reviewed the Cochrane systematic reviews which all supported a multidisciplinary self management approach as the foundation for chronic pain management. I then turned to the qualitative research to investigate what it’s like to be part of a programme from the participant’s perspective. I found that people attending these programmes enter a journey of self-discovery, that some of the skills don’t seem to make sense at first – but do when the person returns to their own setting. I also found that people living with chronic pain relish the opportunity to feel that their pain is acknowledged, that others on the programmes know what it’s like to live with chronic pain so they don’t have to spend ages trying to explain themselves, and to have the chance to be with others who ‘get it’ means breaking out of the isolation that chronic pain can bring.

I also took a look at the ways these programmes can be delivered. While many programmes are face-to-face, with technology making online programmes increasingly more responsive and flexible, I wanted to see whether there were major differences in the outcomes of each programme. Although it’s difficult to tell because the populations using both approaches are not exactly the same, from what I could find, the outcomes were comparable. This is really exciting because it means more people can get access to approaches that have solid research underpinning them without having to travel to and from, and without the staffing needed for face-to-face programmes.

As a result of my report, I suggested that Pain BC might like to investigate developing a whole new programme for helping people live well with chronic pain, and to make this an online programme with some of the features that the research into online behaviour change programmes has identified as useful. Things like having a discussion forum so participants can connect and share their experiences of the reality of living with chronic pain. Having action prompts so that people don’t just read something – but also get prompted to DO something with that information – and most importantly, have this tied to where the person is currently at in their journey towards making changes to live with their pain. I recommended having some self-assessments so people can track their progress, and a place where they could record the things that worked, and those that didn’t work, so it’s easy to share with other people including health professionals.

I’m SO excited to see how Live Plan Be has come together – and it’s now LIVE!

The team that has put this together has done an amazing job, exceeding my wildest dreams of what the programme might look like. It’s sophisticated, easy to use, has lovely graphics and video recordings of real people doing real things, has SO MUCH information on it – and it’s free! If you have chronic pain, or you work with people living with chronic pain, I would love you to take a look at it, and try it out. Then let me know what you think. Whatever feedback you give, you’ll know that the team will work hard to keep on making it better and more useful, so please let them know.

Meantime, I’m hoping that this will bring some hope to people who have struggled with chronic pain, and would like to learn to live well.

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.


I had a nice email from James Hardie from Moodjuice website, an NHS Scotland site developed for both health professionals and individuals to access self help resources.

For patients, the site starts by saying “Emotional problems are often the mind and body’s way of saying that something needs to be changed in our life” – I like that!  I like the way the patient area is based on practical problems like housing, childcare, hobbies and interests, meeting people, relationships and so on.

For professionals, the feature that really appeals to me is the “build your own resource” area.  This enables you to put together the most relevant handouts for the person you’re seeing – a lovely feature! Then you can print the whole lot off, and it’s a pulled-together document that looks a far cry from some of the tatty photocopied things I’ve seen in the past.

The resources in the professional area is designed to be used alongside individualised sessions, so it’s not a “plug and play” kind of site – but it does provide a great range of tools that you can use.

My one tiny criticism? The site doesn’t clearly indicate who developed it – well, it does, but it’s buried in the menu’s right away from the front page. I’d like to see that information on the front page, along with the dates the material has last been updated (just a wee point).

Anyway, here are the pages for the Chronic Pain page

and the Problem Solving Information page

and the Challenging Thoughts page


Develop your skills in CBT for chronic pain

I’ve never found one single book that covers all the areas I think are important for chronic pain management, but today I want to review one that I have found helpful – and I’ll review another tomorrow! I got this one about two years ago, and I’ve referred to it quite often, especially for worksheets.

The book is Cognitive behavioural therapy for chronic illness and disability by Renee Taylor (2006), published by Springer, New York. I got mine from University Bookshop (another wicked place…) for NZ$125 , but as you can see it’s available from Amazon as well.

Renee Taylor is a clinical psychologist, but one with a unique twist – she’s based in the Department of Occupational Therapy, University of Illinois, Chicago, and her book reflects the orientation of this department in that she incorporates the Model of Human Occupation developed by Dr Gary Kielhofner.

She uses four case examples of chronic illness throughout the book to illustrate various aspects of CBT for disability – fatigue, chronic pain from rheumatoid arthritis; sleep disturbance in a man with advanced prostate cancer, and gastrointestinal difficulties in a young man. Alongside the physical illness, each case study has varying degrees of Axis I and Axis II dysfunction to demonstrate the complexity of the biopsychosocial model as it plays out in people’s lives. While I’d probably prefer less of the ‘psychiatric’ labelling that DSM IV provides, it’s nice to see some examples that represent the type of people who do attend pain management centres.

