New! Awesome! Better! (Learning a new approach)

With all the attention being given to cognitive functional therapy (and deservedly so, IMHO) it’s tempting to leap aboard the modality train and go take a course, isn’t it?

Although I’ve picked on CFT today, it could just as easily have been any of the New! Awesome! Better! therapies that hit the clinical headlines on a frequent basis. The temptation to go “Look! Shiny!” and learn about the latest thing isn’t confined to teenagers following some social media trend. Yup, even sober-sides nearly 60-year-olds like me still want to go on learning, getting better at what I do, keeping up with what’s popular…

And yet I worry just a tad when I see the number of therapies that have kicked off with a hiss and a roar but later don’t seem nearly as promising as they did when they started. Why is that? What am I worrying about?

New ideas can often get picked up without critique, as if a new idea comes fully birthed and complete. The slow decades of development, the theory that underpins an approach, and the careful ways researchers couch their conclusions can be completely ignored in the rush to show that ‘I’m up-to-date’ – and that’s a problem. Why? Because while a hallmark of an expert is in describing complex concepts in a very simple way, when we learn a new therapy we are most certainly not expert. So we’re likely to pick up on superficial and relatively black and white ideas, but fail to be aware of how these ideas are scaffolded by theory (Paas & van Merrienboer, 2020).

The difference between a technician and a professional is, I believe, in how deeply a professional will understand the theory. Theoretical knowledge teaches principles, and principles allow us to be versatile as we apply theory to different settings (Kirk, 2022). It takes time to move from superficial to deep understanding, something we expect during undergraduate learning as we develop epistemic cognition (the process of acquiring, understanding, employing and adapting knowledge to specific contexts) – and mostly, we will have had highly structured learning experiences during our training that will have made this process almost invisible to us as we learned them (Yeung, et al., 2021).

I think this makes postgraduate ‘lifelong learning’ tend towards reinforcing known assumptions – clinicians search for habitus (a set of dispositions that ‘incline’ people towards particular practices) because these fit with ‘things the way they are.’ Yeung and colleagues argue that it’s important to develop epistemic reflexivity, or ‘making strange’ the assumptions that go to make up clinical practice, so we can begin to recognise how these assumptions influence clinical reasoning. This process, however, might not be included in our professional training because it can lead to awkward questions – ones like ‘why’ and ‘what if’ and ones without satisfactory answers. Oh darn.

We can blame limited attention to epistemic reflexivity for the superficial way in which Explain Pain has been adopted. Explain Pain is a great way to begin learning about pain mechanisms, and when delivered in the way that the authors hoped it would, offers people with pain a way in to engaging in therapy that might not look much like what they’d thought they’d get. BUT too many people get the book shoved under their noses as ‘therapy’ in the mistaken hope that (a) the person’s pain will magically reduce simply because they know pain is ‘an output of the brain’; and (b) it works as a stand-alone treatment. It does not, except perhaps for fellow nerds like me.

You see, if your world view of therapy is that people are blank slates on which new information is thought to fix things, or that your job is to ‘correct’ abnormalities, and that you are the Holder of Truth, then a therapeutic innovation like Explain Pain can get picked up and bolted on to everyday practice as if it’s just another modality or technique. All the theory underpinning how and why information and learning might be useful (whether this is from a cognitive behavioural approach, or an educational one) gets lost. And the effectiveness either diluted, or at times, negated.

With CFT, built as it is on psychological principles (operant, classical conditioning, cognitive therapy, experiential learning) and delivered by confident therapists who understand movement and aren’t afraid of pain, the results are great. There is something inherently safe in being in a clinical setting with a confident clinician, exploring previously avoided movements in new and gently graded ways.

What CFT is not, however, is a recipe for correcting wrong beliefs, for pushing people into movements they’re afraid of and before they’re ready, by clinicians who themselves are uncertain, and who are looking for ‘movement dysfunctions’ or ‘deficits.’ It’s not intended to be bolted on to ‘usual practice’ which, as we can readily see from the diverse beliefs and practice about back pain in therapists in the ‘usual care’ arm of just about any RCT we care to review, is pretty messy.

To learn a new approach means making existing practice ‘strange.’ It means feeling awkward. Assumptions about ‘the problem’ and what we should do about it can get questioned. It means starting as a novice – therapy takes longer at first because we have to think harder. Our slick competence gets rattled as we can’t just reach for the things we usually (and automatically) reach for.

I’ve learned three forms of therapy that deviate a long way from my original occupational therapy practice. CBT meant I needed to learn cognitive theory, behavioural theory, how to elicit thoughts and beliefs, and link these to actions the person did. The hardest part of CBT was delaying my problem identification until I’d collected enough information to develop a formulation. Then I learned Motivational Interviewing, with its focus on values and eliciting personal reasons for change. Being willing to employ small sets of phrases and summarising then putting the question back to the person for their decision was hard after having spent so long thinking that I knew best. Finally I started learning ACT, and plunged into the complex world of understanding relational frame theory, the power of a behavioural and experiential way of learning that circumvents words (which are my natural home).

In each case, I’ve had to question the assumptions I’d developed as I delved into the theory underlying these approaches. I’ve really had to challenge myself to relate each new concept to what I already thought of as ‘truth.’ The origins of even starting to poke into ‘psychological’ approaches were embedded in my initial biopsychosocial learning that was inherent in my occupational therapy training – and I was lucky enough to have learned these ideas when they were relatively new and just being introduced by Engel. But I have had to question this perspective as well – and the way I view Engel and his work is quite different today from the way I first understood it.

