Clinical reasoning

Ways to stop good clinicians leaving pain management (iii)


I’m an old hack when it comes to teamwork and pain management: I’ve worked in this field a long time. I’m familiar with reactions to both interpersonal differences within a team (and the myriad ways these can be expressed), and to the discourse that happens when posting a publicly available message. In fact, that’s why I publish on social media: so we can have open conversations rather than ones hidden behind paywalls, or in rarified academic settings. Humans are odd, and when poked – even when poked with good evidence – want to react, to bite back. The following comments are not about any specific organisation. I’ll repeat that: comments about what we do in healthcare (ie bullying – nurses call this ‘horizontal violence’, stigmatising, excluding, not supporting etc) in the two articles I’ve written so far on how to prevent good clinicians do not relate to any one organisation. They are based on personal experience (my own) and experiences I’ve read in the literature.

There is an elephant in the room. It’s possibly the biggest one we have in teamwork and it’s about dispute resolution. How do we resolve contrasting clinical models, interpersonal styles, personal and professional values, hierarchies (explicit or implicit) without compromising important and valid points, and without blowing relationships between team members out of the water? An alternative is to leave, as I did, having seen several clinicians put through the wringer by accusations of bullying and being the recipient of bullying myself.

I’m drawn to Dr Todd B. Kashdan’s work in his most recent book “The Art of Insubordination: How to dissent and defy effectively” because he offers well-researched strategies for individuals and groups to disrupt the status quo – not for the purpose of disrupting for the sake of it, but because of personal integrity and ethical standards. Values that clash with “received wisdom”. Creative ideas that could change practice positively, but land flat because they’re “different”. The desire to create social value – not from a place of “I’m superior, you should do it my way” or spite “I just want to get you back for being dominant” or self-interest “I want you to do this because it’ll line my pockets” (p. 11., The Art of Insubordination).

You see, principled insubordination is one reason for disputes in teams. It could be an occupational therapist identifying that participating in daily life really matters to people with chronic pain but working in a team where everyone gets the same recipe for treatment. It might be a physiotherapist who sees that there could be ways to see people in small groups, rather than individually – but gets smacked down because “that’s not the way we do it”. It might be the social worker who dreams of bringing whanau/family into pain management, but can’t get a toe in the door of a team with a strong medical procedure focus.

Each of these people holds strong values, wants to be person-centred, can see there are opportunities, and sincerely communicates them to the team. Even the idea of interprofessional or transprofessional working, where each person steps up to do what matters to the person in front of them although it doesn’t look like conventional “role division” can be an effective way to be a radical and principled rebel.

While the ideas Todd articulates SO well in his book are absolutely worth doing if you’re the principled rebel, one thing I worry about is placing the responsibility only on the rebel. It’s difficult being the one swimming against the current. It can lead to personal isolation, burnout, poor team trust, difficulty sharing information that is unique to your profession (or your encounters with a patient), less reporting critical problems and ultimately, to closing down and walking away (O’Donovan, De Brun & McAuliffe, 2021).

Stephanie Zajac and colleagues (Zajac, et al., 2021) developed a framework for healthcare team effectiveness and clearly identifies the crucial contribution of the organisation, team leadership, technical competence and having team roles and purpose (Fig. 1, p. 4). Without a supportive culture, executive leadership and teamwork reinforcement as a value, the organisational conditions likely work against effective teamwork. Without shared leadership, accountability and coaching, teams flounder and fragment. Without adequate training, the capability to do the work well, and sufficient staffing, teams don’t have sufficient technical competence to be effective. Finally, without role definitions, team directions and developing and monitoring team norms, teams will likely experience conflict and who should or can do tasks, and what’s OK and not OK within the team. Note this doesn’t inevitably mean “my role” and “your role” – inter and transprofessional team work demands blurring between roles. This is about articulating and being clear about how team members work together.

And who needs to ensure these organisational “meta-team skills” are clear, supported and maintained? Yes, it’s everyone’s job – but it’s also the organisation’s leadership team’s job to make sure it happens. After all, the leadership team should have skin in the game.

Conflict is inevitable. Some schools of thought believe that conflict is healthy, a sign of divergent thinking rather than conformity, that conflict enables people to challenge their own assumptions (O’Neill, Allen & Hastongs, 2013). At the same time, forms of conflict can be painful and damaging to the individuals involved. Disagreeing about what is done is less damaging than conflict with a member of the team. Consequently, two points spring to mind: 1. Left to fester, interpersonal conflict will reduce team trust, and ultimately stymie collaboration. People will revert to silence, and a “them and us” will emerge. Processes involving transparent, open conversations (see this link), often moving beyond the key antagonists and into the whole team, are crucial. These may involve clear policies and procedures, and need to be facilitated – preferably by someone external to the team, but knowledgeable. 2. “Ground rules” must be established about how to disagree, challenge one another, articulate different perspectives. Why? Because disagreement and conflict is inevitable, so we need to minimise the fall-out, but more importantly, because conflict when well-managed is the lifeblood of creativity and responsiveness (psst! it’s also really good for critical thinking).

Kim, S., Bochatay, N., Relyea-Chew, A., Buttrick, E., Amdahl, C., Kim, L., Frans, E., Mossanen, M., Khandekar, A., Fehr, R., & Lee, Y. M. (2017, May). Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. Journal of Interprofessional Care, 31(3), 282-290. https://doi.org/10.1080/13561820.2016.1272558

O’Donovan, R., De Brun, A., & McAuliffe, E. (2021). Healthcare Professionals Experience of Psychological Safety, Voice, and Silence. Frontiers in Psychology, 12, 626689. https://doi.org/10.3389/fpsyg.2021.626689

O’Neill, T. A., Allen, N. J., & Hastings, S. E. (2013). Examining the “Pros” and “Cons” of TeamConflict: A Team-Level Meta-Analysis of Task, Relationship, and Process Conflict. Human Performance, 26(3), 236-260. https://doi.org/10.1080/08959285.2013.795573

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Frontiers in Communication, 6(6). https://doi.org/10.3389/fcomm.2021.606445

Ways to stop good clinicians leaving pain management (ii)


I’ve been asked to amend (actually, to remove) these two posts, so I’ve altered the opening sentence – you’re reading it now. I’ve also added some comments to preface these two posts.
I’m an old hack when it comes to teamwork and pain management: I’ve worked in this field a long time. I’m familiar with reactions to both interpersonal differences within a team (and the myriad ways these can be expressed), and to the discourse that happens when posting a publicly available message. In fact, that’s why I publish on social media: so we can have open conversations rather than ones hidden behind paywalls, or in rarified academic settings. Humans are odd, and when poked – even when poked with good evidence – want to react, to bite back. The following comments are not about any specific organisation. I’ll repeat that: comments about what we do in healthcare (ie bullying – nurses call this ‘horizontal violence’, stigmatising, excluding, not supporting etc) in the two articles I’ve written so far on how to prevent good clinicians do not relate to any one organisation. They are based on personal experience (my own) and experiences I’ve read in the literature.