The book is divided into three sections – Theoretical foundations and practice guidelines; Related knowledge; and Specific applications of CBT to the four different physical disorders.
Section one provides an overview of CBT as a therapeutic approach, particularly noting the relevance of CBT to disability, discussing the psychological (note that this is NOT psychosocial?!) issues often found in chronic illness, and then details assessment and sessions as well as CBT techniques used in health.
Section two introduces several concepts that I have to admit I haven’t seen discussed in most CBT texts – empathy, hope and motivation. It’s the motivation chapter that includes the Model of Human Occupation construct of volition – personal causation, values and interests – that help to shape occupational choice.
Section three provides a brief review of some of the literature on the various clinical conditions (fatigue etc), and discusses assessment and treatment options for each.

Things I like about this book – great to see MOHO used to frame motivation, and the inclusion of hope and empathy is also quite novel and positive. I like the clinical examples used throughout to illustrate how the techniques can be applied along with the clinical reasoning for their inclusion. Finally, I really do like the figures used throughout – while the graphics themselves are quite simple, the design of several forms and figures make them really usable. I have to admit I’ve copied and used the ‘Thought Reversal Record’ and the ‘Problem solving worksheet’ with patients!

Things I liked less about this book
– I found the writing style to be a bit dry, and the general layout or typesetting of the book makes it more of a textbook than a ready-reference book. I’m also bothered by the lack of attention to social factors and that the approach does not directly discuss working within a team (either interdisciplinary or multidisciplinary).

If you haven’t read a book that clearly discusses how to use CBT where people have beliefs that are true – but not helpful – this is an excellent book.  It’s really good for the worksheets and figures, and it’s great for including some positive psychology concepts along with MOHO.  A good one for your shelf – or if you’re recommending a book to a library, this one would be an excellent choice.

Facilitating a group

Group-based approaches to pain management are common. They’re used not just for cost-effectiveness (because there are some ‘hidden’ costs to groupwork such as screening participants and team meetings), but also because some processes are better conducted in a group setting – such as observing others ‘well’ behaviours, learning vicariously from others’ experiences – and because experiential learning in a group setting replicates many of the work and family settings that people who experience pain will need to function in.

I use experiential learning, that is, the idea that change and growth take place when people are actively (physically, socially, intellectually, emotionally) involved in their learning rather than just being receivers of inforamtion. It’s not new – cognitive behavioural therapy has used this philosophy since its inception, occupational therapy is based on the idea that doing invokes being. I’ve no doubt many other health professionals also consider that active involvement in processing and learning is essential to integrating new behaviours. To carry out experiential learning, facilitation skills are vital, but again not training that health professions often seriously study during undergraduate study.

Today’s book is one of several I’ve recently obtained to refresh my facilitation skills. I’ve been lucky enough to complete a five-day training several years ago on facilitation run by Zenergy. Zenergy have a distinct philosophy about the value of teamwork, the synergy that occurs when people align to a common purpose and that cooperacy will achieve much for the whole world. For a list of their training courses, go here. Some of us, however, can’t take the time to go to formal training, or want a reference book, so I was pleased to find this book at Amazon.

Now, there is a saying ‘don’t choose a book by its cover’ and I would add ‘don’t choose a book by its title’ because the title is ‘The Secrets of Facilitation’, and that just smacked to me of cheesy pop psychology – but, perhaps surprisingly, this book has some very useable, practical ways for facilitators to ‘ask questions that ignite a bonfire of responses’, ‘discover the three reasons people disagree’, ‘resolve dysfunctional behaviour in four steps’ and ‘build consensus in meetings with five strategies’…

The Secrets of Facilitation: The S.M.A.R.T. guide to getting results with groups, written by Michael Wilkinson, published by Jossey-Bass, A Wiley Imprint: San Francisco, 2004. The book provides a model of group facilitation that incorporates both the flow of a facilitated session (preparing, starting a session, focusing the group, writing down resolutions, gathering information and finally closing the session – and includes asking questions to generate effective responses throughout the process); as well as the processes involved in group dynamics (how to manage dysfunction, build consensus, keep energy levels appropriate and set the agenda).

