N of 1 studies – great examples

It’s true that ‘unconventional’ studies of any kind don’t get published as readily as conventional RCTs even if those studies are under-powered, have errors in their construction and don’t tell us much of anything. Grrr. Publishing studies from my PhD has been fraught because I chose a form of grounded theory that doesn’t conform to the conventional constructivist or Straussian approach. What, then are we to do?

Two things strike me: first we always need to select a research method to give us the best answer to our research question, not something that will ‘get published’ easily. There are many research questions and RCTs simply don’t answer them all. A quantitative method doesn’t lend itself to ‘why’ questions and inevitably require assumptions about the factors thought to be relevant, the measurement strategy, the underlying theory explaining what’s going on. This doesn’t really help us when we have a new field of study to look at, where there is no clear theoretical explanation, where measures don’t measure what’s relevant. Hence drawing on different designs like mixed methods and qualitative approaches. From a pragmatic perspective, the numbers needed for an RCT are much greater than most clinicians can find unless they’re working in a large research setting (and have a bit of funding!). Nevertheless, ‘pilot’ studies using RCT methods do get published even when they don’t have huge explanatory power, partly because they’re familiar to the reviewers.

The second thing that strikes me is: we need to have good exemplars. These give us a template of sorts to learn how to conduct good research, how to communicate why a particular ‘unconventional’ method is the best way to answer the question, and how to write the results/findings in a way that is compelling.

I’ve written before about the failure of much research in human behaviour and experience to understand that ergodic theorum is violated in grouped statistics. This means we can deeply question the results as they apply to the person we see in the clinic. Ergodicity implies that all people in a group will ultimately follow the same trajectory, develop in the same way over the same time, respond to treatment in the same way and follow the same processes. But clinicians know that some people respond very quickly to a component in a programme, while others don’t.

I recently found this example from Tarko (2005) and cited in Lowie & Verspoor (2019)

OK, ’nuff said. Ergodicity matters.

Choosing the right research strategy begins with having a good research question, and most clinicians have a very good research question: what is the best treatment I can offer this person presenting in this way at this time? The follow-up question is: is this treatment helping? or… to be more precise, which component of my treatment/s are helping?

It’s this question that N=1 or single case experimental designs are intended to answer, and they do it very well.

Here are some great examples of published studies using intensive repeated measures – and we need more of these!

Lydon-Staley, D. M., Zurn, P., & Bassett, D. S. (2020). Within-person variability in curiosity during daily life and associations with well-being. Journal of Personality, 88(4), 625-641. https://doi.org/10.1111/jopy.12515

I included this one because it’s not about pain! And yet it sheds light on something important in pain management. Curiosity is about being intrigued by novel, unfamiliar situations. Curiosity doesn’t flourish when a person is anxious, but does when people are wanting to increase their knowledge and skills, and it’s associated with greater well-being. So it’s something clinicians might want to foster – especially for someone who has become afraid to rely on their body and body sensations. In this study, people were asked to complete a daily diary and do some internet browsing (yay! my favourite thing to do!). After some fairly complex statistical analysis (described in good detail in this paper), the results from 167 people who completed 21 days of daily diary measures and a one-off set of measures showed that being consistently curious is associated with feeling good – AND that doing physical movement practices might enhance curiosity via improving mood. Now that’s worth knowing.

Mun, C. J., Thummala, K., Davis, M. C., Karoly, P., Tennen, H., & Zautra, A. J. (2017). Predictors and social consequences of daily pain expectancy among adults with chronic pain. Pain, 158(7), 1224-1233. http://dx.doi.org/10.1097/j.pain.0000000000000903

Now this study is a big one – 231 people in study one, and 220 people in study two. Cutting to the chase, these researchers found that people who expected high pain in the evening experienced greater pain the next day, even when controlling for current pain intensity. The study also found that morning pain predicted next afternoon social enjoyment but not social stress. And what this means is…. clinicians need to promote joy/fun/positive affect, and to help people reduce their expectations that their pain will inevitably increase or ‘be bad’ – it’s anticipation that seems to influence pain intensity and avoidance. These study designs allow researchers to tease apart the factors contributing to experiences over time. We need more of them!

Hollander, M. D., de Jong, J., Onghena, P., & Vlaeyen, J. W. S. (2020). Generalization of exposure in vivo in Complex Regional Pain Syndrome type I. Behaviour Research and Therapy, 124. https://doi.org/https://doi.org/10.1016/j.brat.2019.103511

And from a large study to a much smaller one with – wait for it – 8 participants! That’s more like the numbers we see in clinic, right? This study examined whether it’s more fruitful to expose people to many activities they’ve previously avoided, or instead, to limit the number of activities each person was exposed to. This is SUCH an important component of therapy where people have avoided doing things that bother them because they anticipate either that their pain will go to untolerable levels (or interfere with other important things like sleep) or because they’re worried they’ll do harm to themselves. Why? Because doing things in one safe space is not life. We do lots of activities in lots of different spaces, and most of them are unpredictable and we don’t have a ‘safe person’ to rely on. It’s perhaps one of the reasons exercise carried out in a gym might not transfer into greater reductions in disability in daily life – and why involving occupational therapists in pain management as ‘knowledge translation experts’ is such a good thing.

Caneiro, J. P., Smith, A., Rabey, M., Moseley, G. L., & O’Sullivan, P. (2017). Process of Change in Pain-Related Fear: Clinical Insights From a Single Case Report of Persistent Back Pain Managed With Cognitive Functional Therapy. Journal of Orthopaedic & Sports Physical Therapy, 47(9), 637-651. https://doi.org/10.2519/jospt.2017.7371

Lucky last – a single case study exploring the process of change experienced by one person undergoing cognitive functional therapy. While recent meta-analyses suggest CFT is ‘no better’ than any other treatment for people with persistent pain, what meta-analyses can’t show is those for whom it’s highly effective. Why? Because individual responses don’t show up in meta-analyses, and the mean or even the confidence intervals don’t show those people who do extremely well – or those who don’t do well at all. And yet as clinicians, we deal with each individual.

Now I chose these four studies because they are all published in highly respected and ‘highly ranked’ journals. I don’t care a fig about the supposed rank of a journal, but there’s no doubt that getting into one of these journals requires research of a very good standard. And somehow these ones snuck through!

Am I suggesting that RCTs shouldn’t feature in research? No – but I do think a much more careful analysis of these is needed, so we can understand the golden question: what works for whom and when? And to answer these questions we need far more detailed analysis. Oh – and evidence-based healthcare has always been a synthesis of THREE elements – research yes, clinician’s experience AND the person’s preferences and values. ALL THREE not just ‘research’ and out of research, not just RCTs.

Lowie, W. M., & Verspoor, M. H. (2019). Individual Differences and the Ergodicity Problem. Language Learning, 69, 184-206. https://doi.org/10.1111/lang.12324

Tarko, V. (2005, December 29). What is ergodicity? Individual behavior and ensembles. Softpedia News. Retrieved from https://news.softpedia.com/news/ What-is-ergodicity-15686.shtml

Persistent pain and movement practices

Here I go, stepping into “the bio” to write about movement. Oh dear, what am I doing?

Movement practices of various kinds are part and parcel of pain management. In fact, to read some of the material in social media-land, exercise is the be-all and end-all of pain management, maybe with a dash of psychology. Can we please stop doing this?

I’ve said it often, for many forms of persistent pain, especially the most common forms – nonspecific chronic low back pain, fibromyalgia, and osteoarthritic pain – movement is a good thing, but the effect sizes are small for both pain intensity and disability (eg Jayden, et al., 2021). I’ve reproduced the author’s conclusions below:

We found moderate‐certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low‐certainty evidence) and functional limitations outcomes (moderate‐certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

So for chronic low back pain, short-term pain intensity reduction is clinically significant, but neither functional limitations nor pain intensity reductions over the long-term reached clinical significance. Ouch! This means that we must not oversell the usefulness of exercise as a panacea for chronic pain.