Last week I started a series of posts on how we can stop good clinicians leaving pain management. I began with funding because, at least in New Zealand, lack of funding is a significant part of the problem of staff retention.

Now I want to look at how we prepare clinicians to work in pain management.

One of the major barriers in New Zealand is the dominance of musculoskeletal rehabilitation in physiotherapy clinics around the country. How could direct access to musculoskeletal rehabilitation be a bad thing, you ask? Well, it’s mainly because pain management is not musculoskeletal rehabilitation – and yet most of the workforce for pain management here comes from musculoskeletal physiotherapists.

I like physiotherapists, some of them are even very good friends! And I recognise that good physiotherapists have moved a long way from the old “back school” staff sergeant approach! Many physiotherapists have developed their skills well beyond analysing pelvic tilt and using “special tests” with limited inter-rater reliability and even less predictive validity. There are good physio’s who are skilled in Acceptance and Commitment Therapy, who routinely look at values and use motivational approaches in their clinical practice.

But, how well are new graduate physiotherapists (and indeed other entry-level health professionals) prepared for chronic pain work? (remember that many clinics in NZ employ entry-level therapists because they’re inexpensive, and chronic pain management isn’t a very profitable area – and staff turnover is a thing).

Unlike acute and subacute musculoskeletal rehabilitation, regression to the mean (ie returning to a baseline level of capability) doesn’t happen much in chronic pain rehab. Natural history doesn’t happen either, not four or more years after the original onset. Most treatments for chronic pain show very small effect sizes on both pain intensity and disability.

Progress towards goals is slow, and there are many – many! – flare-ups, set-backs, detours and plateaus. Because pain problems have lasted longer than expected, people have had time to worry, to be given inaccurate information, to have had poor sleep for ages, to have stopped doing the things that bring life into life, to have had several unsuccessful treatments – consequently, people with chronic pain often hold negative expectations about how effective a treatment will be.

How well do we prepare entry-level clinicians for the challenges of treatments not working? Despite the therapist “doing all the right things”?? Do we prepare them for the ambiguity and uncertainty of working without a clear diagnosis? without an algorithm? without a “simplifying process”? Chronic pain is complex!

How well do we prepare entry-level therapists not to take responsibility for a person’s outcomes? Or do we inculcate them into the idea that they must “get it right” all the time or they’ve “done something wrong”?

Do we spend so much time teaching a certain school of therapy, or set of special tests, that we forget to help them learn to listen well first? Do we teach them that mind and body are separate – and that psychological and psychosocial only come into play when “the bio” has failed to respond to treatment? Do we imply this, even inadvertently?

When do we teach entry-level therapists how to deal with therapy failure? How to work in the dark? How to revise their formulation when a treatment doesn’t have the intended effect? Where do we teach entry-level therapists how to seek and accept supervision – and how do we help them view supervision as a supportive opportunity to develop as a person and therapist?

And how well do we prepare entry-level clinicians to work well in a team, where they’ll come into contact with other clinicians seemingly “stepping into my scope”? In other words, where other clinicians have broad skills and experience, and who do what they do… Do we teach undergraduates how to be confident enough in their professional value that they stop being defensive?

Solutions, that’s right. I was going to suggest solutions.

Solutions include much more time working with other professions during training – and not just the ones handy to where they’re being trained. Solutions include ensuring the process of clinical reasoning is emphasised rather than the outcome. Solutions involve teaching undergraduates that they will carry on learning and that more experienced therapists from other professions will teach them a lot. Solutions might include ensuring that all students spend regular time with a supervisor who is not there to “correct” them, but instead to foster their self-reflection, to offer them support when they’re feeling overwhelmed, to encourage them to be OK to feel lost and not know the answers. And perhaps solutions involve recognising that chronic pain management is a specialist area of practice, and it is not musculoskeletal rehabilitation with a psychosocial twist.

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3), e663. https://doi.org/10.1097/PR9.0000000000000663

Lindblad, T. L. (2021, Jun). Ethical Considerations in Clinical Supervision: Components of Effective Clinical Supervision Across an Interprofessional Team. Behavior Analysis in Practice 14(2), 478-490. https://doi.org/10.1007/s40617-020-00514-y

O’Carroll, V., Owens, M., Sy, M., El-Awaisi, A., Xyrichis, A., Leigh, J., Nagraj, S., Huber, M., Hutchings, M., & McFadyen, A. (2021, May-Jun). Top tips for interprofessional education and collaborative practice research: a guide for students and early career researchers. J Interprof Care, 35(3), 328-333. https://doi.org/10.1080/13561820.2020.1777092

Perreault, K., Dionne, C. E., Rossignol, M., Poitras, S., & Morin, D. (2018, Jul). What are private sector physiotherapists’ perceptions regarding interprofessional and intraprofessional work for managing low back pain? Journal of Interprofessional Care, 32(4), 525-528. https://doi.org/10.1080/13561820.2018.1451829

Steuber, T. D., Andrus, M. R., Wright, B. M., Blevins, N., & Phillippe, H. M. (2021). Effect of Interprofessional Clinical Debates on Attitudes of Interprofessional Teams. PRiMER, 5, 14. https://doi.org/10.22454/PRiMER.2021.154149

Scopes, roles, interprofessional practice and person-centred healthcare


A topic that almost immediately gets my hackles up is the one of scopes and roles in pain management and rehabilitation. It’s like “Oooh but that’s MY stuff, get out of it!” and I can see Gollum saying “my preciousssss”…

I trained and graduated in 1984. As a raw newbie occupational therapist I couldn’t articulate much of what my profession brought to healthcare, except that I knew “doing”, “activities” or “occupation” was important to human wellbeing, and that I’d been trained to analyse these. I’ve learned a lot since then and got a PhD in the process. Developing as people and as clinicians is, I hope, deeply embedded in us as professionals.