The book is not written for pain management, indeed it’s not written for health at all – it’s a business book aimed at helping teams function effectively so that group decisions are achieved and implemented (not that health teams EVER need to work on this, do they?). Despite this, so much of the book translates directly into both team functioning and group therapy sessions that I think it’s worth thinking about for your bookshelf.

What I like about the book
is the straightforward language, the summaries at the end of each chapter, and the loads of example phrases and questions that you can immediately transfer into a clinical setting. Like many books, it includes some great tables that summarise the information – for example, a comparison of facilitator vs nonfacilitator responses listing what you might perceive (eg you don’t think what was said was correct), an example of both types of response, then a classification of the type of response that is recommended (eg Direct probe, indirect probe, leading question and so on). The diagrams have immediate appeal for me (I’m pretty visual!), and also help to give an overview of the construction of the book so you can see where each piece of the information given fits in.

What I liked less about the book is the example scenarios that relate to business or school settings, and so are not quite as easily transferred into the health setting – even though health can be considered a complex business enterprise! I also really dislike the ‘secrets’ concept. The book lists 60 so-called ‘secrets’, many of which are not exactly secret. I mean, do you think using energy-generating techniques throughout the session is a ‘secret to maintaining energy’?

Despite this somewhat tedious concept of ‘secrets’ the actual suggested strategies are effective. From the first chapter I picked up things I could use when facilitating group sessions on the pain management programme. Some good examples? Well, if someone comes up with an idea that you’re not sure about, acknowledge the contribution then ask them ‘how do you get around [X]’ and state what your concern is. He calls it ‘Building a PAC’ or listen, playback (reflect), agree (acknowledge the part/s that you can see merit in), then challenge or state your objection in the form of a question that allows the person to either solve your objection or to agree with it.
Another example is in using the whiteboard to record what participants say. The ‘secret’ is to write first (in other words, write down exactly the words the person says) then discuss what they’ve said. This ensures you as facilitator don’t imply that you know better than the participants, elicits more responses from participants who may otherwise begin to depend on you as facilitator for ‘the answers’.

If you want to help your team work together more effectively, or have a group of patients you’d like to help facilitate to achieve their goals – this book might just be what you’re looking for.

A week of book reviews

This week I’ve decided to review some of the books that I’ve recently bought for my bookshelf (not that they stay there!). Anyone who knows me will agree that I’m a bookworm, and the two most horrible websites (at least to my bank balance) are Amazonand Fishpond!

Onto today’s book – just arrived, although not a new book, published in 2006, it’s called ‘Cognitive behavioural therapy in groups’, written by Peter J. Bieling, Randi E. McCabe and Martin M. Antony. It’s published by Guilford Press, and I got mine from Fishpond at a cost of $58.25.

The reason I’m so pleased with this book is that for ages I’ve been looking for something to help with group processes and carrying out cognitive behavioural therapy. While groupwork was a core part of my training as an occupational therapist, and I’ve followed this up with facilitation training, many people working in pain management feel somewhat overwhelmed at the thought of taking a group. What can then happen is that the group sessions become almost an educational ‘lecture’ rather than a cognitive behavioural approach – which isn’t nearly as effective. We know that ‘information’ alone doesn’t necessarily change people’s beliefs or behaviour, and that people need to actively engage with and process new material to reconceptualise the implications of, for example, the fact that hurt does not equal harm.

This quite readable book has three parts – the first part is the most applicable to pain management, and covers the ‘General principles and Practice of Cognitive-Behavioural Therapy Groups’. There are six chapters that discuss why we might use a group approach rather than work individually with people; looks at how to use the inevitable group dynamics productively; then reviews cognitive strategies, behavioural strategies and a basic structure that can be used to implement CBT within a group setting. The final chapter in this section is about some of the problems and obstacles that occur in groups and how to overcome these.

The second part is much less relevant to pain management, and deals with nine mental health diagnoses and how groups have been used in these instances. It’s a shame that chronic pain groups were not included, because group therapy has been a fundamental of most cognitive behavioural approaches to pain management.

The final section looks at comorbidity and CBT groups and finally an FAQ section. There is an extensive reference list (forty pages!), and the whole book is well-indexed.

So, let’s take a quick look at the chapters in Part 1.
Chapter 1 – CBT groups – possibilities and challenges. Several reasons have been put forward for conducting CBT approaches in a group rather than individually since the early days of CBT. Of course the main reason initially given is that it is more cost-effective than working individually with people, but there are other good reasons to consider this way of delivering CBT such as the way that people learn vicariously (ie by watching and learning from what other people say and do) and the way in whcih people can feel less isolated when they meet others with similar problems. The chapter reviews several models for analysing group process from outside the CBT framework and applies these to the specific requirements of the CBT approach. It particularly defines ‘group process’ and ‘CBT technique’, with technique referring to the learning tools and methods people use to review their thoughts, beliefs, emotions and behaviours in order to make changes, while process refers to the interpersonal interactions among and between group members and facilitators.