Parting shot: Being attracted to a new and groovy practice is part of being a human. We’re nothing if we’re not curious (see this post from a few months ago). Let’s keep in mind, though, the need for ongoing critical analysis. Ask questions like: What are we trying to do here? What is the purpose of this approach? What are the theories underpinning this approach? What strategies or means are being carried out to achieve the results? What are the assumptions of this approach? Who benefits from these assumptions? Who is most directly affected by this? Are there alternative perspectives? What else might need to change for this to work? How would we know it had worked? – click here for one of the easily accessed critical thinking worksheets, this one from National Geographic.

Kirk, A. (2023). How physiotherapy students approach learning and their clinical reasoning capability (Doctoral dissertation, University of Otago).

Paas, F., & van Merriënboer, J. J. (2020). Cognitive-load theory: Methods to manage working memory load in the learning of complex tasks. Current Directions in Psychological Science, 29(4), 394-398.

Tremblay, M. L., Leppink, J., Leclerc, G., Rethans, J. J., & Dolmans, D. H. (2019). Simulation‐based education for novices: complex learning tasks promote reflective practice. Medical Education, 53(4), 380-389.

Yeung, E., Gibson, B., Kuper, A., Shaw, J., & Nixon, S. (2019). Making strange’: exploring the development of students’ capacity in epistemic reflexivity. Journal of Humanities in Rehabilitation, 1-15.

“… someone needs to find the cause of my pain, then fix it.” What to do with sticky beliefs

I think most clinicians, and certainly a lot of people living with pain, want to know ‘what’s going on’ – with the hope that, once identified, ‘something’ can be done. Tricky stuff to navigate both as a person living with pain, and as a clinician – because for so many chronic pains, a diagnosis does very little.

Having a label has some benefits, for sure: it acts as a short-hand when talking about what’s going on with others; it can validate that the mysterious problems a person has been having are ‘real’ (though I could say more about that!); it can help people find others with similar problems; and there’s always hope that by giving the problem a name it might lead to effective treatment. In the case of pains involving neuropathic or nociplastic mechanisms however, effective therapies are few, far between, and not terribly effective.

From a clinician’s perspective one of the most challenging situations is knowing what to do when someone is really convinced that there is a ‘something’ to be found, because many know how little diagnoses actually help. After all, each person with ‘lateral elbow pain’ might have pain in their lateral elbow, but how it affects them differs wildly depending on what they want to, and need to do in daily life.

For the person with pain who knows their own body and knows what their ‘normal’ feels like, finding the cause seems utterly logical and the necessary requirement before being able to get better.

Clinicians have used many ways to ‘explain pain’ or otherwise give people a handle on what might be going on. Almost all of our strategies aim to help people feel OK to move even with pain and emphasise that when pain persists, it’s less about harm and ‘alarm signals’ and more about problems in the nociceptive system. The rationale for these explanations is to encourage people to engage with therapy and begin rehab.

Problem is that for the person living with pain this can feel dismissive. Like their worries about what might be going on are trivialised, and they’re being kept in the dark almost as a show of power (or to confirm how useless medicine is).

From an ACT perspective, we have a few options, beginning by first looking at the function of getting a diagnosis. I pointed out some of the benefits of diagnoses in the second paragraph above. These show how diagnoses can function in people’s lives. When a person doesn’t have a diagnosis, the converse can apply: people can feel invalidated, that their pain is mysterious (and usually means something scary), that there is no answer and they’re on their own trying to deal with it, that the people around them may never know what it’s like to deal with it, and that this might be their life forever. I can see why the search for a label continues.

The good thing is, clinicians can help someone with those feelings even without giving a diagnosis. And clinicians will likely still have to help people in the same way even with a diagnosis.

As clinicians we have ways to work with people at this stage in their life with pain. My go-to is to ask the person to tell me the good things about continuing to look for a diagnosis from their perspective. I listen very carefully because this matters, this tells me about what the person is yearning for (even if I need to go below the words and explore the meaning behind them). For example, if a person says “I keep looking because I’m sure it will lead to the right treatment” or “I feel the doctors don’t take me seriously because they can’t find anything” or “I know [insert name] who had the same things going on and eventually they found what’s wrong but too late”, I hear a yearning for ‘life to return to normal’, ‘I want respect and affirmation’, ‘I’m scared this might go on and on and I’ll be stuck like this for life.’ I check my interpretations out with the person as I summarise the ‘good things’ about looking for a diagnosis.

Then I ask the person to tell me the not-so-good-things about looking for a diagnosis. Sometimes I’ll prompt them with examples they’ve already told me: like the hope then despair of going through investigations; the financial and life burden of continuing to look; the endless waiting and waiting for results; the dismissive attitude if nothing is found… The list can be very long indeed. And heartbreakingly sad. The search may have been going on for years. Again, I’ll summarise, and ask the person how this affects them as people. I have such compassion for people who have gone through this for so long. The yearning for making sense is strong in all of us!

By summarising both the good and the not-so-good of looking for a definitive diagnosis, and asking the person what sense they make of it all, the aim is to take a long look at how this search is functioning in the person’s life. For some people it hasn’t stopped them from doing what matters, and the search is almost like a scavenger hunt. Life has carried on. They do the important things for them, and that’s fine. For others, taking a stocktake like this has significant impact. Remember, doing this is not in the service of what I want as a clinician. This exercise aims to find out how the search is working for the person and what matters to them.

Once I’ve gone through this process, I begin looking at whether the person is ready for an alternative approach. Of course, this is only considered if they identify that the costs of continuing to search for a diagnosis are too high, and they recognise that it’s been having a negative impact on them. If it is time to switch things up, I can use the fingertrap example , I might talk about how natural and normal it is to want to make sense of things (we’re in this together, we’re all human and want a sense of coherence), I could draw on the digging a hole metaphor or ‘drop the rope’ metaphor. The aim is to help people recognise that stopping the search is a valid way of responding to this need for coherence.

