Professional topics

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.

“Just a little scratch”


If you’ve had a blood test, flu jab or Covid-19 vax (please do, not just for you but for the vulnerable) you’ll probably have heard those words “Just a little scratch” then the needle goes in and ouch! I’ve wondered why phlebotomists and vaccinators use those words: is it to reduce the pain? give you some warning so you don’t pull away? why use the word “scratch” when it’s not a scratch?!

I suspect, though I haven’t read up on it, that the reason people say “just a little scratch” is to influence expectancies. Expectancies are defined as “cognitions regarding the probability of future experiences, events, and behaviour” (Peerdeman, van Laarhoven, Peters & Evers, 2016). In other words, what we expect to experience, happen or do influences what we actually experience, what happens, and what we do. Expectancies are really important when we consider placebo – and nocebo. Despite commentators who don’t consider placebo to be a thing (the response to being in a treatment ritual, over and above the effects of any active therapeutic agent), in pain, it is most definitely a thing, and one we need to be aware of as clinicians.

Back to expectancies.

Mostly, what we expect is what we experience. If we expect something to REALLY HURT then it’s likely to REALLY HURT! But what happens when we don’t expect something and it happens? Or when we expect something not to really hurt, but it actually does?

Peerdeman, Geers, Porta, Veldhuijzen and Kirsch (2021) investigated this mismatch between what we expect and what actually happens. It’s fascinating because the results weren’t quite in line with what the researchers thought…

What did they do?

The authors selected 82 healthy adults, aged between 18 and 30, with no health problems (physical or psychologist), no chronic pain, no current pain, no medications, no pacemakers, and no pregnancy. The participants weren’t allowed to use any medication, alcohol or other drugs in the 24 hours before the experiment.

Two experimenters undertook the experiments – one wasn’t aware of who was getting what, while the other was unaware of what was getting what until just before she gave the verbal suggestion. The experimenter who was blinded left the room before the second one gave the suggestion, in order to remain blinded throughout.

The participants were wired up to record heart rate, skin conductance, and then thermal and nociceptive perception thresholds were identified – at least in part to give participants a chance to get used to the heat stimulus. The experimenters went in to increase the heat to identify the temperature where participants indicated the pain was “moderately high” (who volunteers for these experiments? Oh – they recruited from around the university and on social media...). Then the experimenters got to work: participants were randomised to get either a suggestion of “no pain” (they’d already had three occasions where the thermal stimulus wasn’t painful, and three where it was), or a suggestion of moderately high pain. Then the stimulus was applied four times, with participants having to rate the expected pain intensity, how certain they were of this prediction, and how afraid they were. Afterwards, they were asked to rate pain intensity and unpleasantness.

For all the details of this experiment, head to the paper itself – it’s very detailed, and could be replicated.

Results

One person dropped out before the trial began – it was too painful – leaving 81 people remaining. The average age was 22 years, but the investigators don’t report gender.

When people were told “it’s not going to hurt” participants rated the pain lower than those who were told it was going to hurt, and while the ratings changed depending on what they experienced, when it was again suggested they’d feel no pain – again their pain ratings were lower than expected. Who knew pain intensity could vary so much? Reported pain intensity in the people who were told they wouldn’t experience pain was 4/10 points lower than the other group who were told it would hurt, and a bit over 2 points lower the second time (on a 0 – 10 numeric rating scale). That’s a thumping great amount of pain reduction! Add to this, these participants also were less afraid of their pain than the other group.

BUT, and this is important, participants in the “it’s not going to hurt” group reported less trust in the experimenter (who would have thought, huh?!). So beware: if you tell someone “oh this won’t hurt a bit” – they may experience less pain, but they’ll look at you sideways and be a bit wary of you because you violated their trust.

Discussion

I haven’t described the second experiment because of space, but go ahead and read it. Essentially they added some more participants, varied the procedure a little to reduce the memory burden on participants, and added a “medium” underprediction element into the process. The results showed similar outcomes – lower ratings of pain in both the “you won’t feel a thing” and the “it’ll hurt but not much” experiments, and yet again, less trust in the experimenter suggesting that it wouldn’t hurt.

Lessons to learn?

Think carefully about inflating how much pain relief someone will experience, especially if you’re going to see that person again. While people might experience less pain, losing someone’s trust in a therapeutic setting is a serious problem. The authors point out that healthy volunteers in a lab setting, getting short-term pain, is not like a therapeutic setting where it’s probable that trust is well-established. We don’t know what effect violating trust in a longer-term relationship might have.

At the same time – it does strike me as intriguing that simply being told “it won’t hurt” can influence pain intensity rating. What’s going on? How can a communication stimulus influence an experience? How could a psychological input change the way we perceive a noxious stimulus? Perhaps the way forward might be to use neutral language or, more positively, suggest that the person can handle it? “Just a little sting and you’ll get through”

Peerdeman, K. J., Geers, A. L., Della Porta, D., Veldhuijzen, D. S., & Kirsch, I. (2021, Jul 1). Underpredicting pain: an experimental investigation into the benefits and risks. Pain, 162(7), 2024-2035. https://doi.org/10.1097/j.pain.0000000000002199

Peerdeman KJ, van Laarhoven AI, Peters ML, Evers AW. An Integrative Review of the Influence of Expectancies on Pain. Front Psychol. 2016;7:1270. Published 2016 Aug 23. doi:10.3389/fpsyg.2016.01270

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

Why I don’t trust my clinical reasoning: and why this matters


“See someone experienced” I hear people with pain say. “They’ll know what’s wrong with you.”