Interprofessional practice is a model of healthcare recommended in pain management and rehabilitation (Oslund, et al., 2009). Interdisciplinary/interprofessional teams involve different health professionals working alongside one another using their areas of expertise, but where all use a common over-arching model such as a biopsychosocial approach. Teams meet regularly to collaborate on treatment goals and priorities (Ruan & Kaye, 2016). There is limited hierarchy and extensive communication, cooperation, and overlap between team members (Körner, 2010).

True interprofessional practice is rare. Why? Because teams on paper are not teams. Teams need time together both formally and informally, stability amongst members, a pool of common knowledge as well as an understanding of what each team member brings in to the mix. Needless to say, high trust is crucial, along with ongoing communication (Zajak et al., 2021). We can’t just use professional labels to know what another profession can offer because we [should] keep on developing.

One of the largest contributors to poor interprofessional teamwork is lack of confidence. Not just lack of confidence in the skills of the other team members, but lack of confidence in one’s own professional contribution. High trust in one another, and yourself is critical.

When you’re feeling uncertain and find it hard to articulate what you bring to a team, any encroachment on “your” turf (call it scope) will likely engender a worry that you’re unnecessary. That others are “taking over” – and in turn, this can mean you search for faults in what other team members do because this helps affirm your rights and your specialness. You might want to rigidly control who does what in a team. It boosts your sense of worth but at the expense of other team members, and more importantly, at the expense of the person the team is trying to help.

The thing is, the person with pain does not care which person in a team works with them. What they care about is that the clinician is knowledgeable, and empathic. Trustworthy. The quality of the interpersonal relationship accounted for 54.5% reduction in pain in one study by Fuentes (Fuentes et al., 2014). People with pain want to know that their individual needs have been taken into account in their treatment plan (Kinney et al., 2020).

If you’re finding it hard to work in a team, perhaps feeling vulnerable about your worth, try this:

Ask your team to meet for an hour, tops.

Ask each member of your team to say what they bring to the team – not just their profession, but what else? Consider age, humour, cultural background, additional courses, personal interests outside of work, the “social secretary”, the “librarian”…and professional skills.

Pool all of these contributions on a big piece of paper – use post-it notes of different colours for each person.

Group similar contributions together in the middle of the paper – and spread unique contributions around the outside.

Review the paper and ask each participant to add any contributions they’ve just been reminded of.

Take a good look at the common contributions and the unique ones: these are what make up your team and they’re there to use for better person-centred care.

You can add some reflective questions to this activity.

  • What are the areas of overlap? It could be goal-setting, offering information about pain, movement practices, addressing fear of pain/reinjury, helping build confidence…
  • What areas of uniqueness are there? These could be hypnosis, knowledge translation from clinic to daily life, exercise prescription, the ability to write a prescription for medications
  • What surprised you? This could be the degree of overlap, or the contribution you didn’t expect from someone, or perhaps a gap in the team’s knowledge or skills
  • What shows up in yourself as you review these contributions? These could be “yeah, right, I don’t believe you can do THAT!” or “but I can do that too!”

Handling your response to what shows up to that last question is where the enormous value of this activity lies. Remember, the team is there for the person with pain, not for you as clinicians. If you think someone is claiming a contribution you can do with more skill, this only means that you can offer that person help from time to time. If you think that you’d like to contribute in an area and you didn’t add that as one of your contributions, now is the time to put it on the paper.

Take a copy of that piece of paper, and keep it close to you.

Your mission from then on, should you choose to accept it, is to review this set of contributions when you are next developing a treatment plan for a person seeking your help. Choose the combination of clinicians that offers the range of skills and knowledge, the interpersonal skills suited, and the availability of each clinician so that the person you hope to help will be seen by a team, and not just a set of individual clinicians. Oh and add in a good case formulation as well…

Remember: it’s all about the person in person-centred pain management and rehabilitation.

Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: An experimental controlled study. Physical Therapy. 94:477–89.

Kinney, M., Seider, J., Beaty, A. F., Coughlin, K., Dyal, M., & Clewley, D. (2020, Aug). The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 36(8), 886-898. https://doi.org/10.1080/09593985.2018.1516015

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

Oslund, S., Robinson, R. C., Clark, T. C., Garofalo, J. P., Behnk, P., Walker, B., Walker, K. E., Gatchel, R. J., Mahaney, M., & Noe, C. E. (2009). Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Baylor University Medical Center Proceedings, 22(3), 211-214. https://doi.org/10.1080/08998280.2009.11928516

Ruan, X., & Kaye, A. D. (2016). A Call for Saving Interdisciplinary Pain Management. Journal of Orthopaedic and Sports Physical Therapy, 46(12), 1021-1023. https://doi.org/10.2519/jospt.2016.0611

Wampold, B. E. (2018). The Therapeutic Value of the Relationship for Placebo Effects and Other Healing Practices. International Review of Neurobiology, 139, 191-210. https://doi.org/10.1016/bs.irn.2018.07.019

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Frontiers in Communication, 6(6). https://doi.org/10.3389/fcomm.2021.606445

The added stress of chronic pain on life


For a minute, I’d like you to grab an ice-cube. If you don’t have one handy, try this at home or when you’re having your next gin and tonic. Hold onto that ice-cube. Keep holding onto it. Put a cloth underneath if it’s going to melt, but keep holding it. Now do your grocery shopping list. Or balance your accounts. While holding the ice-cube.*

Now add some exercises. Exercises you don’t care for, but feel like you have to do “because they’ll help you get better”.

Keep holding onto the ice-cube. Oh, it’s melted?! Fine – go grab another. Hand too cold to pick on up? Never mind, go find one and just do it. And keep doing the grocery shopping list. And the exercises.

Add in a night of not sleeping. Make that a week of not sleeping.

Add in having a new medication to take every day at night at the same time. The medication makes your mouth dry, constipates you, and you can’t wake up because it makes you feel sluggish.

Keep holding the ice-cube.

Phone your employer to say you’ll be in, but a therapist is going to visit you at work to see what you can do. Hold onto the ice-cube. The employer says OK but when are you coming back to work full time? I need you, or I’ll have to get someone else in.

Grab another ice-cube, keep holding it. Hand getting numb and sore? OK, therapy will help that! Here’s some mindfulness to do. And breathe…. and don’t forget the exercises. And that other appointment with a case manager to sign your rehabilitation plan. And do the groceries while you’re there. Keep holding that ice-cube.