Truth is, though, I don’t usually use these metaphors but instead ask the person ‘if your pain wasn’t as much of a problem for you, what would you be doing?’ and collaborate with the person to understand the values underneath that desire. Working with positive directions (appetitive motivation rather than aversive motivation) helps people pick up on what makes their life worthwhile.

All and any of the processes in the hexaflex can be used to help someone who has got stuck in the pursuit of finding a diagnosis. What matters for us as clinicians is: (1) to be mindful of how this search is functioning (don’t mess with something that isn’t getting in the way of living a meaningful life, but just as importantly, don’t buy into the search for coherence without considering how this may be interfering with helping the person do what matters to them); (2) to explore this process with compassion, knowing that we all do this – and that it has at times led us to develop unhelpful explanations and diagnostic labels, use metaphors that don’t hold much meaning to the person, and leave the person feeling like we don’t take their concerns seriously and don’t care.

Want resources for this? My go-to books are: A liberated mind – https://contextualscience.org/publications/a_liberated_mind_how_to_pivot_toward_what_matters

Learning ACT – https://www.newharbinger.com/9781626259492/learning-act/

Westrup, D., & Wright, M. J. (2017). Learning ACT for Group Treatment: An Acceptance and Commitment Therapy Skills Training Manual for Therapists. Context Press.

Radical relief – https://www.optp.com/Radical-Relief-A-Guide-to-Overcome-Chronic-Pain

There are so many ACT research papers available – with nearly 1000 RCTs, many conducted with people living with chronic pain, ACT is one of the most well-researched therapies across diverse populations of any therapy. The processes of ACT have been validated in people with chronic pain, and you can take confidence both as a person with pain, and clinicians, that ACT has shown highly effective and longlasting effects. Clinicians from any therapeutic background can learn ACT and use it without stepping over ‘scope of practice’ issues. I’ve been using ACT as an occupational therapist for around 19, maybe 20 years. I’d love for more clinicians to learn ACT and bring this into their clinical practice because it’s liberating for us too.

On not being an arse

Humans are judgemental beings. All of us are. It’s part of having a big brain and wanting to know who’s ‘in’ and who’s ‘out’. Judgements help us make decisions, they’re surprisingly resistant to change, and they can inadvertently trap us into doing things we would never countenance were we able to stand back from what our minds want us to know (and feel).

My post today is prompted by a couple of conversations recently. One was with a clinician, new to a pain team, who found that experienced members of that team thought actions taken by a person with pain were a sign of ‘catastrophising’ and ‘failing to accept’ and worse – ‘not engaging in the programme.’ He’d thought the very same actions were an indication of someone trying very hard to improve their situation, of being motivated to learn and experiment, of being a self-advocate.

The other conversation was with someone who had not been referred for investigations for a new pain she had developed, on the basis that ‘hurt doesn’t equal harm’ and because she already had a chronic pain problem. She went through many years of distress and disability because her new pain was not investigated – but once it was, she got a diagnosis and the treatment that reduced that pain and relieved her distress. Sadly the psychological distress of not having her concerns addressed lives on.

How can we get it so wrong? How is it that good clinicians with the best of intentions (my assumption) make judgements about a person, their pain, and what they do about it and paint the person with pain in such negative ways?

Perhaps clinicians can be excused for holding negative attitudes towards people with chronic pain because the prevailing belief in our clinical communities is that ‘we, the professionals, know what’s right.’ We know this because we have the randomised controlled trials that show us Truth about What Works and What Does Not. I write these in capitals because while health professionals embrace evidence-based health care, I’m not sure we’re all that au fait with the original model of EBHC and its three-part definition: “a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values (Sackett, et al., 1996).” Note those last two points: clinical expertise and patient values.

We’re also not very good at being critical about research. Well, I take that back, we pull research apart when the results don’t equate with our experience or preferences, and gulp down whole the research that does… but what we don’t do nearly as well is to be critical of implicit issues with research paradigms. What I mean by this is we don’t ask ourselves whether the assumptions used in statistical analyses hold true (I’ve discussed ergodicity before); whether the participants recruited to studies are anything like the people we see (research participants are selected to reflect a ‘pure’ construct for testing, so people with multiple comorbidities, who might have difficulty with language or who might not even engage with healthcare and those who are not from high income countries aren’t represented); whether the treatment/s studied in research look anything like what is actually delivered in daily clinical practice, even how long the follow-ups are and what happens once a person is not part of a research project.

Limited critical analysis means results from research reach practice quite quickly (even though the nuances reported by the researchers in those papers often do not) and what’s worse, help to reinforce a hierarchy separating the person seeking help and us as clinicians. After all, us clinicians spend years learning all this stuff so it should count for something, shouldn’t it?

Well… not as much as we’d like it to, perhaps.

Because if clinicians judge a person based on erroneous beliefs about the superiority of what we know in theory (because quantitative research represents only a ‘failure to reject the null hypothesis‘ not definitive support for a theoretical prediction) we’re not inclined to be curious about what the person brings into our communication. Walt Whitman apparently said “Be curious, not judgemental” – and curiosity allows clinicians to suspend judgement in order to explore, to dive more deeply into detail and context, and ultimately, to be more compassionate. Don’t believe me? Take a look at this paper by Shields, et al., (2013).

“Physicians who used more certainty language engaged in less thorough assessment of pain (β = -0.48, p < .05). Conversely, physicians who engaged in more exploring and validating of patient concerns (β = 0.27, p < .05) had higher ratings on anxiety/concerned voice tone (β = 0.25, p <.01) and engaged in more thorough assessment of pain. Together, these three factors accounted for 38% of the variance in pain assessment. Physicians who convey certainty in discussions with patients suffering from pain may be more likely to close prematurely their assessment of pain. We found that expressions of physician concern and responsiveness (curiosity) were associated with superior pain assessment.”