Some missing bits in this meta-analysis: how many people carried on doing their exercise programmes? Why did they keep on going if they didn’t experience reduced pain or better function? How many people dropped out from follow-up?

But my biggest question is “Why does increased physical fitness and reduced pain not translate into better function in daily life?” And of course, my next question is “What might improve the daily life outcomes for people with pain?”

I might also ask why there is so much emphasis on exercise as an approach for chronic pain? Why oh why? One reason could be the assumptions made about the reasons people have trouble with daily life activities. A reasonable assumption might be that people are unfit. Another might be that people don’t have confidence to move. But if these assumptions were true, we’d see better results than this. Perhaps we need to be much more sophisticated and begin to explore what really does impact a person’s daily life activities? My plea therefore is that we cease doing RCTs comparing exercises of various forms to placebo, no treatment or usual care. Please. We know movement is a good thing, and with the enormous number of studies carried out, surely we can stop now?!*

Here are some clinical reasoning pointers when employing movement practices. I’m being agnostic with respect to what form of movement practice [insert your favourite here].

• Find out what the person enjoys doing for movement/exercise. Aim to do this, or build towards doing this. Start low and build up intensity, load and frequency.
• Find out why the person has stopped doing their movement/exercise practice. If pain has stopped them, be curious about what they think is going on, what they think the pain means, what happens if they experience pain doing their favourite movement practice, and find out how long and how much they’ve done before pain stops them. Then address unhelpful beliefs, re-set the starting point and progress in a gentle graded way.
• If the person hasn’t ever been a movement/exercise person, be curious about why. Explore this in detail – beliefs about movement, movement practices they’ve tried, time available, cost, all the things that might get in the way of doing a movement practice. You might find it was a high school physical ed. practice that totally put them off – but look beyond “exercise” or “sports” and remember that movement includes walking, dancing, gardening, playing with the dog, fishing, kayaking….

When you’re starting to generate a movement practice programme, for goodness sake ask the person when they’re going to find time to do it, and don’t make it too long! Explore when might be the most convenient time, and what might make it easy to do. Use low cost, low-tech practices. Find out what might get in the way of doing the movement practice, and do some problem-solving – anticipate what goes through a person’s mind and together, come up with counter-arguments or better, think of some really important values that might underpin the reason to do what is undoubtedly difficult for this person in their life.

Think about life-long habits and routines. How might this person explore options that could fit into their life as they get older? What might they do if the weather is bad, or they have an addition to the family? How many different movement practices can you and the person think of? And remember, if it’s OK for a person at a gym to do “leg day” one day, and “arm day” another, it’s perfectly fine for someone to do gardening one day, and go for a walk up the hill the next. Don’t be boring! Invite exploration and variety.

Work on translating the movement practices you and the person do in clinic into the daily life movements the person is having trouble doing. This might mean asking the person about their daily life and what’s most difficult for them to do right now. If it’s bending to load/unload the dishwasher, ask them what’s going on, what comes up for them when they do this? Is the problem about physical capability – or is it because it’s at the end of a long day at work, they’re tired and haven’t been sleeping and they’re worrying about how the pain in their back is going to affect their sleep tonight? If it’s the latter – guess what, physical exercise isn’t going to change this! So talk about what they can do to help with their sleep, or if that’s not your forte, talk to another team member (occupational therapist, psychologist) about what might help.

Note that as clinicians, we have no right to dictate what a person’s life looks like. This means we can’t judge a person for their choice of movement practice. We also can’t dictate how often or how intense their “workout” should be. It’s going to vary, depending on all the things this person in front of you values most. And we must respect this – don’t be judgemental, their values may be very different from yours, and this is perfectly OK. Just help them explore the good – and not so good – of their choices.

Finally, don’t be afraid to have fun with movement! Play a little. If disc golf is the person’s thing – go try it out! If jive dance is their thing, maybe it’s time you gave that a go. If they like hiking to a quiet spot to do a little bird photography, go with them and carry your own camera gear. If their life is so busy that movement practice gets squeezed out, work with them to find ways to get movement snacks into their day. Don’t be boring. And worry a little less about “prescribing” movement, and much more about experiencing your body as a living sensory being – get in the moment and enjoy what your body is able to do. That is really what we’re encouraging in movement practices for chronic pain.

*A couple of other guesses for why exercise gets seen as The Best Thing – it’s “cheap” in comparison with other options, people can do it reasonably easily after therapy, there are LOTS of physiotherapists and others who offer this, it appeals to our “simple” (but wrong) beliefs about pain, psychological approaches are more expensive (though don’t offer better outcomes), daily life occupational therapy approaches are really hard to conduct as RCTs….

Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 18 December 2022.

“The social” – a brief look at family

Our most important relationships, the ones we learn most from, probably occur in families (Bowlby, 1978). As kids, even before we begin to speak, we observe our family members – and there’s reasonable evidence showing that how well these early relationships develop influences our experience of pain and how we express it.

I had the occasion to read a little about adolescent and children’s pain, and the influence of parents on young people as they grow up. There’s a great deal of research interest in children’s pain because children with persistent pain grow up to be adults – usually also with persistent pain. And good evidence that parents with persistent pain can, through mechanisms including depression and catastrophising, influence pain and disability in their children (Brown et al., 2022; Brown et al., 2021).

The research is fascinating. Some studies investigating predictors of chronic pain in children, some investigating disability – and a small number of studies looking at what we can do to help parents cope with the pain their children are experiencing. Not many studies (54 in a 2021 scoping review – see Lee et al., 2021). And sooooo many studies focusing exclusively, or close to, the influence of Mothers on children. Where’s Dad? Can I repeat that: where’s Dad?

More recent studies indicate the number of Fathers and Mothers – yay, we’re getting an idea of how many are recruited into these studies – and yet overwhelmingly, it’s Mothers who form the majority of participants. I wonder what effect having a Dad with chronic pain might have on a kid? And it’s only recently that oh darn animal models actually include females… it’s those pesky hormones dammit!

Turning to the next most important relationship, apart from parents, there’s a good deal of research looking at partners. Again, there exists a bias towards heterosexual couples, so we’re a little biased here. There is a wealth of material to review in this area of pain, with some brilliant research designs such as repeated interviews over 18 months, followed by 22 days of repeated daily measures (eg Martire et al., 2019); investigating people with pain problems as common as knee osteoarthritis and chronic low back pain; and examining relationships between things like sleep, caregiving burden, catastrophising, relationship satisfaction, agreement about pain intensity between partners, beliefs and perceptions about pain on interactions, anger, stress. HEAPS of fascinating research to delve into.

And yet, how many clinicians, and programmes, routinely include partners? How accessible are treatment sessions for couples to attend? Who, in a pain management team consisting of largely physiotherapy plus a dollop of psychology, looks after this aspect of living with persistent pain? Waaay back in the day, like the mid-2010s, the facility I worked in had a social worker with experience in family systems and relationships – but there are few social workers working in pain management in New Zealand/Aotearoa, and unless something has changed that I don’t know about, our national insurer doesn’t recognise the value of social workers (and, for that matter, the need to include partners in therapy for chronic pain).