And don’t be like that! Don’t get snippy with the kids, just pull yourself together! Hold onto the ice-cube. Lie awake worrying about work and how you’ll balance the accounts. Forget to take the medications, feel terrible – all sweaty and nauseous. Turn up to the employer with the therapist in tow. Hold on to the ice-cube.

The therapist says you can’t do this, or that, and you need to break your work up into chunks like this, and here’s a gadget that might help. Your employer rolls his eyes at you behind the back of the therapist. Keep holding that ice-cube.

Case manager phones saying she’s very sorry, but the paperwork for your weekly compensation hasn’t been filled out properly, you’ll have to go to the doctor to get another certificate, talk to your employer and have you done your exercises yet? Do you need to see a psychologist? Hold onto the ice-cube.

Your partner, who has been magnificent up until now, loses the plot when he gets home today. Hold onto the ice-cube, don’t let it drop. Feel that pain. Breathe. Do exercises. Take meds. Worry about job. Worry about relationship – partner comes to bed but turns the other way. Realise you missed getting a warrant of fitness for the car, think about putting that on the list for tomorrow.

…and someone said people on compensation for pain are just “non-copers”

Cry.

If you’re a therapist, remember what you ask a person to do is only one thing in a vast, unfamiliar and confusing sea of things to do. All the while holding on to an ice-cube that’s burning into your hand….

*Try this at home so you can experience what it might be like to have pain that’s present, intense, and gets in the way of life. BTW it’s not a treatment for chronic pain!!

Help me solve this puzzle


The IASP definition of pain is:

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Six key notes and etymology:

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

This definition allows for “pain is always a personal experience” and that “pain and nociception are different phenomena” – supporting the idea that the association between what goes on in the tissues and our individual experience of pain is both complex, and currently unmeasurable.

So therefore, why do we have this line in the IASP diagnostic criteria for complex regional pain syndrome: “The patient has continuing pain which is disproportionate to any inciting event” – but wait, there’s more! Kosek et al, (2021) indicate that clinical criteria for nociplastic pain include “…a history of pain hypersensitivity in the region of pain” and “Evoked pain hypersensitivity phenomena can be elicited clinically in the region of pain.”
I’m puzzled.

Pain that is “disproportionate” suggests there is “proportionate” pain… AND at the same time the definition of pain says pain is “always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.” So if I experience pain in the presence of an inciting event, and report it as “OUCH” on the ouchie scale, who can tell me whether my pain is “proportionate” or “disproportionate”?

The nociplastic criteria are similarly confusing: pain hypersensitivity in the region of pain – really painful pain where I’m already experiencing pain? Or do they mean allodynia or hyperalgesia? Or…poke me where I’m sore already and the examiner can tell whether I’m more sore than I ought to be?

Underlying these diagnostic criteria lives a sneaky little beast I call “assumed normalism.” That despite all the work over the decades, some clinicians and researchers really do believe there is a reasonable relationship between nociceptive stimulation and the degree of ouch I might feel. I’m not sure about this…

I wonder if assumed normalism relies on experimental data where people volunteer to undertake nociception tests. These are things like quantitative sensory testing where individuals report the moment they experience heat, cold, pressure, and vibration (pain threshold), and when they want the experimenter to stop doing that thing NOW (pain tolerance).

Let’s think about that situation for a moment. An experimental set-up or lab. Volunteers who know what they’re going to be asked to do. Who know they can say “STOP” when they want to. Who know that no lasting harm is going to occur (ethics, don’t you know). And who volunteers for these kinds of experiments? Nuzzo (2021) pointed out that females are well-known not to volunteer for experiments where there is “an expectation of painful, unpleasant, or risky procedures” and cites research from as far back as 1976! (Rosnow & Rosenthal, 1976) – and earlier (Howe, 1960).

But more than this, Horowitz (2009) states “…QST is a subjective psychophysical test entirely dependent upon patient motivation, alertness, and concentration. Patients can willingly perform poorly, and even when not doing so, there are large intra- and interindividual variations.”

How have clinical diagnostic criteria included definitions that seem too have slid by scrutiny?

Why does it matter?

As soon as we begin thinking of “normal” “objective” “proportional” or “disproportional” in leaps human judgement. Bias. The opportunity to dismiss a person’s experience – on the basis of what we can observe, or what the person can demonstrate. We can only infer that someone else is experiencing pain on the basis of their behaviour – what a person says, does, in the presence of pain, in a particular context. And bias exists when it comes to interpreting behaviour.

As a person living with pain, should I aim to “look well” and be judged as “not suffering enough for pain to be a problem”, or “look poorly and be judged as “not using coping strategies, wanting attention”…

Because, unless all the qualitative studies I’ve read are really erroneous, bias and stigmatising from clinicians and insurers is a thing. From adolescents (Wakefield, 2021), people tapering opioids (Benintendi et al., 2021), gender (yeah, I mean women, Zhang et al., 2021) – oh the list is long….

So, perhaps we could consider an alternative way to describing these kinds of pains: I personally prefer “severe” but maybe there are other words?

Benintendi, A., Kosakowski, S., Lagisetty, P., Larochelle, M., Bohnert, A. S., & Bazzi, A. R. (2021). “I felt like I had a scarlet letter”: Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug and alcohol dependence, 222, 108664.

Howe, E. S. (1960). Quantitative motivational differences between volunteers and nonvolunteers for a psychological experiment. Journal of Applied Psychology, 44(2), 115–120. https://doi.org/10.1037/ h0045002

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Nuzzo, J. (2021). Volunteer Bias and Female Participation in Exercise and Sports Science Research. Quest, 73(1), 82-101. https://doi.org/10.1080/00336297.2021.1875248

Rosnow, R. L., & Rosenthal, R. (1976). The volunteer subject revisited. Australian Journal of Psychology, 28(2), 97–108. https://doi.org/10.1080/00049537608255268

Wakefield, E. O., Puhl, R. M., Litt, M. D., & Zempsky, W. T. (2021). “If It Ever Really Hurts, I Try Not to Let Them Know:” The Use of Concealment as a Coping Strategy Among Adolescents With Chronic Pain. Frontiers in Psychology, 12, 1840.

Zhang, M., Zhang, Y., Li, Z., Hu, L., & Kong, Y. (2021). Sexism-related stigma affects pain perception. Neural plasticity, 2021.

The complex world of identifying nociplastic pains


Towards the end of 2017, IASP put forward a new mechanistic classification: nociplastic pain. The definition is: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

Note: Patients can have a combination of nociceptive and nociplastic pain”.