Well, based on the research I’ve read, I wouldn’t be so sure. In fact, I’m certain my own clinical reasoning is biased, prone to errors that I don’t notice, and influenced by factors that most clinicians would be horrified to think they, too, were influenced by.

Let me give you a few to ponder:

I’m interested in women and pain – and there’s a lot of evidence showing that women’s pain doesn’t get the same kind of diagnostic and management attention as men. Now part of this is due to the inherent bias in research where experimental studies often rely on male rats, mice and undergraduates because they don’t have those pesky hormonal fluctuations each month. Even volunteering to take part in a pain study has been found to be biased – people who volunteer have been shown to be more risk-taking and more extraverted (Skinner, 1982) – though to be fair this is an old study!

But contextual factors such as gender, distress and even the supposed diagnosis do influence judgements about pain intensity (Bernardes & Lima, 2011) including potentially life-threatening chest pain (Keogh, Hamid, Hamid & Ellery, 2004). Gender bias has been identified in a large literature review of gender bias in healthcare and gendered norms towards people with chronic pain (Samulowitz, Gremyr, Eriksson & Hensing, 2018).

And if you have the misfortune to be judged to have low trustworthiness and you’re a woman, you’re more likely to be thought to have less pain and to be exaggerating your pain (Schafer, Prkachin, Kaseweter & Williams, 2016). Beware if you’re overweight and a woman because you’ll be likely judged as having less intense pain, the pain will be judged as less interfering, more exaggerated and less related to “medical” factors – women’s pain in particular is likely to be judged as “psychological” and given psychological therapy rather than other treatments (Miller, Allison, Trost, De Ruddere, Wheelis, Goubert & Hirsch, 2018).

The weird thing is that the clinicians involved in these studies were oblivious to their bias. And let’s not even go there with people of colour or so-called “minority” groups such as LGBTQI.

So as clinicians our initial impressions of a person can lead us astray – and I haven’t even started with the contribution experience has on clinical reasoning. Let me go there then!

Something that cognitive psychologists have explored for some years now, is the type of thinking that we draw on for clinical reasoning. System one is “fast reasoning” – where we rapidly, instinctively and emotionally make decisions on the fly. Kahneman (1982) first described these two processes and noted that fast thinking gets better with rehearsal and are helpful especially for skilled clinicians needing to make decisions in pressured contexts, and draw on “pattern recognition” – or to be precise, draw on deviation from a recognised pattern (Preisz, 2019). System two is “slow reasoning” where decisions are made in a considered way, are not influenced by emotional state, and can be thought of as “rational.” Slow thinking is most useful where the situation is complex, where decisions need to weigh multiple pieces of information, where the situation might be novel, or where, for persistent pain in particular, there are multiple disease processes occurring.

OK, so we should choose system two, right? Not so fast! System one is hard to switch from – it’s what underpins “intuition” or “hunches” – and it gets more entrenched the more experienced we are. According to Preisz (2019), system one “seeks to form a coherent, plausible story by relying on association, memories, pattern matching and assumption.”

Why is system one thinking not so great? Well, we’re human. We’re human in the way we respond to any reasoning situation – we anchor on the first and most “plausible” ideas, and these might be unrelated to the actual presentation we see. For example, if we’ve been reading a journal article on a new treatment and its indications, it’s amazing how many people will present with those exact same indications in the next week! This is availability bias or anchoring bias. We’re also inclined to believe our own patients and judgements are different from “those people” – especially “those people” who might respond best to clinical guidelines. This means that even in the face of clear-cut research showing the lack of effects of knee arthroscopy (Brignardello-Petersen, Guyatt, Buchbinder, Poolman et al, 2017) an orthopaedic surgeon I know argued that “we choose our patients very carefully” – essentially arguing that his patients are different, and this approach is the best one.

If experienced clinicians find it hard to “unstick” from old practice, or move quickly to “intuitive” reasoning (even if it’s called “pattern recognition”), and if we all find it hard to recognise when we’re biased, or even that we are biased, what on earth should we do? All us old hands should retire maybe? All follow algorithms and not use “clinical judgement”? Take the “human” out of clinical management and use AI?

Some of these things might work. There is evidence that algorithms and AI can offer effective and (perhaps) less biased diagnosis and management than our unaided human brain (Kadhim, 2018) but there are also studies showing that direct comparisons between decision aids and clinical judgement are rarely made, and those that have been carried out don’t show superior results (Schriger, Elder, & Cooper, 2017). But watch this space: AI is a rapidly developing area and I predict greater use of this over time.

The risk with decision aids is – garbage in, garbage out. If we look at existing research we can see that male, pale and potentially stale dominates: this doesn’t bode well for people of colour, for women, for the unique and idiosyncratic combination of diseases a person can have, or for untangling the impact of disease on the person – in other words, disability and illness.