We could replace ‘physician’ with any other healthcare professional, and my bet is we’d find the same thing.

Why does this matter?

Well, after being part of a number of “experts by experience” conversations over the years, the message coming through loud and clear is that clinicians who judge people negatively and fail to respond to what it is the person intends or needs, but instead dismiss their concerns as ‘catastrophising’ or ‘maladaptive thinking’ or even ‘not motivated to engage’ leave people with pain in distress. The psychological impact of feeling that your concerns are not important, of being dismissed, of not being heard is long-lasting. One person I’ve spoken to described her anxiety about seeking help from a clinician after a single time where her concerns weren’t acknowledged.

We might not intend to do it. We may think we’re doing the right thing – and possibly we are doing the right thing but doing it in a ham-fisted and damaging way.

• First listen, be curious and understand why a person has done what they’ve done. People don’t get up in the morning to do dumb things. There’s always some underlying reason a person does what they do.
• Then reflect in a compassionate and empathetic way – show the person you’ve heard them. Let them know what it is you’ve understood – let them correct you if you’ve got it wrong and remember that taking the time to do this saves time.
• Ask them how well their approach is working for them. Aim to understand the benefits from their perspective. Normalise their approach – humans do what humans do, try to solve a problem using the tools at their disposal, just the same way we do as clinicians. Ask about the short-term effects, and the long-term impact. Ask about the good and not-so-good of their approach. BE CURIOUS!
• Involve the person in your decision-making. Be honest about your reasoning and be real about the level of uncertainty that exists in our knowledge about pain. This person is an individual, not a number in an RCT, this person probably doesn’t even look like a participant in an RTC.
• Be specific with your reassurance. Don’t dismiss someone’s concern about a new pain: find out what it is they’re concerned about and ensure you clearly address that concern. Don’t be patronising – be authentic and real.

There is so much harm we clinicians inadvertently do because we’re not flexible, we don’t take time to really hear how a person gets to where they are in their journey with pain, and we really need to be more critical about our own assumptions.

Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. Bmj, 312(7023), 71-72.

Shields, C. G., Finley, M. A., Elias, C. M., Coker, C. J., Griggs, J. J., Fiscella, K., & Epstein, R. M. (2013). Pain assessment: the roles of physician certainty and curiosity. Health Communication, 28(7), 740-746. https://doi.org/10.1080/10410236.2012.715380

N of 1 studies – great examples

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

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

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

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

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

OK, ’nuff said. Ergodicity matters.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If a rose is a rose by any other name, how should we study treatment processes in pain management & rehabilitation?

A new instalment in my series about intensive longitudinal studies, aka ecological momentary assessment (and a host of other names for methods used to study daily life in real time in the real world).

Daily life is the focus of occupational therapy – doing what needs to be done, or a person wants to do, in everyday life. It’s complex because unlike a laboratory (or a large, well-controlled randomised controlled trial) daily life is messy and there is no way to control all the interacting factors that influence why a person does what they do. A technical term for the processes involved is microtemporality, or the relationships between factors in the short-term, like hours or days.

For example, let’s take the effect of a cup of coffee on my alertness when writing each day. I get up in the morning, feeling sluggish and not very coherent. I make that first delicious cup of coffee, slurp it down while I read the news headlines, and about 20 minutes later I start feeling a lot perkier and get cracking on my writing. Over the morning, my pep drops and I grab another cup or a go for a brief walk or catch up with a friend, and once again I feel energised.

If I wanted to see the effect of coffee on alertness I could do a RCT, making the conditions standard for all participants, controlling for the hours of sleep they had, giving them all a standard dose of caffeine and a standard cognitive test. Provided I have chosen people at random, so the chance of being in either the control group (who got the Devil’s drink, decaffeinated pseudo-coffee) or the experimental group was a toss of the coin, and provided we assume that anyone who has coffee will respond in the same way, and the tests were all equally valid and reliable, and the testing context is something like the world participants will be in, the results ought to tell us two things: (1) we can safely reject the null hypothesis (that there is no difference between decaffeinated coffee and real coffee on alertness) and (2) we can generalise from the results to what happens in the real world.

Now of course, this is how most of our research is carried out (or the ‘trustworthy’ research we rely on) – but what it doesn’t tell us as occupational therapists is whether this person in front of me will be in the very top or bottom of the bell curve in their response, and whether this will have any impact on what they need to do today.

For this unique person, we might choose another method, because we’re dealing only with this one person not the rest of the population, and we’re interested in the real world impact of coffee on this individual’s feelings of alertness. We can choose single case experimental design, where we ask the person to rate their alertness four or five times every day while they go about their usual daily life. We do this for long enough until we can see any patterns in their level of alertness ratings, and be satisfied that we’re observing their ‘normal’. During this time we don’t ask them to change their coffee drinking habits, but we do ask them to record their intake.

Then we get nasty, we give them the Devil’s decaf instead of the real deliciousness, but we do this without them knowing! So it looks just the same as the real thing, comes in the same container with the same labeling, and hope that it has the same delicious flavour. We ask them to carry on drinking as normal, and rating their alertness levels four or five times every day, and we do this for another two weeks. The only things we need to watch carefully for is that they don’t suspect a thing, and that their daily life doesn’t change (that’s why we do a baseline first).

Just because we’re a bit obsessed, and because we’re interested in the real world impact, we sneakily switch out the rubbish decaf and replace it with the real thing – again without the person knowing – and we get them to carry on recording. If we’re really obsessed, we can switch the real thing out after two weeks, and replace with the pseudo coffee, and rinse and repeat.

Now in this example we’re only recording two things: the self-reported level of alertness, and whether it’s the real coffee or not (but the person doesn’t suspect a thing, so doesn’t know we’ve been so incredibly devious).