When I review the many studies of this part of “the social” and compare the findings from these investigations against current clinical practice, I see an enormous knowledge and skill gap. If the questions we ask people with pain about their relationship are “how is your relationship with your partner?” we’re probably going to hear “oh they’re really supportive” or “I don’t let them know how I am”. Without adequate knowledge about the kinds of factors that negatively influence the partner’s response to the person with pain we’re likely to be oblivious to the risk of partner abuse (56% of people in this study reported past partner abuse, while 29% of the respondents had been abused in the previous year – Craner et al., 2020); we might not be aware that spouses with poor sleep because their partner was sore, were more likely to be angry (Marini, et al., 2020); that 52% of partners without pain reported high-to-severe burden of having to do more both at work and home because their partner was sore (Suso-Ribera et al., 2020) – or that if a spouse without pain did not have confidence in the pain management of their partner with pain, they were more negative (Nah et al., 2020) or that when a spouse without pain thought their partner’s pain “was a mystery” they were more critical and made more invalidating responses (Burns et al., 2019).

You see, while “the social” is complex, difficult to research, and very broad – ranging from employment status, occupation, educational status, ethnicity, culture, gender, sex – it also includes the very intimate and formative relationships we have with our family. In New Zealand/Aotearoa, with our emphasis on Te Whare Tapa Whā as a model of health and for chronic pain, where relationships with whanau are vital, isn’t it time we addressed this lack?

Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Brown, D. T., Claus, B. B., Konning, A., & Wager, J. (2022, Mar). Unified multifactorial model of parental factors in community-based pediatric chronic pain. Journal of Pediatric Psychology, 47(2), 121-131. https://doi.org/doi: 10.1093/jpepsy/jsab085

Brown, D., Rosenthal, N., Konning, A., & Wager, J. (2021, Feb). Intergenerational transmission of chronic pain-related disability: The explanatory effects of depressive symptoms. Pain, 162(2), 653-662. https://doi.org/10.1097/j.pain.0000000000002066

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019, Oct). Spouse and patient beliefs and perceptions about chronic pain: Effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186. https://doi.org/https://doi.org/10.1016/j.jpain.2019.04.001

Craner, J. R., Lake, E. S., Bancroft, K. E., & Hanson, K. M. (2020, Nov). Partner abuse among treatment-seeking individuals with chronic pain: Prevalence, characteristics, and association with pain-related outcomes. Pain Medicine, 21(11), 2789-2798. https://doi.org/10.1093/pm/pnaa126

Donnelly, T. J., Palermo, T. M., & Newton-John, T. R. O. (2020, Jul). Parent cognitive, behavioural, and affective factors and their relation to child pain and functioning in pediatric chronic pain: a systematic review and meta-analysis. Pain, 161(7), 1401-1419. https://doi.org/10.1097/j.pain.0000000000001833

Lee, S., Dick, B. D., Jordan, A., & McMurtry, C. (2021, Nov). Psychological interventions for parents of youth with chronic pain: A scoping review. The Clinical Journal of Pain, 37(11), 825-844. https://doi.org/10.1097/AJP.0000000000000977

Marini, C. M., Martire, L. M., Jones, D. R., Zhaoyang, R., & Buxton, O. M. (2020, Jun). Daily links between sleep and anger among spouses of chronic pain patients. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 75(5), 927-936. https://doi.org/10.1093/geronb/gby111

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841-2847. https://doi.org/10.1097/j.pain.0000000000001673

Meredith, P., Ownsworth, T., & Strong, J. (2008, Mar). A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clinical Psychology Review, 28(3), 407-429.

Nah, S., Martire, L. M., & Zhaoyang, R. (2020, Oct). Perceived patient pain and spousal caregivers’ negative affect: The moderating role of spouse confidence in patients’ pain management. Journal of Aging and Health, 32(9), 1282-1290. https://doi.org/10.1177/0898264320919631

Suso-Ribera, C., Yakobov, E., Carriere, J. S., & Garcia-Palacios, A. (2020, Oct). The impact of chronic pain on patients and spouses: Consequences on occupational status, distribution of household chores and care-giving burden. European Journal of Pain, 24(9), 1730-1740. https://doi.org/10.1002/ejp.1616

Biopsychological pain management is not enough

I recently read a preprint of an editorial for Pain, the IASP journal. It was written by Prof Michael Nicholas, and the title reads “The biopsychosocial model of pain 40 years on: time for a reappraisal?” The paper outlines when and how pain became conceptualised within a biopsychosocial framework by the pioneers of interprofessional pain management: John Loeser (1982) and Gordon Waddell (1984). Nicholas points out the arguments against a biopsychosocial model with some people considering that despite it being a “holistic” framework, it often gets applied in a biomedical and psychological way. In other words, that biomedical concerns are prioritised, with the psychosocial factors relegated to second place and only after the biomedical treatments have not helped. Still others separate the relationships between “bio” “psycho” and “social” such that the interdependent nature of these factors is not recognisable.

Nicholas declares, too:

“… that cognitive behavioural therapy interventions that did not also include workplace modifications or service coordination components were not effective in helping workers with mental health conditions in RTW. That means, just like in the case of reducing time lost at school for children in pain, the treatment providers for adults in pain for whom RTW is a goal should liaise closely with the workplace. Unfortunately, as the studies from the systematic reviews examined earlier for a range of common pain therapies indicated, engaging with the workplace as part of the treatment seems to be rarely attempted.“

I find this confusing. In 1999 I completed my MSc thesis looking at this very thing: pain management combined with a focus on using pain management approaches in the workplace. The programme was called “WorkAbilities” and included visits to the workplace, liaison with employers and even job seeking for those who didn’t have a job to return to. The confusion for me lies in the fact that I’ve been doing pain rehabilitation within the workplace since the mid-1980’s – and that while today’s approach for people funded by ACC is separated from pain management (more is the pity), there are many clinicians actively working in pain rehabilitation in the context of returning to work here in New Zealand.

I’m further puzzled by the complete lack of inclusion by Nicholas of occupational therapy’s contribution to “the social” aspects of learning to live well with pain. This, despite the many studies showing occupational therapists are intimately connected with social context: the things people do in their daily lives, with the people and environmental contexts in which they do them. You see, occupational therapists do this routinely. We work with the person in their own environment and this includes home, work, leisure.

For those that remain unaware of what occupational therapists offer people with pain, I put it like this: Occupational therapists provide contextualised therapy, our work is in knowledge translation or generalising the things people learn in gyms, and in clinics, and helping people do these things in their life, their way.

An example might help.

Joe (not his real name) had a sore back, he’d had it for about three months and was seeing a physiotherapist and a psychologist funded by ACC (NZ’s national insurer). Not much was changing. He remained fearful of moving especially in his workplace where he was a heavy diesel mechanic and was under pressure from a newly promoted workshop manager to get things done quickly. Joe was sore and cranky, didn’t sleep well, and his partner was getting fed up. Joe’s problems were:

• guarding his lower back when moving
• fear he would further hurt his back if he lifted heavy things, or worked in a bent-over position, or the usual awkward positions diesel mechanics adopt
• avoiding said movements and positions, or doing them with gritted teeth and a lot of guarding
• poor sleep despite the sleep hygiene his psychologist had prescribed
• irritability
• thoroughly enjoying the gym-based exercise programme
• hating mindfulness and any of the CBT-based strategies the psychologist was offering him, because as he put it “I never did homework when I went to school, do you think I’m going to do it now? and this mindfulness thing doesn’t work!”

The occupational therapist visited Joe at home. She went through his daily routine and noticed that he didn’t spend any time on “fun” things or with his mates. His intimacy with his partner was scant because the medications he was on were making it hard for him to even get an erection, and his partner was scared he’d be hurt when they made love. Besides, she was fed up with all the time he had to spend going in to the gym after work when he wasn’t doing simple things around home, like mowing lawns, or helping with grocery shopping.

She went into his workplace and found it was a small four-person operation, with one workshop manager, two mechanics and one apprentice. The workshop was a health and safety hazard, messy and cramped, and open to the weather. The relationships between the team were strained with unpleasant digs at his failure to keep up the pace. The workshop manager said that he’d do his best to help Joe out – but in the end he needed to get the work out on time. The other mechanic, an old hand, meanwhile was telling Joe to suck it up and be a man, but also to watch out because Joe shouldn’t do as he’d done and shagged his back.