So, to summarise. We are all biased, and it’s best to acknowledge this to ourselves upfront and personal. We can then turn to strategies that may reduce the biases. For me, the one I turn to most often is a case formulation, using information gathered from a semi-structured interview and a standard set of questionnaires. These have been developed a priori so my biases in information gathering are limited. By taking time to follow a case formulation, my thinking is slowed to that more deliberative system two. At least some of the biases I know I’m prone to are mitigated.

And yet, I know I am biased. That’s why I use a supervision relationship to help me identify those biases, to be challenged and to reflect.

Bernardes, S. F., & Lima, M. L. (2011, Dec). A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain. Psychology & Health, 26(12), 1642-1658.

Brignardello-Petersen, R., Guyatt, G. H., Buchbinder, R., Poolman, R. W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N., & Vandvik, P. O. (2017, May 11). Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open, 7(5), e016114. https://doi.org/10.1136/bmjopen-2017-016114

Kadhim, M. A. (2018). FNDSB: A fuzzy-neuro decision support system for back pain diagnosis. Cognitive Systems Research, 52, 691-700. https://doi.org/10.1016/j.cogsys.2018.08.021

Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.

Keogh, E., Hamid, R., Hamid, S., & Ellery, D. (2004). Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain, 111(1-2), 209-217.

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018, Jan). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. J Pain, 19(1), 57-66. https://doi.org/10.1016/j.jpain.2017.09.001

Preisz, A. (2019, Jun). Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. Journal of Paediatric Child Health, 55(6), 621-624. https://doi.org/10.1111/jpc.14447

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018.

Schafer, G., Prkachin, K. M., Kaseweter, K. A., & Williams, A. C. (2016, Aug). Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 157(8), 1618-1625. https://doi.org/10.1097/j.pain.0000000000000536

Schriger, D. L., Elder, J. W., & Cooper, R. J. (2017, Sep). Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior. Ann Emerg Med, 70(3), 338-344 e333. https://doi.org/10.1016/j.annemergmed.2016.12.004

Skinner, N. F. (1982, 1982/12/01). Personality characteristics of volunteers for painful experiments. Bulletin of the Psychonomic Society, 20(6), 299-300. https://doi.org/10.3758/BF03330107

Knowledge gaps for working together


Whenever we work with someone living with pain, we form a team. A team, by definition, is “a distinguishable set of two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal/objective/mission” (Salas et al., 1992). So while many clinicians work outside an interprofessional team, they are always working in a team consisting of at least the person with pain, and themselves.

There’s a good deal of research on teamwork, and a heap of references in pain management literature on the benefits and, indeed, the need, to work in a team for best outcomes (both in terms of effects for the person and in terms of cost-effectiveness). Gilliam and colleagues (2018) demonstrate that long-term outcomes are retained by participants attending an interdisciplinary pain rehabilitation programme, while Guildford and colleaguees (2018) also showed reductions in analgesic use during an interdisciplinary pain management programme. It’s not new news folks!

Teamwork is well-investigated in health, particularly interprofessional/interdisciplinary teamwork. Much of this research, however, is focused on nursing and medicine interactions, with rather less attention paid to allied health and nursing/medicine teamwork. This matters because while nursing and medicine are moving away from the old medical model, the professions probably represent the two most similar in terms of clinical models. And this matters because one thing that’s found to be important for good teamwork in health is having a shared mental model (for example – from operation room – Wilson, 2019).

All good so far – nothing new here, move along, right?

Hold it right there, folks.

You see, when we work together in a team, particularly for people with persistent pain, we often generate a heap of new information about the person we hope to help. In New Zealand, the person will have completed the ePPOC set of questionnaires, then there will probably have been some physical performance testing, maybe some basic ROM, and muscle testing, perhaps some daily life functioning tasks, certainly some more psychological questionnaires, if the person sees a medical practitioner, there will be the obligatory bloods, urine, perhaps imaging – you know what I mean! A heap of information that each clinician deems necessary and I haven’t yet gone into each clinician’s desire to “hear the story from the beginning again!”

What’s lacking in our research on teamwork in persistent pain is discussion about how we assemble this information so that we move from a multidisciplinary team – Multidisciplinary teams involve people from different health disciplines working alongside one another while using clinical models drawn from their own professional discipline (Körner, 2010) – to an interprofessional/interdisciplinary team – Interdisciplinary teams also involve people from different health disciplines working alongside one another but meet regularly to collaborate on treatment goals and priorities (Ruan & Kaye, 2016). There is limited hierarchy and considerable communication, cooperation and often overlap between team members (Körner, 2010).

Not only a lack of a shared mental model (because we all think our model is The Best), we also lack an understanding of team processes. How do we develop an effective way to communicate, to cooperate, to deal with conflict in an open and creative way, to coordinate our work so things happen at the right time, to be coached so that the team-as-a-whole moves in the same direction and new people coming to the team feel part of the culture? Not forgetting that teams work in an ever-changing context, and team membership changes over time, while the overall team culture is something that emerges from a team collective (Salas, et al., 2015).

Are pain rehabilitation teams different from teams working in older person’s health, or palliative care, or as part of a primary health team?

I suspect so, but I can’t find good research detailing how our pain teams are different. It’s like a black box of mystery (a bit like interprofessional pain management programmes – one murky black box out of which a person pops!)