We can then draw up some cool graphs to show the level of alertness changes over the course of each day, and with and without the real coffee. Just by eyeballing the graphs we can probably tell what’s going on…

Usually in pain management and rehabilitation we’re investigating the impact of more than one factor on something else. For example, we’re interested in pain intensity and sleep, or worry and pain intensity and sleep. This makes the statistics a bit more complex, because the relationships might not be as direct as coffee on alertness! For example, is it pain intensity that influences how much worrying a person does, and does the worry directly affect sleep? Or is it having a night of rotten sleep that directly influences worrying and then pain intensity increases?

To begin with however, occupational therapists could spend some time considering single case experimental designs with a very simple strategy such as I’ve described above. It’s not easy because we rarely ‘administer’ an intervention that doesn’t have lingering effects. For example, we can’t make someone forget something we’ve told them. This means we can’t substitute ‘real’ advice with ‘fake’ advice like we can with coffee and decaf. The ‘real’ advice will likely hang around in the person’s memory, as will the ‘fake’ advice, so they’ll influence how much the person believes and then acts on that information. There are strategies to get around this such as multiple baseline designs (see the Kazdin (2019) and Kratochwill et al., (2012) article for their suggestions as to what this looks like), and for a rehabilitation-oriented paper, Krasny-Pacini & Evans (2018) is a great resource.

If you’re intrigued by this way of systematically doing research with individuals but wonder if it’s been used in pain management – fear not! Some of the most influential researchers in the game have used this approach, and I’ve included a list below – it’s not exhaustive…

Next post I’ll look at some practical ways to introduce single case intensive longitudinal design into your practice. BTW It’s not just for occupational therapists – the paper by Ruissen et al., (2022) looks at physical activity and psychological processes, so everyone is invited to this party!

Selected Pain Rehab SCED studies (from oldest to most recent)

Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research & Therapy., 39(2), 151-166.

Asenlof, P., Denison, E., & Lindberg, P. (2005). Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single-case studies of patients with recurrent and persistent musculoskeletal pain in primary health care. Physical Therapy, 85(10), 1061-1077.

de Jong, J. R., Vlaeyen, J. W., Onghena, P., Cuypers, C., den Hollander, M., & Ruijgrok, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain, 116(3), 264-275. https://doi.org/10.1016/j.pain.2005.04.019

de Jong, J. R., Vlaeyen, J. W. S., Onghena, P., Goossens, M. E. J. B., Geilen, M., & Mulder, H. (2005). Fear of Movement/(Re)injury in Chronic Low Back Pain: Education or Exposure In Vivo as Mediator to Fear Reduction? Clinical Journal of Pain Special Topic Series: Cognitive Behavioral Treatment for Chronic Pain January/February, 21(1), 9-17.

Onghena, P., & Edgington, E. S. (2005). Customization of pain treatments: single-case design and analysis. Clinical Journal of Pain, 21(1), 56-68.

Lundervold, D. A., Talley, C., & Buermann, M. (2006). Effect of Behavioral Activation Treatment on fibromyalgia-related pain anxiety cognition. International Journal of Behavioral Consultation and Therapy, 2(1), 73-84.

Flink, I. K., Nicholas, M. K., Boersma, K., & Linton, S. J. (2009). Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain. Behaviour Research and Therapy, 47(8), 721-728. https://doi.org/doi:10.1016/j.brat.2009.05.003

Schemer, L., Vlaeyen, J. W., Doerr, J. M., Skoluda, N., Nater, U. M., Rief, W., & Glombiewski, J. A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67. https://doi.org/https://doi.org/10.1016/j.brat.2018.07.002

Caneiro, J. P., Smith, A., Linton, S. J., Moseley, G. L., & O’Sullivan, P. (2019). How does change unfold? an evaluation of the process of change in four people with chronic low back pain and high pain-related fear managed with Cognitive Functional Therapy: A replicated single-case experimental design study. Behavior Research & Therapy, 117, 28-39. https://doi.org/10.1016/j.brat.2019.02.007

Svanberg, M., Johansson, A. C., & Boersma, K. (2019). Does validation and alliance during the multimodal investigation affect patients’ acceptance of chronic pain? An experimental single case study. Scandinavian Journal of Pain, 19(1), 73-82.

E. Simons, L., Vlaeyen, J. W. S., Declercq, L., M. Smith, A., Beebe, J., Hogan, M., Li, E., A. Kronman, C., Mahmud, F., R. Corey, J., B. Sieberg, C., & Ploski, C. (2020). Avoid or engage? Outcomes of graded exposure in youth with chronic pain using a sequential replicated single-case randomized design. Pain, 161(3), 520-531.

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

Edwin de Raaij, E. J., Harriet Wittink, H., Francois Maissan, J. F., Jos Twisk, J., & Raymond Ostelo, R. (2022). Illness perceptions; exploring mediators and/or moderators in disabling persistent low back pain. Multiple baseline single-case experimental design. BMC Musculoskeletal Disorders, 23(1), 140. https://doi.org/10.1186/s12891-022-05031-3

References

Kazdin, A. E. (2019). Single-case experimental designs. Evaluating interventions in research and clinical practice. Behav Res Ther, 117, 3-17. https://doi.org/10.1016/j.brat.2018.11.015

Krasny-Pacini, A., & Evans, J. (2018). Single-case experimental designs to assess intervention effectiveness in rehabilitation: A practical guide. Annals of Physical & Rehabilitation Medicine, 61(3), 164-179. https://doi.org/10.1016/j.rehab.2017.12.002

Kratochwill, T. R., Hitchcock, J. H., Horner, R. H., Levin, J. R., Odom, S. L., Rindskopf, D. M., & Shadish, W. R. (2012). Single-Case Intervention Research Design Standards. Remedial and Special Education, 34(1), 26-38. https://doi.org/10.1177/0741932512452794