What did our erstwhile occupational therapist do? Absolutely nothing new that the physiotherapist and psychologist hadn’t taught Joe – but she worked out when, where and how Joe could USE the strategies they’d discussed in his life contexts. She went through the way he moved in the workshop and guided him to relax a little and find some new movement patterns to be able to do his work. She graded the challenges for him, and stayed with him as he experimented. She discussed alternating the tasks he did, interspersing tasks that involved bending forward with those where he could stand upright or even work above his head (in the pit). She discussed how he could use being fully present at various times during the day (mindfulness) to check in with his body and go for a brisk walk if he felt himself tensing up. She worked through communication strategies that they rehearsed and he implemented to let his manager know what he could – and could not – do.

They discussed his home life, and ways he could begin doing some of the household tasks he’d been avoiding, and she showed him how to go about this. They worked out the best time of day to do this – and to vary the exercise he did so that it wasn’t all about the gym. He started to walk over rough ground to get more confident for when he went fishing again, and he got himself a little stool to sit on from time to time. Joe and his occupational therapist talked about his relationship with his partner, and they met together with her so they could share what his back pain meant, the restrictions he had, what he could do, and how else they could be intimate. Joe was encouraged to rehearse and then tell his doctor about the effect of his meds on his sex life.

The minutiae of daily life, translating what is learned in a clinic to that person’s own world is, and always has been, the province of occupational therapy. It’s just a little sad that such a prominent researcher and author hasn’t included any of this in this editorial.

Just a small sample of research in which occupational therapists are involved in RTW.

Bardo, J., Asiello, J., & Sleight, A. (2022). Supporting Health for the Long Haul: a literature synthesis and proposed occupational therapy self-management virtual group intervention for return-to-work. World Federation of Occupational Therapists Bulletin, 1-10.

Berglund, E., Anderzén, I., Andersén, Å., Carlsson, L., Gustavsson, C., Wallman, T., & Lytsy, P. (2018). Multidisciplinary intervention and acceptance and commitment therapy for return-to-work and increased employability among patients with mental illness and/or chronic pain: a randomized controlled trial. International journal of environmental research and public health, 15(11), 2424.

Cullen K, Irvin E, Collie A, Clay F, Gensby U, Jennings P, Hogg-Johnson S, Kristman V, Laberge M, McKenzie D. Effectiveness of workplace interventions in return-to-work for musculoskeletal, pain-related and mental health conditions: an update of the evidence and messages for practitioners. J Occup Rehabil 2018;28:1–15.

Grant, M., Rees, S., Underwood, M. et al. Obstacles to returning to work with chronic pain: in-depth interviews with people who are off work due to chronic pain and employers. BMC Musculoskelet Disord 20, 486 (2019). https://doi.org/10.1186/s12891-019-2877-5

Fischer, M. R., Persson, E. B., Stålnacke, B. M., Schult, M. L., & Löfgren, M. (2019). Return to work after interdisciplinary pain rehabilitation: one-and two-year follow-up study based on the swedish quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 51(4), 281-289.

Fischer, M. R., Schults, M. L., Stålnacke, B. M., Ekholm, J., Persson, E. B., & Löfgren, M. (2020). Variability in patient characteristics and service provision of interdisciplinary pain rehabilitation: A study using? the Swedish national quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 52(11), 1-10.

Ibrahim, M.E., Weber, K., Courvoisier, D.S. et al. Recovering the capability to work among patients with chronic low Back pain after a four-week, multidisciplinary biopsychosocial rehabilitation program: 18-month follow-up study. BMC Musculoskelet Disord 20, 439 (2019). https://doi.org/10.1186/s12891-019-2831-6

Marom, B. S., Ratzon, N. Z., Carel, R. S., & Sharabi, M. (2019). Return-to-work barriers among manual workers after hand injuries: 1-year follow-up cohort study. Archives of physical medicine and rehabilitation, 100(3), 422-432.

Michel, C., Guêné, V., Michon, E., Roquelaure, Y., & Petit, A. (2018). Return to work after rehabilitation in chronic low back pain workers. Does the interprofessional collaboration work?. Journal of Interprofessional Care, 32(4), 521-524

Nicholas, M.K. (in press). The biopsychosocial model of pain 40 years on: time for a reappraisal? Pain.

Adam’s slow recovery

Not long ago I wrote about Adam Meakins back pain, and the astonishing response he’s had from fellow clinicians as he’s documented his recovery. Sadly, the polarised views of how therapists should approach a person with low back pain show me just how appallingly badly we adhere to low back pain guidelines… and worse, the kind of language and attitudes shown to a colleague who knows what he’s doing, demonstrates why change is so very slow.

What do I mean? Well, Adam has been following evidence-based low back pain guidelines that haven’t really changed a great deal since the advent of New Zealand’s “Yellow Flags” and guide to low back pain published waaaaay back in 1997. I’ve jumped to the NICE guidelines, as an example of one guideline, but you could look to many others.

NICE suggest these steps:

Assess for alternative diagnoses – in particular, “cancer, infection, trauma or inflammatory disease such as spondyloarthritis”

Risk assessment – basically, sorting people into those who are pretty OK with their pain, non-distressed and recommending those people receive “reassurance, advice to keep active and guidance on self-management.”

If Adam was distressed, or had a whole lot of risk factors for ongoing disability, then he might benefit from “more complex and intensive support for people with low back pain.” And yes, this mentions exercise programmes, manual therapy, psychological approaches.

Imaging – is not recommended, with imaging only used if the result is likely to change management.

Treatment – self-management, no orthotics or belts, no traction, and only offer manual therapy as part of an overall package that includes exercise.

No acupuncture, no electrotherapy.

Maybe use psychological therapies in conjunction with exercise.

Add in some NSAIDs

And don’t do much else…

In other words – exactly what Adam has been doing.

Why are there so many clinicians offering unsolicited opinions, without examining Adam, and without listening to his preferences, and without referring to the evidence?

What does this say about our clinical practice? What does it say about our confidence? What does it say about knowledge translation?

Most of all, what does this DO to the people we hope to help?

Seriously, folks. Watching the responses gives me nightmares.

I’ve been working in this field for 30 years now, and saying essentially the same thing about low back pain management for most of those years. I worry that an enormous business is built around scaring people, offering treatments with limited effect, for a condition that is common and responds well to doing normal movements.

In fact, one gripe I do have with the NICE guidelines is that they utterly and completely ignore daily life activities that a person needs to return to, and quickly. There’s nothing on managing sleep – and Adam’s described really rotten sleep until two days ago. There’s nothing on how to manage washing yourself, driving your car, sitting at a desk, doing the grocery shopping, preparing a meal, care for kids (or older parents) – absolutely nothing on the daily life activities that people need and want to do.

But, then again, I would say this – occupational therapists are the profession concerned about daily doing. The context of every day life. Knowledge translation from clinic/gym/exercise to what people actually do in their daily routines. It looks oh so simple – until you have to do it.

Back to Adam’s slow recovery. As I’ve watched Adam’s videos, I’m struck with the thought that many people just don’t know what to say – and so offer advice because that’s one way to deal with their own disquiet at helplessness. Clinicians, we need to develop better skills at managing our OWN emotional responses. We need to develop greater skills at sitting with our uncertainty. We need to stop leaping in with unsolicited advice that we offer just because we’re not comfortable doing nothing.

Could we just, for a moment, stop thinking about our reactions – and listen to what Adam (and I’m sure a whole bunch of our patients, too) says he wants? Listening means stopping that inner voice that’s got the “good” advice. It means really hearing what a person says. And only formulating a verbal response after we’ve digested the meaning the person is trying to convey.