I’m left with this feeling that because teams in pain management and rehabilitation have become scarce in most part of the US, and that this is where all the research funding lives, there’s not very much that we actually know. We don’t know who holds the positions of power – is it the medical practitioner? the psychologist? the physiotherapist? the occupational therapist? Who makes the call as to when it’s time to work with the person to move from pain reduction to living well alongside pain? Are the team members actually using a common model or are they really working in parallel? And how can a team be maintained over time – I’ve had the privilege of working in a very close-knit and effective team for some years, but I’ve seen that team become smaller, fragmented, more multidisciplinary than interprofessional, with limited attention to processes of induction, developing effective conflict management, and really becoming weakened.

There is one conclusion I can draw from the mountains of material I’ve been learning and it’s this: it’s impossible to put a bunch of clinicians together and call them a team without putting effort in to develop those processes I’ve listed above. And when was the last time you attended a CPD session on “how to work in a team?”

Gilliam, W. P., Craner, J. R., Cunningham, J. L., Evans, M. M., Luedtke, C. A., Morrison, E. J., Sperry, J. A., & Loukianova, L. L. (2018). Longitudinal Treatment Outcomes for an Interdisciplinary Pain Rehabilitation Program: Comparisons of Subjective and Objective Outcomes on the Basis of Opioid Use Status. J Pain, 19(6), 678-689. https://doi.org/10.1016/j.jpain.2018.02.010

Guildford, B. J., Daly-Eichenhardt, A., Hill, B., Sanderson, K., & McCracken, L. M. (2018). Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change. Br J Pain, 12(2), 72-86. https://doi.org/10.1177/2049463717734016

Körner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), 745-755. https://doi.org/10.1177/0269215510367538

Ruan, X., & Kaye, A. D. (2016). A Call for Saving Interdisciplinary Pain Management. J Orthop Sports Phys Ther, 46(12), 1021-1023. https://doi.org/10.2519/jospt.2016.0611

Salas, E., Dickinson, T. L., Converse, S. A., & Tannenbaum, S. I. (1992). Toward an understanding of team performance and training. In Teams: Their training and performance. (pp. 3-29). Ablex Publishing.

Salas, E., Shuffler, M. L., Thayer, A. L., Bedwell, W. L., & Lazzara, E. H. (2015). Understanding and Improving Teamwork in Organizations: A Scientifically Based Practical Guide. Human Resource Management, 54(4), 599-622. https://doi.org/10.1002/hrm.21628

Wilson, A. (2019). Creating and applying shared mental models in the operating room. Journal of Perioperative Nursing, 32(3), 33.

The stigma of being a woman in pain


Women, it is often thought, must be much tougher than men when it comes to dealing with pain – after all, don’t women have babies without anaesthetic? Don’t men faint at the sight of a needle?

Ummmm, not quite so fast. Now before I begin, in this post I’m referring to cis-gender females, and in the experiments, participants were selected on the basis that they believed that negative gender discrimination was a thing. And as I write this post, I want to be clear that sometimes we have to begin with a very simplified model before research can be conducted on a much more messy cohort – and that this doesn’t negate the incredibly harmful and known effects of gender discrimination, and trans/inter/queer experiences. I can only hope that by starting this kind of research, as a community we’ll begin to understand the terrible impact that stigma has on people.

This paper investigated whether stigma related to one’s identity influenced the perception of nociceptive stimulation. It’s written off the back of earlier research showing that when people are excluded socially, their experience of nociceptive stimulation was greater (ie people didn’t need as much stimulation for it to be perceived as painful) (Eisenberger, Jarcho, Lieberman & Naliboff, 2006). Other studies have shown that people with low back pain who perceive themselves as stigmatised reported greater pain intensity, and that stigmatisation is the main source of social consequences for this group of people (Zhang, Barreto & Doyle, 2020).

These researchers (Zhang, Zhang, Li, Hu, Kong & Su, 2021) conducted two experiments to test the hypothesis that stigmatised women would experience greater pain intensity with nociceptive stimulation.
The first experiment used tonic cold pain (cold pressor test) in participants who had already been selected because they believed they had been stigmatised as a woman, asked them to immerse their hand in icy cold water (1 degree C) for as long as they could (to a maximum of 3 minutes), then take part in a mock online job interview. Some of the participants were told that was the end of the study; another group were told they were successful in the interview; and a third group were told that “woman are generally not suitable candidates for these kinds of jobs”; and the final group were simply told “you didn’t get the job” with no reason given. The latter three groups then underwent another cold pressor test as before. And finally they were all debriefed.

The researchers found that those who were told “women are generally not suitable for this kind of work” did feel more stigmatised than the others, and not only reported more sensitivity to cold (threshold) but also showed lower tolerance to the pain experienced in the cold pressor test.

The second experiment involved women who were selected as above. This group of women were shown images downloaded from Google – one set was of content showing devaluing of women, while another set were control or neutral images. The authors used a heat stimulation this time, and randomly showed either neutral or stigmatising images just before the heat was applied. Participants rated the pain after each stimulation.

The results of this experiment showed that when participants were shown the stigmatising content, they reported higher pain intensity from the same nociceptive stimulation. In other words – stigma-inducing images led to these women reporting more pain when given the same amount of heat stimulus.