This was great news! Prior to this, the term “central sensitisation” was used and abused to describe processes involved in ongoing pain that wasn’t inflammatory or neuropathic. Problem with that term is that it’s apparent in nociceptive mechanisms, as well as both inflammatory and neuropathic…. When the way people used the term was more akin to “well, the pain hasn’t settled down, so ‘something weird’ is going on and it must be in the central nervous system so we’ll adopt this term seeing as Clifford Woolf described it in the spinal cord” (Woolf, 1996, 2007).

In other words, any pain that seemed to radiate, hang around, and no respond to treatment was “centrally sensitised”. Perhaps so. Perhaps not. Suffice to say, people got confused because most of the typical central sensitisation from nociceptive/inflammatory processes subsides over time, but these “centrally sensitised” pains did not.

I, for one, am glad there’s a group in which weird pains that don’t appear to involve typical nociceptive, inflammatory or neuropathic mechanisms can be put.

Problem is: how do we know what fits into this group? We can be pretty certain when it comes to neuropathic pain, because the definition is very clear (though not so clear in the clinic) – “Pain caused by a lesion or disease of the somatosensory nervous system.” The notes go on to say that “neuropathic pain is a description, not a diagnosis” and I’d say the same about nociplastic pains (which is why I use the plural…). I also step out to say that I don’t think ALL nociplastic pains will be found to have the same biological mechanisms, especially given how widely variable neuropathic pains are.

Nevertheless, we need some way to decide which pains are in, and which are out of this group.

This table comes from Kosek et al., (2021) and summarises the findings from a consensus process within an expert group. They make the point that acute pain isn’t helpfully included in this group, and instead it should be used for pains that persist for 3 months or longer. They also point out that regional pain is included while discrete pain is typically not because of the central sensitisation processes involved (note: this is the correct use of the term! Confused? CS is a neurophysiological phenomenon, associated with more than nociplastic pain).

Looking at the above criteria, possible nociplastic pain is present if the person has criteria 1, and criteria 4. Probable nociplastic is present if the person has all the above.

There are some notes, of course: regional means the musculoskeletal pain is deep, regional or in several places or even widespread (not localised to one place), and each condition eg frozen shoulder and OA knee needs to be assessed separately. If there is an identifiable nociceptive source (or neuropathic source) then the pain needs to be more widespread than “usual” for that pathology. Finally, because nociplastic pain unlike neuropathic pain, has no definitive test currently, there is no “definite nociplastic” category – but once there is, this will be added.

What does this mean for us as clinicians?

Firstly it ought to stop people being thought as faking, malingering or otherwise not being believed. That should be a given but unsurprisingly because of legal and health systems and our own frustration at not being able to “fix” people, people with pain get that impression more often than they should. It also ought to stop psychopathologising people who have this kind of pain: we can’t distinguish between people with nociplastic pain and the DSM5 “Somatic Disorder” – so let’s just not add another unhelpful mental health label to what is already a stigmatised situation.

Then it ought to stop clinicians using treatments that simply don’t help – such as opioids for fibromyalgia. It might help clinicians pause before prescribing movement therapies at a level that is too intense for the person, because this only revs the nervous system up even more making the whole process unpleasant. Beginning at the level the person can manage and gradually increasing is crucial to success. And it ought to stop clinicians from administering “explanations” or “education” and expecting that alone to reduce pain. Because while cortical processes are part and parcel of every pain there is, it’s in this group of pains that some people think “top down” by thinking yourself out of pain is a thing. FWIW pain reduction is lovely and part of treatment, but shouldn’t ever be the only outcome (Ballantyne, 2015), and many times in this group of pains, may not even be an outcome.

Finally, it should stimulate helpful discussion about what “whole person” approaches to managing these pains looks like. The authors say “patients with nociplastic pain are likely to respond better to centrally than peripherally targeted therapies” and this does not mean talk therapy alone, or exercise alone, or indeed medications such as gabapentin or nortriptyline alone. To me, it means individualised, tailored, and integrated strategies to moving, managing daily life, restoring sleep, enjoying an intimate relationship, managing mood and memory, and these might best be offered by pain coaches rather than siloed “therapies” of physical, psychological or whatever other stripe there is.

Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of Chronic Pain — The Wrong Metric? New England Journal of Medicine, 373(22), 2098-2099. https://doi.org/10.1056/NEJMp1507136

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Woolf, C. J. (1996). Windup and central sensitization are not equivalent. Pain, 66(2), 105-108.

Woolf, C. J. (2007). Central sensitization: uncovering the relation between pain and plasticity. The Journal of the American Society of Anesthesiologists, 106(4), 864-867.

Rehab Fails: What goes wrong in pain rehabilitation 3


I’m beginning to think this series could grow into a monster – so many #rehabfails to pick from!

Today’s post is about rehabilitation that doesn’t fit into the person’s life. Or that the person hasn’t been supported to fit the rehabilitation into their life. THEIR life, not ours!

You know what I mean: for six to twelve weeks, this person has been coming along to their treatment sessions, doing the things the therapist suggests. They make progress and it’s time to end the programme. “Good bye patient” the therapist says. And the patient skips off into the sunset, fixed for life.

Yeah right.

Roll that movie right back to the start.

At the first consultation, therapists often ask the person about what they’d like to achieve. Often the person doesn’t really know, after all most people don’t routinely set goals – and particularly if someone is experiencing the disruption of dealing with a painful problem that doesn’t go away like it should. It’s not for nothing that people describe this time as being in “zombie land” and dealing only with “the essentials” (Lennox Thompson, et al, 2019). Nevertheless, therapists ask and people are expected to come up with something that can then form the focus of subsequent therapy. A recent systematic review, however, found that many studies describing goal setting practices fail to implement all the components of effective goal setting – in particular, omitting “formulation of coping plan” and “follow up” (Kang, et al, 2022).

Now these two components are crucial for long-term adherence to rehabilitation, and especially in persisting pain where it’s probable the person will need to follow therapeutic practices for a very long time. The “coping plan” consists of identifying barriers and facilitators to doing the actions that lead to achieving goals, and also involves assessing confidence to do so, along with generating a plan to deal with unexpected situations. “Follow up” involves self-evaluating progress, evaluation, and adjusting the plan to suit. (Kang et al., 2022).

Why are these two components so important?