Ruissen, G. R., Zumbo, B. D., Rhodes, R. E., Puterman, E., & Beauchamp, M. R. (2022). Analysis of dynamic psychological processes to understand and promote physical activity behaviour using intensive longitudinal methods: a primer. Health Psychology Review, 16(4), 492-525. https://doi.org/10.1080/17437199.2021.1987953

Persistent pain and movement practices

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How much “pain ed” do people need? And what to do when someone is not convinced…

This post has been a long time coming. There’s no doubt that giving explanations about pain mechanisms is common, and that we’ve (health professionals) been doing it a looooong time. Yes, way back to the 1970’s! In the early 1980’s when I started working in this field it was already commonplace to offer people an explanation for chronic pain (and to explain why some pains are such pains, while others bother us less – even when they involve the same degree of nociceptive input). Of course, way back then we used Gate Control Theory (GCT) to explain the distinction between hurt and harm, to explore why attention and emotion matter, and to introduce the idea of counter-stimulation and TENS: suffice to say clinicians used these metaphors especially for people with persistent pain (Katz & Rosenbloom, 2015).

Then along came Moseley, Nicholas and Hodges (2004) with a nicely-designed RCT comparing “pain neurophysiology” education with “back anatomy and physiology” provided by “trained physical therapist educators.” The results of this study showed “Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability.” Somehow the lack of relationship between changes in pain cognitions and physical performance and perceived disability got lost in translation, but what happened next was an explosion of interest in the effects of providing explanations about pain mechanisms.

Today, the old adage “if you have a hammer, all you see are nails” seems to apply when it comes to “pain mechanism explanations.” Everyone gets an explanation, many of the explanations are exactly the same (sometimes down to the same book being used), and I wonder how people with pain feel about this. Like the way we feel at the end of Christmas Day feasting – noooooo! not another mouthful!

Recently I was asked “how much pain ed do people need?” and my first thought was “it depends.” That’s my answer to most things in pain! Suffice to say, I think we need sound clinical reasoning before we launch into any intervention, and this means we need to understand the rationale for giving someone a pain mechanisms explanation. This post attempts to shed some light on when it might be useful.

One reason given for “educating” people (please, no! “educating” someone sounds so like an info-dump, and focuses us on what WE do, rather than on the EFFECT this information is intended to have) – one reason is to reduce pain intensity. Education, however, doesn’t have an incredibly powerful action on my pain when I burn myself doing silversmithing. The effect of information on pain may be via appraisal: if I think my pain is not a direct measure of tissue damage, then I might not be as distressed by it (and indeed, this is one of the effects identified in the Moseley, et al., 2004 study – changes in the Survey of Pain Attitudes and the Pain Catastrophising Scale showing reduced catastrophising brought about by recognising that hurt isn’t equal to harm).

As a result of not being as distressed, a person doesn’t have to communicate their fear through a number on a 0 – 100mm VAS. Because remember, we don’t have a pure measure of pain intensity and the VAS is a communication device. Pain behaviour, or what we do about our pain, is at least partly about communicating to others (Hadjistavropoulos et al., 2011; Lackner & Gurtmann, 2004) – and we all know we’d never get prescribed analgesia in an Emergency Dept with 30mm pain on a 0 – 100mm VAS!

Similarly, if we’re not as afraid of what pain means, we’re less likely to be worried about moving – so I wasn’t at all surprised to see the changes in straight leg raising and other physical performance measures. I also wasn’t surprised to see no change to perceived disability because doing functional activities in the real world is a whole lot more scary than in a controlled, supervised clinical setting. Remember this, folks, when you’re prescribing movement practices: they do not directly transfer into confidence and performance in daily life!

So if giving an explanation is about reducing distress, maybe it’s also about reducing uncertainty. Zaman and colleagues (2021) found that uncertainty hasn’t been studied as much as I’d hope and worse, it’s often studied in experimental settings where there is certainty that the pain will end, and this in turn is quite unlike me and my fibromyalgia pain which is both unpredictable and not controllable. There’s no doubt that helping someone understand that their pain isn’t a dread disease (cancer, some weird inflammatory disease, a nasty neurological – oh wait, it IS a nasty neurological thing…!) will likely reduce their distress, and might even reduce uncertainty – because at least we know what it’s not! But uncertainty remains with persistent pain because no-one knows when/if it will end, often we don’t know why it gets set off, and we clearly don’t have a handle on why it goes on and flares.

It makes sense, then, to consider pain mechanism explanations when a person 1) is not sure what it all means, 2) worries that it’s something nasty, and 3) thinks it’s both a direct reflection of what has happened to their tissues and 4) that they personally can’t do much about it.

We might also think of giving someone some information about their pain if we want to help them understand why we might be trying something like mindfulness, relaxation, stress management, or even normal movement. We can employ the little we know about cortical processes and descending inhibition, and polyvagal theory and sympathethic arousal, as well as physiological responses to movement/exercise to explain the rationale for these interventions if we so choose.

BUT we don’t have to all the time. Why? Because we can do these things anyway and help the person explore their responses in vivo! This may be more powerful than giving any kind of ham-fisted explanation, whether it be a cookie cutter one, or a tailor-made metaphor.

A few posts ago, I wrote about McCracken and Scott’s (2022) paper exploring the potential problems of making sense. This showed that sense-making can impede a person’s readiness to engage in therapy if their desire to make sense means they reject explanations that don’t fit with their understanding or when they overthink what the explanations mean. In these instances, it makes much more sense for us (see what I did then?) to help them begin to do what matters in their life than continue looking for explanations.

My guidelines for working through “pain mechanisms”?