Not content with this, the researchers conducted a third experiment, this time examining nociceptive-evoked brain responses. They used the same experimental design as for the second experiment, but instead of self-reporting, participants had EEG signals recorded during each heat stimulation.

The results of this experiment once again showed that when participants were shown stigmatising images, they rated their pain experience more highly, and that this was reflected in the EEG results they obtained. N1 amplitude and P2 latency in time and LEP magnitude in the time-frequency domain were influenced by the stigmatising cues.

What does this all mean?

Well, for one thing it’s nice to see research being conducted in women (there’s a bit of a bias against women being involved in basic science pain research because of that pesky old hormone thing – see Samuloitz, Gremyr, Eriksson & Hensing (2018) for more). And for a study to have positive findings.

I’m particularly interested in the brain responses – simply by manipulating the sense of stigma, the same nociceptive stimulation was processed differently. Now this isn’t the same as saying “psychological factors cause pain” because this study is not looking at that – nociceptive stimulation was included – but the same nociceptive stimulation was prioritised in parts of the brain usually active in emotional responses, while P2 is an area involved in the “advanced stage of perceptual processing” was activated sooner in the stigmatised manipulation than in the control condition. The authors argue that because stigma is a threat to sense of self, and because this sense of threat can lead to vigilance about potentially stigmatising cues, greater attentional processing is allocated to threat information, and this in turn, enhances the experience of pain. The greater N1 amplitude demonstrate that attention was drawn to stigmatising material and then influenced the subsequent nociceptive information.

Let’s take a moment to consider the implications of this. Many women have reported their feelings of being devalued both because of their gender as well as their reports of pain. Women may be told “there’s no cure for being a woman” and given inadequate pain relief for period pain (true story). Women do report more pain, are more likely to develop persistent pain, and seek help for pain more readily than men. The latter can be seen as a bad thing – shouldn’t we just “cope”?

Implicit attitudes towards women remain throughout our society, despite the efforts of Kate Sheppard who was one of the women who worked so hard to enable women to vote (in New Zealand, in 19 September 1893). People with pain are also often stigmatised. My post last week is intriguing in that I pointed out that we cannot determine who is, or isn’t, “faking”. It’s the only post I’ve had with nearly 40 votes, but a total score of 2/5. It’s unplatable to some to think that a subjective experience is just that – subjective, not able to be measured, and for clinicians, that we need to accept what a person says without judgement. Stigma is judgement – let’s not do it.

N. I. Eisenberger, J. M. Jarcho, M. D. Lieberman, and B. D. Naliboff, (2006)“An experimental study of shared sensitivity to physical pain and social rejection,” Pain, 126(1), pp. 132– 138.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research and Management, 2018.

Waugh, O. C., Byrne, D. G., & Nicholas, M. K. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 550-e1.

M. Zhang, M. Barreto, and D. Doyle, (2020) “Stigma-based rejection experiences affect trust in others,” Social Psychological and Personality Science, 11(3), pp. 308–316, 2020.

Zhang, M., Zhang, Y., Li, Z., Hu, L., Kong, Y., & Su, J. (2021). Sexism-Related Stigma Affects Pain Perception. Neural Plasticity, 2021, 1-11. https://doi.org/10.1155/2021/6612456

Why do people with pain report differently on questionnaires than they do in physical performance testing?


One of the topics thrown around by people who don’t have an up-to-date understanding of pain is why people say one thing on a questionnaire, for example, what they can and can’t do, and perform quite differently when asked to do the same task in a clinic. It’s a good question, on the face of it: after all, people should know what they can and can’t do, and be consistent. If there is a difference, well obviously the physical performance test is far more objective than self-report – the therapist is right there watching, so there’s no room for doubt about which measure is The Most Accurate.

The main reason, according to these clinicians, for someone doing differently in the clinic compared with self-reporting, has to be because they’re biased. The person wants to misrepresent what they can and can’t do. Of course.

Superficially, and if you’re not knowledgeable about pain, behaviour, context and human interaction, you could be forgiven for accepting the idea that what you see in clinic is consistent with what’s being done in every day life. The physical movements are pretty much the same and the person is just being asked to do something they do all the time.

BUT – and it’s an enormous exception – humans are not robots. Not body bits that move when they’re pulled like a puppet on a string. People are meaning making, interpreting, social creatures with rapidly responding body systems that represent contexts in relation to memories, predictions and current demands.

I wrote a talk recently on some research that made my heart sing a bit. As an occupational therapist, my profession has long recognised that doing activities (occupations) that hold meaning is quite a different thing from doing a-contextual, meaningless movements. This is why occupational therapists are known to ask about what matters to you, and to use meaningful activities/occupations both as therapy and as outcome (Hitch & Pepin, 2021). The research I referred to was a proposal for an “ecologically grounded functional practice” within rehabilitation (Vaz, Silva, Mancini, Carello & Kinsella-Shaw, 2017). In this paper, the authors point out that “improvements at one level of functioning might not transfer immediately to other levels” and by this they mean that elbow flexion/extension improvements may not transfer into a person being able to feed themselves. They also pointed out that when people perform well-rehearsed activities in the context of goal pursuit – such as getting dressed, ready for work; catching a ball as part of a fast-moving game of netball; hammering a nail – the movements are not just about motor control, they’re about goal-directed behaviour in a context with an interaction between the person, the environment, any tools, the purpose of the activity and so on.