Kia kaha Adam. You’re a brave man, a strong man, and I have much respect for you.

When therapists get hurt

“Physician, heal thyself” – usually used to suggest that the person should fix their own problems before trying to fix someone else. And when a therapist gets hurt all the armchair critics (social media proclamists) go off pointing the finger and telling that person what to do – even when the therapist is doing exactly what evidence suggests is the right thing to do.

Adam Meakins has hurt his back while lifting weights in the gym – he’s documenting his progress on social media, which I think is both a very brave thing to do and also something I’d love to see more of. If you want to follow his progress, head to The Sports Physio on Facebook where he’s posted footage of the onset, and now Days 1 and 2.

Why do I think it’s brave? Well because Adam’s outspoken and highly visible on social media. That means anything and everything he does about his LBP is likely to be scrutinised in detail. All manner of opinions have already been put forth. Diagnoses made (yeah, I know – over the interwebs…), and so many treatment options offered!

Adam’s predicament gets much more attention than Mrs Jones down the road who hurt her back the same day. Yet Adam knows what to do, is doing it, and holding strong to what research suggests is best.

Mrs Jones, on the other hand, is likely subject to some of the opinions that Adam’s getting (go on, take a look, especially on Instagram and Twitter) but without the background and experience Adam has to draw on. No wonder Mrs Jones feels confused.

Adam is brave because, as he pointed out today, having LBP means your mind leaps to unhelpful conclusions, often “thinks the worst” and in the dark of the night, it’s probable that doubts about whether he’s doing the right thing creep in. And if Adam’s recovery is slower than usual, I can hear the chorus of bystanders roar for his blood “You didn’t do what I said you should do”

Because isn’t it peculiar, and common, that when recovery doesn’t follow the standard trajectory, it’s the person’s fault…

Think of Mrs Jones – if her recovery goes the way so many people’s recovery goes and burbles along with flare-ups and periods where it settles, then she’s likely to carry on seeing at least one clinician, probably more. She’ll likely get a whole range of different ways to manage her low back pain – but usually starting with one approach and getting more of it until the clinician decides to change tack, and then onto another one until that clinician decides it’s not working and changes tack….And along the way she’ll acquire labels like “catastrophiser” or “avoidant” or “noncompliant”.

I also said that I’d love more clinicians to post about their recovery. I’ve seen a few, but couldn’t we do more? Why? Because showing how clinicians also “think the worst”, worry, have trouble sleeping, want to keep going but find it tough – despite our knowledge of pain, and all our experience working with people who have pain – is good for us as clinicians.

Because if you’ve never had a bout of back pain it’s relatively easy to think that the way a person reacts to their pain is abnormal. The label “catastrophising” gets bandied about, along with all the other psychosocial factors that can often get used and abused in a way that lays the fault for the person’s predicament on them.

But back pain is really common. Most of us will have a bout at some point in our life – maybe more severe than Adam’s, maybe less severe, maybe associated with heavy lifting as Adam’s was, maybe just bending to pick up a pair of socks. Some of us will be really fit like Adam, others of us will be less fit.

Back pain isn’t very choosy and this is why we haven’t yet found a way to prevent it from ever happening, we can only work with the person to prevent it hanging around and getting in the way of life.

Being honest enough to show that clinicians are human too helps other clinicians rethink the “them and us” divide that is common between people seeking help, and those who would offer help. Because how often do we hear that Mrs Jones was unfit, probably lazy, had a bad lifestyle, ate the wrong foods, did no exercise, and it was probable that she’d develop a back pain. Yet Adam is pretty fit, lives a healthy lifestyle, is certainly not lazy, and like Mrs Jones does not deserve a low back pain.

I hope that Adam doesn’t get the advice I’ve heard given to so many people: get fit, change your lifestyle, get back to work, do more. Mrs Jones might be working two physically demanding jobs (cleaning, and waiting tables). She might walk 20 minutes to get to the bus-stop, and is on her feet all the time she’s at work. She might leave home at 6.00am, get back at 5.00pm to prepare a meal for the rest of her household, then go out again for another three or four hours to her second job, finally arriving home to sleep at 9.00pm. And some youngster suggests she needs to “prioritise herself” and “do exercise”! Who else is going to do what Mrs Jones does for her family?

Finally, I really hope that people offer Mrs Jones a lot more of an empathic response than Adam has had. Anyone experiencing pain needs support – and don’t need a whole bunch of well-intentioned advice from people who don’t know them personally. And some of the comments offered to Adam are not well-intentioned. What does that kind of vicious behaviour show to the general public?

Below – just a small selection of the longitudinal studies exploring the trajectories of back pain in the population. Worth looking at if you think you’ve got The Answer to What To Do – because so far it’s not working.

Canizares, M., Rampersaud, Y. R., & Badley, E. M. (2019, Dec). Course of Back Pain in the Canadian Population: Trajectories, Predictors, and Outcomes. Arthritis care & research, 71(12), 1660-1670. https://doi.org/10.1002/acr.23811

Chen, Y., Campbell, P., Strauss, V. Y., Foster, N. E., Jordan, K. P., & Dunn, K. M. (2018, Feb). Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain, 159(2), 252-260. https://doi.org/10.1097/j.pain.0000000000001097

Gatchel, R. J., Bevers, K., Licciardone, J. C., Su, J., Du, Y., & Brotto, M. (2018, May 17). Transitioning from Acute to Chronic Pain: An Examination of Different Trajectories of Low-Back Pain. Healthcare (Basel, Switzerland), 6(2). https://doi.org/10.3390/healthcare6020048

Kongsted, A., Kent, P., Axen, I., Downie, A. S., & Dunn, K. M. (2016, May 21). What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord, 17, 220. https://doi.org/10.1186/s12891-016-1071-2

Pico-Espinosa, O. J., Cote, P., Hogg-Johnson, S., Jensen, I., Axen, I., Holm, L. W., & Skillgate, E. (2019). Trajectories of Pain Intensity Over 1 Year in Adults With Disabling Subacute or Chronic Neck Pain [Journal: Article]. Clinical Journal of Pain, 35(8), 678-685.

When living with pain is too hard

**If you’re a person living with pain, and this headline caught your attention because you’re feeling it’s just too hard to carry on – PLEASE take a moment to seek help. If you’re feeling you can’t because they might judge you, or try to stop you feeling this way, at the very least give yourself an hour before you take any action. If that feels too long, give yourself a minute. Get through that, and give yourself another minute. And so on – until you’ve give yourself some time to let this awful feeling ease up a little. You can always revisit your decision to wait. Speak to someone – anonymously if you need to. There are helplines in every country. Phone one. Please.**

Living with persistent pain can be really hard, and clinicians, family and the person with pain can be worried about suicidal thoughts and possible actions. There’s good reason to be concerned, too, as a recent study from the 2012 Canadian Community Health Survey shows.

Grocott, Sommer and El-Gabalawy (2021) used the data obtained from this Canadian Health Survey to explore the relationships between pain intensity and suicidality in people with arthritis, migraines and low back pain.

The first question is how many people in the overall population involved in this study had any of the three diagnostic groups – and, as expected and in line with many epidemiological studies, between 10.3% (migraines) and 18.1% (low back pain) indicated they had been diagnosed. The “usual” pain levels across all three groups were between 25.9 – 27.7% indicating their pain was “mild”, 52.5 – 54.5% said it was “moderate”, and 19.7 – 20.9% described it as “severe”. This does not surprise me one bit – moderate levels of pain intensity are really common, and, albeit acknolwedging the difficulty of rating pain intensity on a numeric scale and the complex relationship between pain intensity and interference with daily life, demonstrate just how necessary persistent pain services are as a health services priority.