Well, think of one of your recent patients. Think about the things you (and others in your clinical team) asked that person to do. Are any of these things typical for this person? Are they habits, built into daily routines? Are they familiar? What is this person’s daily routine like? What does their family need to do and what does this person need to do for them? If the person usually works, and is still trying to maintain that on top of their usual home and family activities, how much are you and your colleagues asking the person to do on top of these? When they’re already struggling with the debilitating effects of their pain problem?

See why we might have trouble with adherence? Let alone ensuring that the person feels it’s worthwhile doing what it is we’re asking them to do!

I’ve seen this problem time and time again. Little, if any, consideration of this person’s usual daily life context. Little thought to the burden of trying to manage normal life and what the therapists is asking the person to do. No discussion about what might get in the way of fitting these therapy things into their life – and then I’ve heard clinicians have the audacity to suggest the person isn’t motivated!

So much for person centred rehabilitation. So much for helping the person work out how they might fit these things in, and how they might develop a routine or habit that they can continue once they leave the therapist’s care.

While I’ve looked at goal setting and therapy for persistent pain, what I notice is that even in acute musculoskeletal management, studies have shown that therapists don’t really understand goal setting. Alexanders and colleagues (2021) found that physiotherapists undertaking goal setting for anterior cruciate ligament rehabilitation might employ SMART goals – but didn’t understand the theory behind goal setting, didn’t know that expectations were important, and didn’t use feedback sufficiently. And this is for SMART goals that have already been found wanting (see Swann et al., 2022).

What do I suggest?

  1. Start by understanding the person’s current responsibilities in life, and the impact their pain problem is having. Recognise that those impacts will also have an impact on their capability for adding to their daily routine.
  2. With the person, establish the best time of day for them to do whatever it is you think they should do. Work through what might get in the way – and what might support them.
  3. You may need to help them develop some additional skills to deal with what might get in the way of undertaking your activities – maybe skills to communicate with family, or the boss, so they can take 10 minutes out to do the breathing practice you’ve suggested, maybe some work with thoughts to help them be OK with guilt for “not doing things as normal.”
  4. Assess their confidence to engage in this additional task. Use motivational interviewing to boost their confidence (and it probably would help you to consider the importance of what you’re asking them to do in the context of their values and activities).
  5. Check how much you’re asking the person to do – is it achievable in this person’s life? A certain intensity might be theoretically important for physiology, but if the person doesn’t do it because he or she can’t fit it in, it just won’t get done.
  6. Check in with the person in between appointments. If you see them once a week – send a text 3 days in to that week to see how they’re getting on. Or ask the person if they’ll send you a text to let you know. Give feedback, alter your plan, encourage, celebrate.
  7. And once the person is nearly ready for discharge, make sure you have a set-back or relapse prevention plan in place. What should this person do if things begin to go pear-shaped? Do they need to keep going at the same intensity as they have during your therapy? What are their warning signs for things beginning to fall apart? (clue: it’s often not when people are beginning to hurt again, it’s often because the person is feeling good and starts to drop the things that have helped!)

Don’t do #rehabfails

Kang, E., Kim, M. Y., Lipsey, K. L., & Foster, E. R. (2022). Person-Centered Goal Setting: A Systematic Review of Intervention Components and Level of Active Engagement in Rehabilitation Goal-Setting Interventions. Archives of Physical Medicine and Rehabiltation, 103(1), 121-130 e123. https://doi.org/10.1016/j.apmr.2021.06.025

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

Lenzen SA, Daniels R, van Bokhoven MA, van der Weijden T, Beurskens A. (2017). Disentangling self-management goal setting and action planning: a scoping review. PloS One,12:e0188822.

Swann, C., Jackman, P. C., Lawrence, A., Hawkins, R. M., Goddard, S. G., Williamson, O., Schweickle, M. J., Vella, S. A., Rosenbaum, S., & Ekkekakis, P. (2022, Jan 31). The (over)use of SMART goals for physical activity promotion: A narrative review and critique. Health Psychology Review, 1-16. https://doi.org/10.1080/17437199.2021.2023608

What goes wrong in pain rehabilitation (2)


One size does not fit all. Cookie cutter treatments fail to take into account the huge variability each person brings into a clinical encounter, particularly when the person is living with persisting pain. Not really earth shattering news, is it?!

Let me unpack this one.

When we’re treating a person with an acute musculoskeletal injury, let’s say a lateral ankle sprain, I’m going to hazard a guess that most of the recovery occurs without our assistance (don’t shoot the messenger – go read Chen et al, 2019). In essence, we’re creating an environment that supports tissues to do what they do well – get on with healing. Because of this, there’s good reason to follow a basic treatment algorithm that will work for most people. That is, unless or until recovery stops for some reason.

It’s here that algorithms begin to lose utility, because the factors that are implicated in delayed recovery are many and varied – and it’s important to narrow down the particular factors involved for this person with their ankle.

So, IMHO, cookie cutter treatments begin to fall apart when recovery is slower than expected because there are a heap of variables involved. And yet what do I see? “Oh it failed but let’s do the same thing again but harder!” or “the person wasn’t doing their exercises” or “it must be psychosocial factors.”

Well, no, actually, perhaps psychosocial factors are involved, but they were there from the outset (just ignored because the tissue-based factors capture our attention). And no, doing the same thing again but harder leads to the same outcome, only more disappointing. And we have no idea whether the person was, or wasn’t doing their exercises – or whether the prescribed exercises were useful, or whether they even make much of a difference anyway! (again, don’t shoot the messenger, go read Wagemans, et al 2022).

But probably the most heartbreaking thing about using “one size fits all” is that this doesn’t take into account this person’s goals, lifestyle, current priorities, other contextual factors like workplace, family and friendship obligations that are integral to being a person, not just a lateral ankle sprain.

I once worked at a chronic pain centre where every person was assessed by three clinicians: a medical practitioner for diagnosis and medication management; a psychosocial clinician to understand life stressors and the person’s understanding of their pain and their current coping strategies; and a person who assessed how he or she was managing with daily life and functional activities. What I couldn’t understand was how almost every patient was given the same management plan: to try some drugs, see a psychologist, and do a home exercise programme. Come to the centre to see each clinician on a different day of the week. Irrespective of the unique presentation, the same recipe was given. The ingredients might have been a little different when the person was seen for treatment, but without fail, the basic elements were exactly the same.

How is this person-centred care? What if this person was a 4 wheeldrive off-roading enthusiast who loved to go fishing? What if this person was a traveling sales rep with a well-developed meditation practice? What if this person had five kids and couldn’t get to the pain centre for the twice weekly appointments? What if this person was hankering after spending some time with other people who were also living with pain so she could hear that she wasn’t alone, and could pick up tips from people who knew what it was like?