Chapter 2 – Group process – This chapter very clearly describes a number of the group process dynamics that occur longitudinally as group members and facilitators interact. These processes may directly influence self disclosure, a sense of optimism, reduce isolation, moving from a ‘self focus’ to a focus that includes others, direct modification of behaviours (particularly applicable in relation to reducing pain behaviours), and group cohesion and emotional processing. I particularly liked a table included in this chapter that identifies the process factor, defines the factor and summarises how to positively influence and use the process for client change. Some very good dialgoues are provided to illustrate ways to attend to group process while carrying out some of the basic CBT techniques within a group setting. I’ve learned some good things about how to structure my responses to facilitate better group participation especially around home learning review. The last part of this chapter considers the longitudinal development of group development and presents another wonderful table identifying the ‘stage’ of the group and effective therapist responses to ensure the CBT approach is maintained throughout.

Chapter 3 – Cognitive strategies within a group setting.
This chapter explains the range of cognitive therapuetic techniques such as guided discovery, collaborative empiricism and Socratic dialogue, and provides an overview of how these can be applied. Once again it uses dialogue to guide through examples of how this might work in a group – and although the examples are specific to mental health issues, they can still be applied in most cases to people with chronic pain.

Chapter 4 – Behavioural techniques in a group setting.
It’s good to look at both the advantages and disadvantages of groupwork for CBT, and this chapter reviews this very briefly. Basic behaivoural approaches such as exposure therapy, behavioural self monitoring, using the group to monitor each other’s behaviour and so on are discussed in the chapter, but I have to say I think there are more aspects of behavioural therapy that can be used than are described in this chapter, as well as more challenges than are discussed.

Chapter 5 – Structre and organisational issues. Now this is one chapter everyone should read before starting to take a group CBT programme! Four aspects vital to effective group programme management are discussed: participant selection, therapist factors, between-session structure and within-session structure. The emphasis is on learning and experience both within the group, and the chapter makes it clear that balance between all aspects of both group process and CBT technique is needed throughout. A good solid read on the ‘how to’ of administering a group-based CBT programme.

Chapter 6 – Problems. Another chapter that everyone should read – or will want to read because it has answers! I can’t think of a single group where at least one of the issues that is discussed in this chapter has not occurred. From having a dominating group member to someone who speaks on behalf of the others to ‘help’ to someone who rarely turns up or appears disinterested…hmmm sound familiar? Like some of the other chapters, it has a great table describing various member behaviours and appropriate therapeutic responses to them. The final section deals with group process that derive from aspects of the CBT model such as didactic aspects of some parts of therapy, the very structured approach that CBT sessions take, the need for some ‘outside of group’ sessions in certain circumstances, and how to deal with trainees and non-group people observing.

To summarise: while the second part of this book may not necessarily directly apply to people taking pain management group sessions using a CBT approach, the first part is, I think, essential reading for anyone wanting to really apply CBT within a group setting. The writing style is straightforward, the example dialogues very helpful, and summary tables really clear. There are heaps of references (if you’ve ever had to justify having a co-therapist to your manager, you’ll appreciate some of them in particular!), and the FAQ section answers yes, some of those really frequently asked ones! This is a book I just wish had either included chronic pain groups, or was published in two volumes so the first part was available in a stand-alone edition.

Overcoming Pain – David Hall’s new book!

Every now and then you run into someone who makes a real impact on you – Dave’s one of those people.  I met him in Sydney at the International Association for the Study of Pain World Congress in 2005 (take a look here at the information on the next one), and we’ve intermittently kept in touch by email ever since.  David is one of these almost relentlessly energetic people – he looks fit, healthy and balanced.  You’d never guess that he’s experienced chronic neck pain and has had to learn how to become ‘CAPABLE’ so he can live this good life.

His book (and pain management programme by the same name) is called Overcoming Pain, and it’s available from his website at the very reasonable price of Aus$25 + postage.  It’s all about the things he’s learned as a physiotherapist, person experiencing pain, and avid reader of lots of good research, and what’s more, he’s got a refreshing and down-to-earth style that makes what he says easy to digest.