The team then identified the rates of “lifetime” suicidality – these were measured using the following questions.

“you seriously thought about committing suicide or taking your own life” (i.e., suicide ideation; yes, no), “you made a plan for committing suicide” (i.e., suicide plans; yes, no), or “you attempted suicide or tried to take your own life” (i.e., suicide attempts; yes, no).

It’s important to note that this question asked about whether the person had ever, during their life, had these thoughts – not that they were currently present. Remember this as you interpret this study, because suicidal thoughts are relatively common but acting on those thoughts is less common.

The authors found that people who were usually in pain were more likely to have suicidal thoughts, plans or had made an attempt than those who had periods of time without pain (ie intermittent pain). The different rates were reasonably large, too – just in terms of ideation, between 18.7 – 34.0% of people who were usually in pain had suicidal thoughts as opposed to those with intermittent pain (10.5-16.6%), and this association was particularly strong for people with migraine. For people with low back pain, having pain all the time was associated with much greater odds of suicidal thoughts (1.79, 95% CI [1.19-2.68], p<.05).

Pain intensity was also a factor – lifetime suicidality prevalence increased as pain intensity increased, and this was relevant to all pain conditions measured, and especially amongst people with severe pain and migraines.

A good question to ask is whether the odds were the same for people with current mental illness as for those without – and using the magic of statistics, the authors found that this only held for some forms of pain. People with arthritis (note they didn’t identify the kind of arthritis people had) reported lower levels of suicidality even in the presence of mental ill health.

The authors point out that this is an interesting study in that yes, suicidality was higher in people with migraines, and similar to other studies, but their intriguing finding was that differences in the intensity of usual pain increased the odds, along with elevated odds if people reported higher levels of pain intensity.

Why did I choose to summarise this paper?

A few reasons: one is that as health professionals, we may not be aware of just how many people in our communities live with pain. It’s a lot – and this study only included specific diagnoses. Yet, at least in New Zealand, pain management services for people with pain are scarce.

Most people in New Zealand will maybe get referred to a physiotherapist, but it’s often difficult for people with persistent pain to raise their issues with pain with their health provider and for those providers to respond with empathy (Thompson, Dowell, Hilder, Macdonald, Stubbe & Alchin, 2021). This means that many people may not be seen by clinicians with confidence to help people with psychosocial aspects of their pain (eg Holopainen, Simpson, Piirainen, Karppinen, Schutze, O’Sullivan & Ken, 2020, Zangoni & Thompson, 2017) if they even indicate that this is a concern for them during the consultation.

Another reason is that many clinicians who work mainly in “physical” health may not know what to do if someone does disclose suicidal thoughts. It is confronting to hear someone say they don’t want to live any more – and knowing what to do next can feel highly risky. How does this fit within my scope of practice? What if I say something wrong and the person goes ahead and attempts suicide?

Note though, that this study didn’t look at current levels of suicidal thought – it’s lifetime prevalence. Perhaps people who have had occasion to think about killing themselves have a greater degree of vulnerability for persistent pain, particularly when pain is intense. We don’t know – but the authors speculate. Worth reading the paper in full to find out their thoughts.

My thoughts (briefly!) are:

• Prepare ahead of time. We’ll all likely encounter a person who is really distressed, at the end of their tether, and indicates they’re thinking of harming themselves. Being prepared makes responding to this situation much easier.
• Preparation should include writing a policy for your practice or your setting. It should include a list of people to contact in a psychiatric emergency (when a person indicates they’re ready to take action to harm themselves), as well as specific actions to take when talking to the person.
• We’re not all psychologists and it’s not our job to be psychologists – all we’re asked to do in this kind of situation is be a human. What I mean by this is – listen, affirm that the person is feeling really bad and support them to access the help they need. This might mean calling the psychologist if you have one you work with regularly, or calling the person’s family doctor, or calling psychiatric emergency services.
• Ensure you hand the person to someone who will take care of them. This means not letting them go off in their car without letting their family doctor know, even if they say they’re fine. For your own reassurance this is important.
• Take care of yourself. Don’t just go on to see the next person waiting for you. Take some time to process what’s happened, what you did, and debrief with someone you trust. It doesn’t need to be a trauma counsellor – it’s just as useful to talk to your colleagues who know you and the kind of work you do. Go have a cup of coffee, go for a walk, give yourself space to recognise that you just helped someone who was really distressed. That’s an important job.
• Don’t ignore the person and pretend they didn’t just say that. Affirm that they’re feeling rotten. Don’t trivialise it and suggest they should just harden up, or it’s not really that bad, or that they’re at fault for feeling this way. Just be gentle and human, and recognise the privilege you have – this person trusts you enough to say how they’re really feeling. It’s an honour. So if you can’t think of anything to say, just sit with them and bear witness to their distress. Hand them a tissue. Be there for them.

Oh, and in that paper, while 18.7 – 34.0% had suicidal thoughts over their lifetime, 7.2–14.5% had made actual plans, while 6.6–14.7% had made attempts. Don’t trivialise suicidal thoughts, but at the same time, don’t freak out that the person is going to kill themselves – just take action to support them, and in most cases, the thoughts will fade as the person gains hope.

Grocott, B., Sommer, J. L., & El-Gabalawy, R. (2021, Jun 28). Usual presence and intensity of pain are differentially associated with suicidality across chronic pain conditions: A population-based study. Journal of Psychosomatic Research, 148, 110557. https://doi.org/10.1016/j.jpsychores.2021.110557

Holopainen, M. R., Simpson, M. P., Piirainen, D. A., Karppinen, P. J., Schutze, D. R., Smith, P. A., O’Sullivan, P. P., & Kent, A. P. (2020, Jan 16). Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain. https://doi.org/10.1097/j.pain.0000000000001809

Thompson, L., Dowell, A., Hilder, J., Macdonald, L., Stubbe, M., & Alchin, J. (2021, Jan 4). How do patients and General Practitioners talk about pain and negotiate empathy in consultations? A direct observational study. Health & Social Care in the Community. https://doi.org/10.1111/hsc.13259

Zangoni, G., & Thomson, O. P. (2017, 2//). ‘I need to do another course’ – Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskeletal Science and Practice, 27, 71-77. https://doi.org/https://doi.org/10.1016/j.msksp.2016.12.015

Modifying pain behaviour (2)

Two concepts that receive limited attention in the allied health literature are nomothetic and idiographic approaches. I’m discussing these concepts here because when we’re considering pain behaviour, I think we can focus much more on “generic” (nomothetic) concepts than we do idiographic ones – and yet we say we’re about the unique person in front of us.

Firstly, this site offers a good summary of the difference between nomothetic and idiographic – click

Essentially, nomothetic approaches focus on underlying generalities, perhaps traits, and are a solid part of the science of measurement in psychology. Given that much of our allied health measurement practice is based on psychological theories (such as using aggregated or grouped data to search for differences in means between two groups), it’s not surprising that we’ve tended to reach for a self-report measure when we want to understand what a person thinks and does when they’re sore. Think of the Oxford Knee Score, or the Oswestry Disability Index, for examples!

Here’s an item from the Oswestry Disability Index (Fairbank, Couper, Davies et al, 1980)

Section 5 – Sitting
I can sit in any chair as long as I like.
I can sit in my favorite chair as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than ½ hour.
Pain prevents me from sitting for more than 10
minutes.
Pain prevents me from sitting at all.

When a person reads these items, they’re asked to indicate the answer that best fits their experience, but left unanswered are these points: what time of day? what kind of chair? what is the person doing in the chair? who is around that person? why is the person sitting for a long time? what is it about the pain that stops the person from sitting? what do they think is going on?

While the measure itself is based on rigorous methodology, has excellent psychometric properties and so on – it doesn’t investigate important dimensions that we need as clinicians to help this person perhaps alter their sitting tolerance.