Today I still hear of people being given a copy of “Explain Pain”, get to do the “Protectometer” and then told to go see the physio and psychologist. Nothing about the person’s desire to work out the impact pain has on their daily life, nothing about the understanding the person already has about their own pain fluctuations, and nothing that’s tailored to what this person needs and wants to do.

Seriously folks, pain rehabilitation and management is all about tailored, bespoke, clever therapy based on what the person needs and wants to do, what they already know and bring to their own recovery, and it probably needs to include connection with other people who are in the same situation. Why? Because while “other people” might not give the advice the journal articles recommend, they offer advice from their own experience. And mostly, people with persisting pain need affirmation that they’re resilient, capable, knowledgeable and can work a way through this.

Maybe what we need to do is include people who live with pain in service design (Sandvin Olsson, et al., 2020) – and pain management delivery (Farr, et al., 2021). It seems to work.

Chen, E. , McInnis, K. & Borg-Stein, J. (2019). Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports, 18 (6), 217-223. doi: 10.1249/JSR.0000000000000603.

Farr, M., Brant, H., Patel, R., Linton, M. J., Ambler, N., Vyas, S., Wedge, H., Watkins, S., & Horwood, J. (2021, Dec 11). Experiences of Patient-Led Chronic Pain Peer Support Groups After Pain Management Programs: A Qualitative Study. Pain Med, 22(12), 2884-2895. https://doi.org/10.1093/pm/pnab189

Sandvin Olsson, A. B., Strom, A., Haaland-Overby, M., Fredriksen, K., & Stenberg, U. (2020, Aug). How can we describe impact of adult patient participation in health-service development? A scoping review. Patient Educ Couns, 103(8), 1453-1466. https://doi.org/10.1016/j.pec.2020.02.028

Wagemans, J., Bleakley, C., Taeymans, J., Schurz, A. P., Kuppens, K., Baur, H., & Vissers, D. (2022). Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis. PLoS One, 17(2)http://dx.doi.org/10.1371/journal.pone.0262023

Rehab fails: What goes wrong in pain rehabilitation (1)


Well obviously I’m not going to cover everything that goes wrong – and certainly not in one post! But inspired by some conversations I’ve had recently, I thought I’d discuss some of the common #fails we do in rehabilitation. Things that might explain why people with pain are thought to be “unmotivated” or “noncompliant” – because if the rehab doesn’t ‘work’ of course it’s the person with pain who’s at fault, right? So for today, here goes.

Starting at the wrong intensity

One of the main things that happens when someone’s in pain is to reduce overall activity level. Pain has been called “activity intolerance” and it’s common for people to stop doing. So naturally when a clinician is developing an activity or exercise programme, the aim is often to simply increase how much movement a person does in a day. So far, so good. Muscles and cardiovascular systems improve when we use them.

But guess what? There’s a person inside that body! And people have minds. Minds with opinions about everything and in particular, anything to do with doing. There’s often a “should” about how much movement or activity to do. This rule might be based on “pain is a sign of tissue damage” so anything that increases pain clearly “should not be done”. There may equally be a “should” about how much exercise this person used to do, or wants to do, and often mental comments about “what kind of a person does this amount of exercise.”

I’ve heard good clinicians say that their patients “have unrealistic goals” – this is probably because the person’s mind has an opinion about what he or she “should” be able to do!

What can good therapists do about this? Well, firstly to ignore the person who inhabits the body is plain wrong. Secondly, flashy gadgets like coloured tapes or special elastics or foam thingies probably won’t do much for the person’s opinionated mind except to temporarily distract — oooh! shiny!!

Something I might do would be to ask the person what level they think they can begin at – beginning where the person is at, and moving at his or her pace is a solid foundation for developing a relationship where experimenting with movement becomes about the person and his or her relationship with their body. I think one of the aims of movement rehabilitation is to help the person develop trust in their own body and how it moves, so enhancing playfulness and experimentation can be a good start.

I might ask the person “what shows up when we begin doing this set of movements/exercises”? By “showing up” I’m talking about thoughts, images, sensations in the body that pop into a person’s mind (minds are soooo opinionated!). We might need to guide the person to notice quick thoughts or images, to put words to emotions and feelings, and to get in touch with fleeting sensations in the body.

Some of the things I’ve heard people say include: “only weak losers would call this exercise”, “I used to be able to lift 40kg sacks of cement and now all I can move is this pathetic 5kg dumbbell”, “he wants me to do what?! I hate boring exercises”, “but what am I going to feel like tomorrow?”

What do we do with these thoughts?

First: make room for them to be present. Don’t quickly deny them “Oh of course you’re not weak”, “5kg isn’t pathetic”, “exercise is great fun”, “you’ll be fine, you can do this”. Saying these sorts of things dismisses the validity of the person’s fears and won’t win you any friends.

Second: empathic reflection. Indicate that you’ve heard what the person has said, validate that this is their experience, their thoughts. Something like “it’s a long way from what you used to lift, and that’s hard”, “it’s tough beginning to build up again”, “you’re worried that this is going to be unrewarding”, “you’ve had pain flare-ups before, and it’s hard to deal with”.

Third: Ask the person where they’d like to begin, put them in control of the intensity. Then ask them “how do you think that’s going to pan out” – in other words, will their option get them to where they want to be? What’s good about it? What’s not so good about it? from their perspective not yours! The idea is to establish how workable the person’s starting point might be. It might be perfectly fine, even if it’s not your choice!

Fourth: Affirm that the choice is the person’s – and that this is an experiment that will be reviewed at the next session. You might say something like “So you’d like to try doing 5 minutes of walking instead of the treadmill that I suggested, because you think this shouldn’t flare your pain up as much. What’s your choice now that we’ve talked about the good and not so good? We can review it next time.”

Fifth: Review how it went at the next session! Note down the rationale the person had for the level of intensity they chose, and then review how well that intensity worked from this perspective. For example “you wanted to do 5 minutes of walking because it wouldn’t flare you pain up as much, what did you notice? What showed up? How well did it work?” Notice all the open-ended questions, the reminder that the person thought this intensity wouldn’t flare their pain as much, and the focus on workability. Because at the beginning of a movement or exercise programme, what you’re looking for is adherence, sticking to the level of intensity chosen. Habits take time to make, and often adhering to a programme is because the opinionated mind is having a go at the person, interfering with their willingness to stick with it. If we avoid that roadblock, we have at least one point on the board.