The book is a slim paperback with 157 pages of cleanly-laid out text.  It has 12 chapters covering things like Dave’s own story, understanding pain, physical recovery, psychological recovery and something that’s a bit unusual in self help books: how to use the health system effectively.  He includes a good number of excellent references, some great illustrations and another thing that I thought was a distinctive feature – case examples of people who have demonstrated how they have become CAPABLE.

What does CAPABLE mean?

C – confronting the true causes of your pain

A – acknowledging responsibility for your situation

P – problem solving your way to recovery

A – assertiveness to change your situation

B – bravery to overcome your fears

L – Look forward by setting goals

E – Enjoying the journey…

There are always aspects of a self help book that don’t fit with my views on managing pain – I’m not entirely convinced by the section on ‘core stability’, and the word ‘overcoming’ sounds a bit like the relationship between you and pain is some kind of war – BUT I think these are tiny bits of what is overall an excellent self help book that I’ll definitely recommend to people I see.  It would certainly sit nicely on a GP, physiotherapy or occupational therapy shelf, but might need to be chained down because I could see people taking off with it!

If you don’t believe my review, head over to here for some other reviews by people who’ve read Overcoming Pain.

Oh, and no you can’t have my copy, I’m going to re-read it (and that’s really unusual for me!)

Symptoms of unknown origin: A medical odyssey

Having just a little more time to myself over the holidays has meant I’ve been able to read more.  Not that I EVER stop reading, but I did have some time to really read some great books, one of which is a slim book by the title of my heading above.  It’s written by Dr Clifton Meador, published by Vanderbilt University Press, 2005, and the ISBN is ISBN 0-8265-1473-1 (cloth : alk. paper), ISBN 0-8265-1474-X (pbk. : alk. paper).

It’s the story (or a series of stories) about the journey Dr Meador took to move from his original training as a physician who sought to ‘fix people’ to a doctor who learned the art of listening and gently helping the very challenging patients he was seeing to move from being patients to being people again.  He described the scene in his medical school training where he was exposed to the miraculous effects of physostigmine on a woman with myasthenia gravis and immediately became enraptured with the idea of ‘[being] able to have that effect on a patient, to be able to find the chemical defect, find the missing hormone, and discover what bacteria or virus had invaded the body. I wanted to make a diagnosis and give the drug or chemical that would precisely correct the biochemical lesion or kill the invading organism. I wanted to do all of that and treat patients and give a normal life back to those who were afflicted.’ (more…)

Terrific trivia – look at what piques my interest today!

I couldn’t go very far past Scott Blake’s site for his ‘Bar Code Art’. This guy has a mind even more way out than mine!! To quote: ‘I started making art with barcodes right before Y2K, inspired by the year 2000 computer bug, and threatening digital apocalypse.’ What he’s got on his website is truly whimsical – you too can get your own, personalised barcode to represent YOU – your age, weight, height, gender and country! And you can take a look at his barcode counter that is counting ‘10,000,000,000 UPC barcodes. (that’s 10 billion possibilities) Capturing every imaginable product. This animation takes 10 years to complete.’ Uh, I don’t think I’ll be watching them all…

Anyway, if you have ever wondered about bar codes and how they’re created – here’s the explanation. You can now die happy. (more…)

‘its taken over my life’…

Each time I spend listening to someone who is really finding it hard to cope with his or her pain, I hear the unspoken cry that pain has taken over everything. It can be heartbreaking to hear someone talk about their troubled sleep, poor concentration, difficult relationships, losing their job and ending up feeling out of control and at the mercy of the grim slave-driver we call chronic pain. The impact of pain can be all-pervasive, and it can be hard to work out what the key problems are.

To help break the areas down a little, I’ve been quite arbitrary really. I’m going to explore functional limitations in terms of the following:
1. Movement changes such as mobility (walking), manual handling, personal activities of daily living
2. Disability – participation in usual activities and roles such as grocery shopping, household management, parenting, relationships/intimacy/communication
3. Sleep – because it is such a common problem in pain
4. Work disability – mainly because this is such a complex area
5. Quality of life measures

The two following areas are ones I’ll discuss in a day or so – they’re associated with disability because they mediate the pain experience and disability…as I mentioned yesterday, they’re the ‘suffering’ component of the Loeser ‘rings’ model.
6. Affective impact – things like anxiety, fear, mood, anger that are influenced by thoughts and beliefs about pain and directly influence behaviour
7. Beliefs and attitudes– these mediate behaviour often through mood, but can directly influence behaviour also (especially treatment seeking)

There are so many other areas that could be included as well, but these are some that I think are important.
Before I discuss specific instruments, I want to spend yet more time looking at who and how – and the factors that may influence the usefulness of any assessment measure.