• If the person is a geek and likes to delve into learning about their body and responses – go for it! (ie, people like me :-))
• If the person asks for information, or has questions about specific aspects of their pain or treatment
• As part of generating a case formulation, where the person and you collaborate to develop a model of what’s going on for them. As a clinician you’ll be using guided discovery to work out the processes that occur in predictable patterns, and these patterns in turn can become the focus of where and how you might interrupt them.
• After asking the person for their understanding, and there’s something in their version that’s unhelpful for their progress. For example, if the person tells you that they think a scan will uncover “the real reason” for their pain, or if they’ve taken on board an unhelpful belief that their joints are grinding bone on bone… you know the sort of thing. After asking permission to explore these thoughts/beliefs, you might find it OK to offer an alternative – but if it’s not getting in the way of them engaging in therapy, then just go along with it and use guided discovery instead.

What to do instead of explaining mechanisms?

• Focus on helping the person move towards what matters in their life, even if it doesn’t always make sense to the person. Use their experiences to guide their understanding, it’s far more powerful than any kind of external “truth”.
• Use guided discovery, drawing from their own experiences and asking them to reflect on the effect of what they do and know on their experience. For example, ask the person what it’s like when they’ve been worrying about what’s going on in their OA knee, what do they notice about their overall stress level, what does that do to their pain, what effect might that worry have on sleep or fatigue and how this might influence their pain and doing what matters.
• Offer skills to help deal with uncertainty and worries such as mindfulness (but OMG not to reduce pain, puhleaze!), attention management, and cognitive defusion.
• Always draw a connection between what you explain and what this means clinically. For example, if you want to discuss nociplastic mechanisms, what this might mean is a tendency for “normal” injuries or tissue disruption pain to hang around a lot longer. It might also mean pain spreads out a bit more. It can help explain why many medications are ineffective. And it’s useful when another clinician has suggested that because “there’s nothing on your scan, therefore there’s nothing wrong.” But tread lightly because there is SO much we do not know!

I like to draw on the principles of motivational interviewing in my work with people. Respecting their autonomy and right to decide means I need to ask permission before I give information to them. I need to have a clear clinical reason for doing so – and this isn’t “because it reduces pain” – it needs to have specific indications for this person. Understanding how and why “pain education” can be helpful is critical, and always remembering that knowing “about” something doesn’t mean it changes behaviour. I’m still not keen on spiders even though I know we have no poisonous ones here in Aotearoa, and I’m much bigger than them!

Katz, J., & Rosenbloom, B. N. (2015). The golden anniversary of Melzack and Wall’s gate control theory of pain: Celebrating 50 years of pain research and management. Pain Research & Management: The Journal of the Canadian Pain Society, 20(6), 285-286.

Hadjistavropoulos, T., Craig, K. D., Duck, S., Cano, A., Goubert, L., Jackson, P. L., Mogil, J. S., Rainville, P., Sullivan, M. J., de C. Williams, A. C., Vervoort, T., & Fitzgerald, T. D. (2011). A Biopsychosocial Formulation of Pain Communication. Psychological Bulletin, 137(6), 910-939. https://doi.org/10.1037/a0023876

Lackner, J. M., & Gurtman, M. B. (2004). Pain catastrophizing and interpersonal problems: a circumplex analysis of the communal coping model. Pain, 110(3), 597-604. https://doi.org/10.1016/j.pain.2004.04.011

McCracken, L. M., & Scott, W. (2022). Potential Misfortunes in ‘Making Sense’: A Cross-sectional Study in People with Chronic Pain. J Pain. https://doi.org/10.1016/j.jpain.2022.09.008

Moseley, G. L., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain, 20(5), 324-330.

Zaman, J., Van Oudenhove, L., & Vlaeyen, J. W. S. (2021). Uncertainty in a context of pain: disliked but also more painful? Pain, 162(4), 995-998. https://doi.org/10.1097/j.pain.0000000000002106

Frustration in the clinic

I’m prompted to write this post because it’s something I see in social media so often – a clinician gets frustrated. Things don’t work. The person getting treatment doesn’t respond in the way that was expected. The person doesn’t look like what the clinician usually sees. The evidence doesn’t fit with practice. All the things! So I thought today I’d write about emotions and thoughts that might turn up – and what might underlie those feelings. (For people living with pain – we also have frustration in the clinic. Things don’t work out. The therapist isn’t what we expected. I’ll write more about this soon!)

Emotions are a complex reaction pattern, involving experiential, behavioral and physiological elements (https://dictionary.apa.org/emotion). From a cognitive behavioural perspective, an event happens, we appraise it (judge it), and we experience an emotion – then we do something as a response. It’s much more complex than this, and each part interacts with the others – so we end up with a big diagram looking something like this: (from – https://www.researchgate.net/figure/Cognitive-behavioral-therapy-model-of-depression_fig1_338695579).

Instead of “depressive”, just put in “beliefs/expectations about who I am and what I can expect from myself”. This is a pretty generic model in CBT, and is well-established even if there are plenty of arguments about accuracy and adequacy!

Clinicians generally want to help. Yes, some are in it for fame or fortune (choose something else, kthx), but on the whole people enter a clinical profession because they think they can do some good, and people will “get better.” Our communities hold long-standing expectations about what seeing a health professional should entail: read Benedetti’s “The Patient’s Brain” for a much more detailed description of the historical and evolutionary basis for a therapeutic encounter.

Why does this matter? Because it sets the scene for how we think a therapeutic encounter should go.

Rules and assumptions about what “ought” to, or “should” happen often underlie emotions.

We’re happy when all the things line up and the patient does what we expect of patients while the clinician does things that work. When things don’t go to plan (ie our expectations are violated) that’s when we get some feelings, and they can be pretty big.

What do we expect from patients?

Despite moves towards person-centred care where patients are seen as people and clinicians offer options rather than dictate orders, our societies still hold expectations about the roles a patient and a clinician should play.