For example, if I want to eat soup, I not only need to have sufficient elbow flexion/extension, I also need to know where the soup bowl is (tried eating soup while lying down?), the texture of the soup (is it thick, thin, lumpy?), the heat of the soup (hot, cold, spicy) and even the social context – I might be OK slurping when I’m on my own, but I’m less inclined to slurp when in polite company. The way in which I carry out the flexion/extension will be very different with each contextual variation.

OK. So context matters, and both the what and why of movement will influence how I go about my performance.
What else?

Well, with a painful condition and especially when I’m not confident I can do it without increasing my pain, I’m much more likely to attempt a difficult movement task in the presence of someone who can monitor what I’m doing. Firstly that person might stop me if they think I’m doing something harmful (professional liability insurance offers some protection!). Secondly, it’s a lot harder to say “no” to someone who is right there in the room! This is called “demand characteristics” and has been associated with problems of the rubber hand illusion (Lush, Vazier & Holcombe, 2020). If someone expects you to do something, you’ll probably do it – because we social creatures don’t like to offend, because the person may inadvertently signal the response they want (see link).

There are other reasons people don’t report the same level of disability on a questionnaire and in physical performance testing: they don’t measure the same things, people forget (especially if they haven’t tried in a while), the day of physical performance testing could be a bad day (or a good day), in physical performance testing the person is usually asked to do it maybe once or twice – in daily life that same activity might be carried out many times across a day, week, month. The environment in a clinical testing environment is typically well-lit, the space around the person is clear, the noise level is usually reasonably low, the floor surface is flat and usually hard lino and free of rugs or pets, there’s minimal distraction, the only thing the person has to think of is this one movement – they’re not picking up the washing off the floor while rushing to put it in the washing machine before dashing out the door to pick the kids up from school.

Even the questions are different – “does pain interfere with…?” is a different question from “can you step up onto this step using a hand rail?”

And don’t let me even start on the meaning of performance either way – for example, if the person is really keen on getting knee surgery, might “good” performance mean they, without even knowing it, alter how they do a movement? What if the person is apprehensive about how the results of this testing might affect their rehabilitation and return to work – again without even knowing it, might this not have some influence on how the person performs?

Testing and measurement is a core skill and research area in psychology. Dang, King & Inzlicht (2020) offer some really good insights into the reasons responses differ between self-report and performance, and to be fair, they don’t even consider the influence of pain and physical capability as I have above. Pain-related performance is a specialty area of its own, nonetheless we can still draw from their paper because many of the problems they recount are absolutely part of pain and disability self-report and physical performance.

They describe the reliability paradox (that reliability = variance between individuals divided by variance between individuals + error variance) – in other words, we need low levels of between-person variability so that any experimental manipulation is maximised. But in real life, we almost always exhibit variability in our performance – so the reliability of two measures limits the correlations that can be observed between then, with lower reliability leading to weaker observed correlations.

The authors also describe the very different response processes involved in self report and performance – as I mentioned above, self-report measures ask people to reflect on what they do in real life in many different contexts that are unstructured. Performance measures take a snapshot based on performance in specific and highly structured situations. Self-report measures capture a person’s perception of their capabilities whereas physical performance reflects the observations of someone else. And performance assessments generally tap into peak performance, not daily performance – tapping into some of the discrepancies we see between “can do” and “will do” (competence-performance discrepancy).

So, when you read arguments on social media from well-known physiotherapists suggesting that the person who reports a difference between what they perceive they can do, and what they have done in a physical performance test is “biased”: know that we have absolutely NO WAY to determine “bias”, “malingering”, “faking bad”, “faking good” – and that there are many well-understood reasons for the difference in performance. Read this paper for more on why we can’t detect “malingering” in people with pain: Tuck, N. L., Johnson, M. H., & Bean, D. J. (2019, Feb). You’d Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain. J Pain, 20(2), 133-145. https://doi.org/10.1016/j.jpain.2018.07.002

Dang, J., King, K. M., & Inzlicht, M. (2020). Why are self-report and behavioral measures weakly correlated?. Trends in cognitive sciences, 24(4), 267-269.

Hitch, D & Pepin, G. (2021) Doing, being, becoming and belonging at the heart of occupational therapy: An analysis of theoretical ways of knowing, Scandinavian Journal of Occupational Therapy, 28:1, 13-25, DOI: 10.1080/11038128.2020.1726454

Lush, P., Vazire, S., & Holcombe, A. (2020). Demand characteristics confound the rubber hand illusion. Collabra: Psychology, 6(1).

https://methods.sagepub.com/reference/the-sage-encyclopedia-of-communication-research-methods/i4252.xml

Not all pain is the same


When I started working in the field of persistent pain, many of the approaches used were based on the idea that every pain was the same. Oh yes, of course we had neuropathic pain and inflammatory pain, but our treatments tended to approach each person as if they were pretty similar. We later refined that approach and started to look at people in groups. In the service I worked in, we used the Westhaven-Yale Multidimensional Pain Inventory which generates three main psychologically-based profiles – and for a long time this was a very useful way of establishing who needed the three-week residential programme, and who would do well with a briefer outpatient programme.