Who should assess these areas? Well, it’s not perhaps who ‘should’ but how can these areas be assessed in a clinical setting.

Most clinicians working in pain management (doctors, psychologists, occupational therapists, physiotherapists, nurses, social workers – have I missed anyone?) will want to know about these areas of disability but will interpret findings in slightly different ways, and perhaps assess by focusing on different aspects of these areas.

As I pointed out yesterday, there are many confounding factors when we start to look at pain assessment, and these need to be borne in mind throughout the assessment process.

How can the functional impact of pain be assessed?

  • Self report, eg interview, questionnaires – and the limitations of these approaches are reliability, validity threats as well as ‘motivation’ or expectancies
  • Observation, either in a ‘natural’ setting such as home or work, or a clinical setting
  • Functional testing, again either in a ‘natural’ setting such as home or work, or a clinical setting – and functional testing can include naturalistic procedures such as the AMPS assessment, formal and structured testing such as the 6 minute walk test, the sock test, or even certain functional capacity tests; or it may be clinical testing such as manual muscle testing or range of movement, or even Waddell’s signs

All self report measures, whether they’re verbal questions, interview or pen and paper measures are subject to the problem that they are simply the individual’s own perception of the degree of interference they attribute to pain. The accuracy of this perception can be called into question especially if the person hasn’t carried out a particular activity recently, but in the end, it is the person’s perception of their abilities.

All measures need to be evaluated in terms of their reliability and validity – how much can we depend on this measure to (1) assess current status (2) contribute to a useful diagnosis (or formulation) (3) provide a basis for treatment decisions (4) evaluate or measure function over time (Dworkin & Sherman, 2001).

Reliability refers to how consistently a measure performs over time, person, clinician.

Validity refers to how well a test actually measures what it says its measuring.  The best way to determine validity is if there is a ‘gold standard’ against which the test can be compared – of course in pain and functional performance, this is not easy, because there is no gold standard!  The closest we can come to is a comparison between, for example, a self report in a clinic on a pen and paper test compared with a naturalistic observation in a person’s home or workplace – when they’re not being observed.

Probably one of the best chapters discussing these aspects of pain assessment is Chapter 32, written by Dworkin & Sherman chapter in the 2nd Edition of the Handbook of Pain Assessment 2001 (DC Turk & R Melzack, Eds), The Guilford Press.

Importantly for clinicians working in New Zealand, or outside of North America and the UK, the reference group against which the client’s performance is being compared, needs to be somewhat similar to the population the client comes from.  Unfortunately, there are very few assessment instruments that have normative data derived from a New Zealand or Australasian population – and we simply don’t know whether the people seeking treatment in New Zealand are the same on many dimensions as those in North America.

I’m also interested in how well any instruments, whether pen and paper, observation or performance-based assessment translate into the everyday context of the person.  This is a critical aspect of pain assessment validity that hasn’t really been examined well.  For example, the predictive validity (which is what I’m talking about) of functional capacity tests such as Isernhagen, Blankenship or other systems have never been satisfactorily established, despite the extensive reliance on these tests by insurers.

Observation is almost always included in disability assessment. The main problems with observation are:
– there are relatively few formal observation assessments available for routine clinical use
– they do take time to carry out
– maintaining inter-rater reliability over time can be difficult (while people may initially maintain a high level of integrity with the original assessment process, it’s common to ‘drift’ over time, and ‘recalibration’ is rarely carried out)

While it’s tempting to think that observation, and even functional testing, is more ‘objective’ than self report, it’s also important to consider that these are tests of what a person will do rather than what a person can do (performance rather than capacity). As a result, these tests can’t be considered infallible or completely reliable indicators of actual performance in another setting or over a different time period.

Influences on observation or performance-based assessments include:
– the person’s beliefs about the purpose of the test
– the person’s beliefs about his or her pain (for example, the meaning of it such as hurt = harm, and whether they believe they can cope with fluctuations of intensity)
– the time of day, previous activities
– past experience of the testing process

And of course, all the usual validity and reliability issues.
More on this tomorrow, in the meantime you really can’t go far past the 2nd Edition of the Handbook of Pain Assessment 2001 (DC Turk & R Melzack, Eds), The Guilford Press.

Here’s a review of the book when the 2nd Edition was published. And it’s still relevant.