Your opinionated mind might now be telling you that “oh they’ll never make progress at that pace”, “they’ll do themselves an injury if they lift that much”, “this is just pandering to their lack of motivation”

Be careful! At this point you could reflect on what’s showing up for you. Are you worried their outcomes will reflect badly on you? Do you only have a few sessions with the person and need them to get somewhere or you’ll have failed? Make room for those uncomfortable feelings. Let them be present and listen to what your opinionated mind is telling you. Maybe remind yourself that outcomes don’t depend on you – they depend on the person sticking to the programme, and a programme that doesn’t start because the person’s mind tells them it’s not worth it is a #rehabfail Remember also that you’re aiming for the person to gain confidence in their body, learn to listen to what happens when they try something out – the repeated progress reviews you do with the person are the actual active ingredients in therapy, they’re the bits that help the person to reflect on what works, and what doesn’t. That’s gold.

ps The technique I’ve described above is – gasp! – a psychological approach, based on ACT and motivational interviewing. You won’t find a specific study examining this approach in journals (at least not in a cursory search like I did!), but it’s an application of well-studied approaches into a movement or exercise context. It’s the same approach I use in contextually-relevant occupational therapy. Reading Bailey et al, 2020, affirms to me that we have a way to go to define and measure adherence, so I feel justified in using these strategies!

Bailey, D. L., Holden, M. A., Foster, N. E., Quicke, J. G., Haywood, K. L., & Bishop, A. (2020, Mar). Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review. Br J Sports Med, 54(6), 326-331. https://doi.org/10.1136/bjsports-2017-098742

Eynon, M., Foad, J., Downey, J., Bowmer, Y., & Mills, H. (2019). Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 29(5), 638-650. https://doi.org/10.1111/sms.13403

Levi, Y., Gottlieb, U., Shavit, R., & Springer, S. (2021). A matter of choice: Should students self-select exercise for their nonspecific chronic low back pain? A controlled study. Journal of American College Health, 1-7. https://doi.org/10.1080/07448481.2021.1960845

Reflective practice


In occupational therapy and some other health professions, reflective practice is a vital part of professional clinical activity. In others – not so much. And the term reflective practice has a heap of assumptions attached to it, so it may mean different things to different people.

I thought I’d unpack a bit about reflective practice today because I think it needs to be part of working with people experiencing pain. It helps us get out of our own mindset (when it’s done well), and opens a space for questioning what we do and why we do it – and as you probably all know, questioning is part of who I am!

According to Wikipedia (NO! Not an academic source – but kinda handy in this instance) “Reflective practice is the ability to reflect on one’s actions so as to take a critical stance or attitude towards one’s own practice and that of one’s peers, engaging in a process of continuous adaptation and learning” (Schon, D, 1983). In other words, we take an action then step back from what we’ve done to critically appraise it. The appraisal might be simply asking “what worked, what didn’t work, what would I do differently?” or it might be a more complex process in which someone else helps us to ask these questions or compare what we’ve done against a theory or another way of working.

I will admit that I hold some skepticism about how well we do reflective practice (the “we” being us human beings in general). This is because we’re incredibly prone to cognitive errors such as anchoring, commission and omission biases, framing effects, availability bias, vested interest bias and groupthink (see Scott, et al., 2017). The sneaky thing about these biases is that they’re implicit: that is, we often are oblivious that we do them. To combat them we need to take deliberate steps, and most of us haven’t been taught how to do this. Even when we have another person to work with as a prompt, we can get caught up in biases and fail to be critical about what we think of as “normal”.

Lilienfeld & Basterfield (2020) agree with me, pointing out that reflective practice theory and practice doesn’t draw on an understanding of the difficulties using introspection to become aware of biases (because we’re not aware of these intrinsic biases), that self-assessment often omits areas in which we either feel highly confident or we’re afraid we don’t know and don’t want to admit we’re struggling, and that we often don’t learn from experience. Ooops.

Yet, there’s enough evidence to show that by employing reflective practice, people can develop meta-cognitive skills in which they check their own assumptions, identify gaps in their knowledge, seek new information to fill those gaps, then try that knowledge out in practice (Ziebart & MacDermid, 2019).

BUT how do we do it, and does it make for better outcomes for the people we hope we help?

Lilienfeld and Basterfield (2020) offer some ideas – and caution us not to accept clinician satisfaction with the process of reflective practice with evidence of effectiveness. They propose drawing on research understanding debiasing: things like “consider the opposite” or “consider the alternative” as deliberate questions clinicians can ask themselves. Asking clinicians “how might I test out an alternative hunch?” could be a useful approach. Suggesting clinicians and their supervisors/mentors take an “outsider perspective” to step back from their decision-making as ‘disinterested third-party observers’ might help break through our tendency to overlook habitual practices just because they’re familiar (and perhaps help us remain willing to be vulnerable and compassionate towards ourselves instead of defensive).

I suspect clinicians working in pain management could do well with an ongoing relationship with a supervisor. Not someone who holds themselves as the “font of all wisdom”, not a “mentor” who feels responsible for shaping therapists into something new, but more as a mirror lens on practice. A neutral but supportive partner who can ask questions like “I wonder if we could use this [novel theory] to explore what’s going on” or “what if we thought about this [opposite theory] for a while to see what we learn”.

In situations where we are utterly certain of a causal relationship between X and Y, and where this leads to treatment A being the only viable option, we possibly only need to reflect on whether we’ve done the right diagnostics. In pain coaching/rehabilitation/management we have little certainty, far less to guide us, and a person experiencing pain. This person is often in a very vulnerable position where they trust us to do the right thing by them. If we fail them by being too certain we’re right without being challenged, we can do them an enormous disservice.

Lilienfeld, S. O., & Basterfield, C. (2020). Reflective practice in clinical psychology: Reflections from basic psychological science. Clinical Psychology: Science and Practice, 27(4). https://doi.org/10.1111/cpsp.12352

Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books. ISBN978-0465068746. OCLC8709452.

Scott, I. A., Soon, J., Elshaug, A. G., & Lindner, R. (2017, May 15). Countering cognitive biases in minimising low value care. Medical Journal of Australia, 206(9), 407-411. https://doi.org/10.5694/mja16.00999

Ziebart, C., & MacDermid, J. C. (2019). Reflective Practice in Physical Therapy: A Scoping Review. Physical Therapy, 99(8), 1056+.