Well things change over time, and we’ve become more aware of what Clifford Woolf describes as a “mechanism-based” classification approach (Woolf, 2004). In this approach, clinicians try to establish the dominant mechanistic group in which a person’s pain might be classified, then suit the treatment to that mechanism. This means clinicians diagnose inflammatory pain, neuropathic pain, and nociplastic pain – and use what looks like the best combination of medications to suit the mechanisms. For example, for neuropathic pain it’s more likely people will be given gabapentin/pregabalin and a tricyclic antidepressant in combination than an opioid.

There’s a problem, though – in fact, TWO problems I can see.

Methods for identifying pain mechanistic groups

The first problem is that we don’t have wonderful methods for establishing the main mechanistic groups.

In fact, in a recent very large and thorough review of methods used to discriminate between each category, the authors found that “few methods have been validated for discrimination between pain mechanism categories”, and although there was “general convergence” between methods, there was also “some disagreement” (not that this is unfamiliar to anyone who reads research!) Shraim, Masse-Alarie, & Hodges, 2021).

What was interesting, albeit not too unexpected, was the overlap of findings between categories because people present with mixed types of pain; and that many of the studies attempted to only discriminate between two of the groups, rather than more. Having said this, the authors identified five groups of method used to help clinicians and researchers distinguish between pain mechanisms: clinical examination; quantitative sensory testing; imaging; diagnostic and laboratory tests; and questionnaires asking participants to describe their experiences.

Now I know that research studies aim to be a little more rigorous than clinical practice, but that should sound an alarm when we begin looking at what we need to do in clinical practice. “Subjective” pain examination included aggravating and easing factors, pain location and pain characteristics (can anyone tell me when pain is NOT subjective?). It also included psychological factors (although my radar went off at this – more of this later!). Physical examination (is this supposed to be ‘objective’ pain examination?) included general clinical assessment, general neurological testing, nerve provocation testing and neurodynamics, clinical bedside somatosensory function testing, movement and functional testing. Quantitative sensory testing had no greater degree of sensitive, specificity and reliability than physical examination and “subjective” history, and laboratory testing was pretty poor despite superficially looking more “accurate.” A similar state exists for questionnaires – oh lordy!

So these authors found 200 methods that could be used to determine which pain fits into a specific box, but overall the results are pretty underwhelming for clinicians wanting a direction for their approach. It’s not helped that the current “gold standard” used is – wait for it – clinician-based diagnosis.

Where are we left? Well, I think we’re not that far away from where we were in the 1990’s and early 2000s. We really don’t have a clear way to distinguish between the various mechanisms, and many people likely present with pain that includes more than mechanism. However – these authors provide a table summarising the commonly used, and possibly most likely approaches to diagnose pain mechanisms, and this is useful for those of us who want the “best guess” for now.

Problem two

At the beginning of this piece, I said there were two problems with using mechanistic descriptors. You can see the problems with reliability, specificity and so on – and the lack of agreement in the research and likely “mixed” presentations we will see in clinic – from my comments above (do read the whole article, though, it’s well worth it).

The second problem is that these descriptors, even when accurate and reliable, don’t tell us anything about the person experiencing pain. Unless, and until we have effective treatments for each of these mechanisms, we are inevitably running experiments to see what might work for this person in front of us. And this means we find less utility in diagnosis than we would if we drew on a case formulation approach.

What’s the difference? Diagnosis allows us to group “like with like” – on the basis of similar underlying mechanisms. We can then treat those mechanisms, and voila! the person recovers! It works well with fractures, with infectious diseases, and even with diabetes. It doesn’t work as well when we don’t have treatments we can use on the mechanisms. For example, although we can diagnose many neurological disorders, for so many of them we have very poor treatments. This means people live with their disease – and this is where a diagnosis falls down. It does not tell us HOW this person will experience their disease. Diagnosis doesn’t explain illness, disability, functional status, or participation.

And, because all of us are unique, this means that a one-size-fits-all approach to persistent pain (or even an algorithm, subtype, or subgroup) isn’t likely to offer clinicians or the person with pain a useful path towards well-being.

You’ll remember I said my radar went off with the psychological assessments included in the methods used to identify a pain mechanism. My reason is this: pain is a stressor. Even a paper-cut captures my attention (albeit just a little until I use a hand sanitiser!), my heart rate goes up a bit, I’m alerted to the experience and want to get away from it. Now imagine if that pain continued. Maybe variably, maybe constantly, maybe intermittently. And imagine if I couldn’t get a good understanding of what’s going on. And perhaps I was being questioned by my clinicians – and maybe even stigmatised. “What do you mean, you have pain we can’t diagnose, we can’t image, we can’t treat?” I’m guessing by now, perhaps some months after my pain started, I’d be feeling a bit irritated, perhaps a bit low in mood, my sleep might not be great, I might find it hard to do what matters to me because I’m not sure if I’m doing myself some harm.

What we don’t know in many studies of pain “predictors” is whether they are cause or effect. There is undoubtedly an association between various measures of pain-related anxiety, avoidance, low mood, thinking the worst. What we do not know is whether this was present before the pain came on – or whether it came afterwards.