Alternative measurement approaches are available: item response theory is one (click) and multi-level modelling is another (click) – but the former still considers latent traits (ie can we identify a general underlying response that underlies all the variability we see in the data), and multi-level modelling also assumes that the respondents still belong to a general population who will demonstrate similarities around the variable in question.

The problem is that people don’t always follow the rules. Here’s an example:

A woman I saw once had low back pain, and was very afraid to bend forward. She was particularly worried about bending down in the shower to wash her lower legs, and when she saw me she avoided putting her handbag on the floor because this would mean she’d need to bend down to pick it up.

To get around this concern, she’d learned to sit on the floor of her shower to wash her lower legs, used pull-on shoes with elastic laces, or court shoes for work, and she’d put socks and pantihose on while sitting on the floor.

At the same time, she was comfortable sitting for around an hour, was able to stand as a customer service person for an eight hour day, and was happy driving – but not happy about reaching into the back of her car (it was a two-door) because it meant she was bending.

For this woman, her score on the Oswestry was below 20% or considered to be “minimal disability” – and yet she was almost turning herself inside out to be able to do what mattered to her.

An idiographic approach to her situations looks a little more deeply at the function of behaviour in context. If we take a look at the amount of spine flexion within her activities of daily living, we can see that sitting on the floor to wash her legs, and to pull shoes and socks on involves just as much movement as if she was bending down. What was different? Well, she was really afraid she’d slip in the shower and land in an undignified heap on the floor, needing to be rescued – while being naked! She said she’d been told that she shouldn’t bend because she had a disc prolapse and she’d seen one of those spine models with the bright red disc bulge and thought this was going to be much worse if she bent over. She was very concerned about appearances as she worked in a customer service role, so developing a way to still get dressed while avoiding bending forward was really important to her – but it took her much longer to do, much more effort to do it, and she remained quite certain that this red jelly would ooze from her disc if she bent forward.

In a behavioural approach to pain management, it’s important to understand the antecedents and consequences of a behaviour, so we can understand what elicits the behaviour, and what consequences occur to maintain it. In this woman’s case, any context where she might need to lean forward – such as making her bed, picking clothes up from the floor, putting shoes and socks on from standing, picking her handbag up, reaching into the back of her car to fetch something – elicited a thought (image) for her of her disc oozing out. Combined with her interpretation of the advice not to bend when she first sought help, her response was one of fear – and one thing we learn very early on as humans is that we should avoid things that generate fear.

The consequences of her avoiding forward flexion were many: her fears weren’t allayed except in the moment, and she remained highly concerned about the disc bulge; she felt relieved in the moment as she avoided doing the movements she thought would harm her. This is negative reinforcement – fear (negative experience) is reduced (withdrawn) because she avoided the movement (relief – I’ve avoided a disaster!). She also avoided doing many things she’d enjoyed – like playing tennis (bending down to pick up a ball? No way!), picking her clothes up from the floor (she had a home helper do this, and do her washing), she’d changed the shoes she wore to avoid having to bend down to tie laces, and she sat on the floor of her shower to avoid having to bend down to wash her legs.

When we started to work on helping her move on with life, it was really important to understand the unique combination of context and function of her strategies for avoiding bending. Just telling her that her discs wouldn’t bulge out wouldn’t alter those powerful images in her mind! We can’t unlearn an association once we’ve learned it. And she’d been practicing this association between an image of disc bulge oozing and bending – and all the activities where we bend, and all the associations she’d made between jelly wobbling (because the disc is basically jelly, right?), and all the other things she knew about jelly – it’s not strong, it can smear over things, it wobbles, it can melt…. My approach was to help her experience doing without the dire consequences, starting from simple and moving to more challenging over time. More on this next week!

As clinicians, our words matter, as do the images and models we have in our clinics. We also must be mindful that the people we try to help will bring their history and the unique associations they’ve made between things they’ve been told, metaphors they’ve heard and the values that matter to them. Respecting all those vitally important and idiosyncratic aspects of being human is integral to a behavioural approach to pain rehabilitation. Let’s not put people into algorithms or groups or boxes, because if we take the time to learn about their uniqueness we can create more powerful – and fun! approaches to helping them live their lives again.

Fairbank J, Couper J, Davies J, et al. The Oswestry low back pain questionnaire.
Physiotherapy 1980;66:271–3.

What to do about acute low back pain

I should add another line to that heading: in one easy step! And I’d be inundated with hits and if I could cash in on them I’d be rich! And wrong.

If there was a simple recipe for success, I’d expect that by now we’d have it. The very fact that SO MANY options for managing a bout of low back pain exist is a good reason for skepticism should you ever get tempted to take a headline like mine as a cause for celebration. However I do want to talk about acute low back pain because I think clinicians are often probably doing it wrong.

First of all, low back pain doesn’t include pain that also goes down the leg. Let’s get the definitions clear before we talk! In 2008 a Delphi study by Dione, Dunn, Croft, Nachemson, Buchbinder, Walker and colleagues (2008) developed two definitions: a minimal definition, and an optimal definition. These definitions were developed for epidemiological studies and the minimal definition is very simple – “In the past 4 weeks, have you had pain in your low back?” and “If yes, was this pain bad enough to limit your usual activities of change your daily routine for more than one day?”

from Dionne, Dunn, Croft, Nachemson, Buchbinder, Walker et al, (2008)

Now when it comes to defining a first bout of acute low back pain, Ardakani, Leboeuf-Yde & Walker (2019) raise some very interesting points: researchers investigating acute low back pain don’t clearly distinguish between the factors associated with the disease of low back pain (as they put it, the onset of the very first episode) from its recurring episodes – as they put it, “the continued manifestations of the “disease”.” In fact, in their systematic review for identifying risk factors from “triggers” (their term for subsequent episodes), they could find only one study dealing with the true incidence of first time low back pain – and this was low back pain caused by sports injury. All the remaining studies either explored new episodes, or recurring episodes. The major problem with these studies? They didn’t define how long a person should have had no low back pain at baseline. And given many of us develop back pain in adolescence (see Franz, Wedderkopp, Jespersen, Texen and Leboeuf-Yde, 2014, or Jones & MacFarlane, 2005) for example) it’s probable that studies investigating those over 18 years old will include a lot of people who have had that first bout already.

The trajectories for those of us who do develop low back pain are also reasonably murky because of the challenges around definitions, and there are several studies with slightly different results as you’d expect. Essentially, though, most researchers find that there are three or four patterns that emerge from longitudinal studies: lucky ones who have one bout and no or low levels of pain thereafter; those who have persisting mild pain, those who have fluctuating bouts over time, and those who develop persistent and severe pain. Chen and colleagues (2018) found that “lower social class”, higher pain intensity at the beginning, the person’s perceptions of more challenging consequences and longer pain duration, and greater “passive” behavioural coping were most significantly associated with the more severe trajectory over five years.

So, what does this mean for clinicians – and how well are we doing?

Acute low back pain can really frightening for people, especially if the pain is severe. As clinicians generally choose this work because we care about people, we get hooked into wanting to reduce pain and help. There’s nothing wrong about this – unless it means we also get hooked into trying to offer something we cannot. We’re inclined to believe that people seek help for their back pain because of the pain – but as Mannion, Wieser & Elfering (2013) found from a study of over 1,000 people with back pain at the time of the survey, 72% hadn’t sought care over the previous four weeks; 28% had sought care – and most from more than one provider. Women were more likely to seek care, those who had experienced more previous bouts, those who had trouble with activities of daily living and more trouble with work activities. While pain intensity did feature, it wasn’t as much of a predictor as many clinicians would expect. Indeed, an earlier meta-analysis by Ferreira and colleagues (2010) found that disability was a stronger predictor for seeking treatment than pain intensity.