So, to my mind, using psychological factors as part of diagnosis risks labelling people and what are probably normal responses to abnormal experiences. Let’s not do that.

Where am I left after reading this paper? I’m glad someone set about doing this review. I think it offers a good summary of the state of play, and identifies some of the current problems with a mechanistic approach. We need to get consensus on definitions, we need far better methods, we need to stop using the word “subjective pain examination” (because ALL pain is subjective), and we need to leave psychological factors out of diagnosis until we can clearly identify which came first.

Shraim, M. A., Masse-Alarie, H., & Hodges, P. W. (2021, Apr 1). Methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a systematic review. Pain, 162(4), 1007-1037. https://doi.org/10.1097/j.pain.0000000000002113

Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med 2004;140:441–51.

Family and friends matter


I’m going back to my series on behavioural approaches to pain management (it’s a slow process!). For the first two go here and here. Now I want to talk about the impact of family and friends on people living with pain.

The people we live with are so influential on what we do and believe about pain. It’s our parents who first taught us the relationship between the word “pain” and the experience we know as pain. It’s our parents and family who responded when we cried, who kissed it better (or not), who told us to “harden up” (or not), who took us to the doctor (or not), who showed us, through their own behaviour, how to “do pain.”

There’s a good deal of research investigating the impact of friends and family on pain behaviour (remember the distinction I make between pain-the-experience and pain behaviour or what we do when we’re sore? click). For instance, a systematic review by Snippen, de Vries, van der Burg-Vermeulen, Hagedoorn and Brouwer (2019) looked at people with chronic diseases, and the attitudes and beliefs of significant others. They found that “positive and encouraging attitudes regarding work participation, encouragement and motivating behaviour and open communication with patients” were facilitators for work participation while “positive attitudes towards sickness absence and advise, encouragement or pressure to refrain from work” were barriers to returning to work.

In another study, Burns, Post, Smith, Porter and colleagues (2019) observed spouse dyads behaviour after arguing then the person with pain undergoing a pain induction task. Spouses that believed that the patient’s pain was a mystery were significantly more likely to be perceived by the patient as giving critical/invalidating responses toward the patient during the discussion; while spouse perceptions that the patient’s pain was a mystery were related to internal and negative attributions spouses made while observing patients display pain behaviors during the structured pain behavior task (p. 1176).

In another study, this one a daily diary study with people living with osteoarthritis in their knee, found that on days when the person with pain reported more thinking the worst, their spouses were more unhappy during the day. And on the days when the partner was more irritated with the person living with pain, that person reported more thinking the worst the next morning. The link? The people with pain who were thinking the worst were also more grumpy through the day, and this was rubbing off on their partner. (Martier, Zhaoyang, Marini, Nah & Darnell, 2019).

Makes sense, doesn’t it? That when we see our loved one demonstrate that they’re sore, and they’re grumpy – and if we’re not sure they’re for real – we might be less supportive as partners than if we think their pain is for real. And over time the pattern of being sympathetic might wear thin – in fact, Chris Main (psychologist) describes a pattern of initial solicitous behaviour (the “there, there dear, I’ll fetch you a cup of tea”), then resentment (“surely you’ve recovered now?”), then anger and punitive behaviour (ignoring the person, getting irritated with them), but then feeling guilty about this (“OMG I know, it’s not your fault and I’ve been so mean”), returning to being solicitous – until the next time the partner feels fed up.

What does this mean for a behavioural approach?

Well, it’s not surprising that if one of the partners thinks the other “should be well now”, they’re likely to be unsympathetic as we begin changing the person’s behaviour. Often we’re attempting to help someone be consistent with their daily activities, and this can often begin by reducing how much should be attempted so the person can “do no more on a good day, and do no less on a bad day.”

And if the partner is really worried about the person with pain, and afraid that doing more is going to increase pain and prolong disability, it’s also not surprising that the partner is likely to be worried about us asking the person to do things differently (especially exercise!).

And don’t forget that during this time, both partners are probably trying to keep some semblance of normal going. They still have the usual household tasks to get done, to pay the bills, to get the kids to and from school, to keep in touch with extended family and friends and so on.

It’s stressful. And we add to the burden when we ask the person to do something different, whether this be doing exercises, using a mindfulness or relaxation technique, perhaps go to various appointments all around town…and if we don’t include the impact of what we expect on the partner, we’re possibly not going to have “the team” on board with the rehabilitation programme.

The very best option is to ask the person’s partner to come in to at least one of our treatment sessions, so we can spend some time talking about what we’re asking the person with pain to do, and getting an indication from the partner about their willingness to follow the programme. The next best option is to write the programme down, and include “things family can do to help” – listing the kinds of things family and friends can do (and what they should avoid doing).

You see, people we see for help never live in a vacuum. They always have a context of friends, family, home, responsibilities, expectations from them, expectations for the work we do. Forgetting about this and expecting a good result fails to recognise the embedded nature of life. Contextual factors are important, no person is an island.

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019). 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.

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.

Snippen, N. C., de Vries, H. J., van der Burg-Vermeulen, S. J., Hagedoorn, M., & Brouwer, S. (2019). Influence of significant others on work participation of individuals with chronic diseases: a systematic review. BMJ Open, 9(1), e021742. doi: 10.1136/bmjopen-2018-021742