So what do clinicians focus on? I suspect, though I aim to be proven incorrect, that almost every clinician will ask “what is your pain intensity on a scale from 0 – 10?” Frankly, this question is one that irritates me no end because how on earth do you rate pain? Seriously. Yes, there are a lot of clinicians who then ask about activities a person wants to be able to do (yay!) though when we look at the treatments offered, I wonder how many follow through with practical goal-setting for daily activities like getting shoes and socks on, carrying the groceries, sitting while driving the car or at work… And treatments? the arguments on social media between clinicians would be fun to watch if only they weren’t accompanied by such vehemence!

What I don’t see are conversations about how we help people recognise that they’re likely to follow one of those four trajectories, and what we do to help people self manage a life alongside low back pain.

I don’t see much attention paid to helping people sleep well.

Lots of conversations about pain neurobiology – in an attempt to use this explanation to bring someone on board to engage in treatments.

I don’t see a lot of discussion about how to ask about the person’s main concern – perhaps it’s nothing to do with pain, but more about “my niece is coming to visit and I’m not sure I can cope with entertaining her and managing my back pain”, or “we’re coming up to the busy time at work and I can’t not go in, but when I get home I’m trashed, how can I manage that?”, or “Monday’s are our busiest day, and I have to keep going because the team needs me, what do I do?”

I wonder whether clinicians could be persuaded to get out of the way and stop confusing people with recipes or algorithms or “special exercises” that “must be done this way” – I wonder if we could offer some very simple steps: specific answers to the person’s main concerns (best form of reassurance there is!); goal setting around the things the person needs and wants to do over the first six to eight weeks; sleep strategies including some mindfulness because that’s likely to help long-term; and lots of encouragement as the person returns to activity. Developing a relationship with the person doesn’t need lots of prescriptive steps or cookie cutter programmes, it does mean listening, showing trust in the person’s own capabilities, and willingness to let go of a few sticky thoughts we’ve acquired during our training. Maybe 2021 could be the year clinicians get back to basics and begin to support resilience in the people we see – firstly by showing them that we trust they have the capabilities.

Ardakani, E. M., Leboeuf-Yde, C., & Walker, B. F. (2019). Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature. Pain Res Manag, 2019, 6959631. doi: 10.1155/2019/6959631

Dionne, C. E., Dunn, K. M., Croft, P. R., Nachemson, A. L., Buchbinder, R., Walker, B. F., . . . Von Korff, M. (2008). A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine, 33(1), 95-103.

Franz, C., Wedderkopp, N., Jespersen, E., Rexen, C. T., & Leboeuf-Yde, C. (2014). Back pain in children surveyed with weekly text messages-a 2.5 year prospective school cohort study. Chiropractic & Manual Therapies, 22(1), 35.

Jones, G. T., & MacFarlane, G. J. (2005). Epidemiology of low back pain in children and adolescents. Archives of disease in childhood, 90(3), 312-316.

Mannion, A. F., Wieser, S., & Elfering, A. (2013). Association between beliefs and care-seeking behavior for low back pain. Spine, 38(12), 1016–1025

Did you miss me?

It’s been a while since I last posted on my blog, as I’ve had other projects on the go this summer. Over this time I’ve been pondering, as I usually do, why pain management/rehabilitation has so many problems. Conceptually, I can understand that pain is a complex experience that we’re a long way from understanding. I get that it’s a philosophically challenging subject. That because it’s subjective (like love, disgust, fatigue or hunger) it’s difficult to examine dispassionately.

I also get that it’s big business. Pain is one aspect of being human that captures the entrepreneur’s imagination. People don’t like pain (on the whole), and even those who seek pain (I’m not thinking fetishes – just sports people!) aren’t inclined to want it to hang around. There’s a ready market for anything that helps “get rid of” pain – even though it’s impossible to fully “get rid of” pain without simultaneously creating other problems!

Some of us clinicians focus almost exclusively on finding a presumed cause. The search can go on for weeks, months, years. Professionals will use tests, investigations, even treatments to see whether they’re on the right track to find what’s initiating the experience. And clinicians can believe, because a treatment was followed by a reduction in pain, that they’ve found it! Happy customer, happy therapist.

Huge arguments are waged across social media platforms. The proponents of one view argue against the proponents of another view. The pendulum is said to swing violently from one side to the other. “Too much bio” “Too much psychosocial” “but what about the bio” “the bio’s always in there, it’s even in the name” – and so on.

I’m a clinician who rarely gets caught up in the “but what about the bio” argument – because I’m unashamedly clear that I don’t treat pain. I don’t attempt to change pain. I don’t try to find the cause. I don’t really look at the diagnosis very much. I don’t try to explain what’s going on. Not because I don’t have some ideas about what might be going on, but because the people I see have usually had “the bio” so extensively investigated that it’s moot. Given that most of our treatments for persisting pain are pretty mediocre, I figure that by the time someone gets to see me (on average two years after the onset) it’s time to focus more on living alongside pain. And if pain does happen to change or go, that’s a total bonus. I’d argue that being able to do that even in the early stages might go a long way towards reducing the overwhelming impact of pain on the daily lives of people.

But in not focusing on pain reduction, not locating the supposed “source” of the problem, some people are horrified. “But look at my success” or “this person suffered for X years and then I solved the problem and their pain went!”. You know, that’s awesome and I think it’s fabulous when someone finds something that reduces pain. It’s just that I don’t think it’s necessary to prioritise pain reduction over living life – I think the two can be done concurrently, albeit with care.

The energy people put in to arguing their position, whichever orientation they prefer, is extraordinary. And it’s this that makes me feel somewhat worried. When we put so much effort into defending a position, we argue ourselves into a stance that’s difficult to change. And we become less sensitive to information that doesn’t fit with our argument. We hold onto our beliefs more strongly, while filtering everything we see and hear through a lens that skews our view of our world.

I’ve argued that clinicians need to hold their beliefs about what we think we know fairly lightly. When we recognise that pretty much all we think we know is provisional and should be subject to more testing, it’s worth remembering that something we assume we know for sure could be wrong.

Take rest for low back pain: from the late 1880’s until around 1986ish, rest for seven days was The Treatment. It’s only through testing and vigorous (really vigorous) arguments that we’ve arrived at the situation we have now, where it’s pretty clear that bed rest isn’t a good option (See the two refs below!). But OH the angst over the years 1975 – 2004! Much argument and rage and frustration and even litigation…

Now we have the era of exercise is good for back pain (well, everything if you read the headlines!). But is “exercise” the panacea? How does exercise help? What are the mechanisms, and can they be activated in other ways? What if you don’t enjoy “exercise” as administered by so many therapists? (see Searle, et al, 2015, below).

I think we’ve learned a great deal about what doesn’t work in pain rehabilitation/management. Mostly, our effect sizes are modest to tiny. And what we haven’t dealt with is how do we help people move from being patients to being people. To being people with lives they want to live. Transferring what seems to help into a person’s OWN life, not the one we think they ought to live.

This year’s blogging is likely to continue my tradition of grasshoppering from topic to topic, but at the heart of my writing is my desire to see people with pain being able to live their own lives, in their own way, with their own priorities and values, and in their own context. Maybe it’s time to step outside our clinic doors, and remember the reason people come to see us: they want to be able to do what’s important in their life. The rest of this philosophical and methodological and factionistic arguing is beside the point.

Hagen, K.B., et al., Bed rest for acute low‐back pain and sciatica. Cochrane Database of Systematic Reviews, 2004(4).

Searle, Angela, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation 29.12 (2015): 1155-1167.

Waddell, G., G. Feder, and M. Lewis, Systematic reviews of bed rest and advice to stay active for acute low back pain. British Journal of General Practice, 1997. 47(423): p. 647-652.