Patients are expected to seek help when they’re sick. They’re expected to be truthful about their symptoms, and tell clinicians everything that is relevant about their condition – AND about any other aspect of their health, even if it’s not immediately relevant to their current problem. Symptoms experienced by patients are expected to be what the clinician expects, and the disease a patient has should fit within “typical” parameters (usually based on males). Patients are also expected to follow instructions, not do things that go against instructions, and of course, to get better. Patients are meant to be grateful for their treatment, even if it’s disruptive, has unpleasant side effects, or isn’t 100% effective. Patients should do their best all the time.

As a corollary, clinicians have a huge number of expectations they take on (and are given!). Some of us have these explicitly handed to us during our training, while others find they’re an implicit set of assumptions that we adopt, perhaps in the guise of “being professional.”

What do we expect from clinicians?

Clinicians expect to be in control in the clinical encounter. We’re expected to know what to ask about, and from this, what to test for. We’re expected to have the answers, and be right. We’re also expected to be calm, caring and focused – even when our personal lives are topsy-turvy. We’re meant to know what the patient wants, and how to give that to them. We’re also expected to be up-to-date, do no harm, change our practice according to evidence (even when that evidence is contradictory, or just emerging), and to stay interested in our work even if we’ve been doing it for years.

We’re expected to know our scope of practice, but practice using a broad “whole person” framework even if we were never trained to do this. We think we should be compassionate and caring, even if we were selected for training on the basis of our academic prowess and not on emotional literacy. We must take on responsibility for outcomes, even though we’re not there to “make sure” the patient “does what they’re told” in their own time. We assume when we tell someone to do something, they’ll drop everything in their life to do it – because their health should matter most, and even when other things in their life matter more.

Clinicians can be expected to practice independently from the moment they qualify, and are either “right” or “wrong” and never shades of in between. Clinicians expect that if something goes wrong, and the person doesn’t get better, it’s either the person’s fault (they didn’t do what they should have done), or the clinician has done something wrong and made a wrong diagnosis, or chosen the wrong treatment (or the treatment was right but the intensity was wrong…. so just do it again). And clinicians shouldn’t ask for emotional help because that means they’re “too emotionally invested” or “not distanced enough.”

Expectations suck

We all have them. And the ones I’ve listed above, while not always present, often underpin the way we expect clinical encounters to go. Many of them are implicit, so we don’t even realise we hold them – until BAM! Something goes wrong.

When expectations are violated, we feel emotions and some of these can be pretty strong. Many are less strong, just little niggles, little irritations, a bit of cynicism, some disappointment, some frustration. And they go both ways: people seeking help, and people trying to help. Over time, violated expectations feel like your head hitting against a brick wall, or swimming against the tide, or just plain demoralisation or even burnout.

Ways through them

Some of us have professionally-endorsed support systems to help us. Occupational therapists and psychologists have mandatory clinical supervision with someone who is there for you, who supports your development as a clinician, who challenges your assumptions, who pokes and prods at your reactions, who encourages taking a broader view. Individual clinicians in other professions may also pick up on using supervision in this way.

Some of us don’t have that kind of support. So we seek it elsewhere – I suppose, in part, I started writing this blog those years ago to “find my tribe.” Social media is one way we get affirmation, validation and even (sometimes!) great ideas to help us shift our approach.

Some clinicians leave their profession, do something else that’s more lucrative and less emotional effort. Some move out of practice and into academia. Some use “outside work” interests to blow off steam, or give emotional space.

Some of us are a little fused with the assumptions we hold. It’s hard to create a little space around those assumptions, because they’re held so tightly (or they’re so deeply buried). When we do get a tap on the shoulder suggesting our beliefs are out of whack it can feel so terribly humiliating, so inherently WRONG that we shut off, or bite back.

Creating “wiggle room”

Slowing down is a good way to begin creating some space to feel what is showing up when we’re feeling frustration. This could be by taking one or two minutes at the end of a session to be present. Yes, a little mindfulness to notice what is present in the body. To be OK with being aware of emotions, thoughts, and body sensations. NOT TO CHANGE THEM! To simply be with them. (An explanation here: https://www.youtube.com/watch?v=v9NkUomOO_w). This helps in many ways, but it does not (and isn’t intended to) reduce them. It helps you notice that you’re having feelings. It helps you pay attention to your own state of mind. It can create a moment to ask yourself “I wonder why I feel this way?” It can help you be more present with the next person you see because you’re not carrying those feelings into the next encounter.

Reflective practice is another way to create some space to be human, feel things, be curious about why they happen, and check in with your own values. A great resource that’s freely available is Positive Professional practice: a strength-based reflective practice teaching model – it might be a ‘teaching’ model, but clinicians teach All The Time!

Taking small steps, making small changes

The first step towards making a change is knowing that it’s needed. And the second is knowing that it’s possible. The third? Knowing what to do. I hope these suggestions help a little in this seldom-discussed aspect of practice. My own preference is to question WHY do we hold these expectations? WHO made them a thing? WHAT purpose do they serve? WHEN might those expectations be a good thing – and when might they not? WHERE can we nudge just a little to make change? And preferably, as clinicians, I think it’s OUR job to make the adjustments because we’re not ill or sore or seeking help.

Some references:

Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing Clinicians’ Well-Being and Patient-Centered Care Through Mindfulness. Journal of Continuing Education in Health Professions, 36(1), 11-16. https://doi.org/10.1097/CEH.0000000000000021

Huft, J. (2022). The History and Future of the Sociology of Therapy: a Review and a Research Agenda. The American Sociologist, 53(3), 437-464. https://doi.org/10.1007/s12108-022-09534-3

McGarry, J., Aubeeluck, A., & De Oliveira, D. (2019). Evaluation of an evidence-based model of safeguarding clinical supervision within one healthcare organization in the United Kingdom. International Journal of Evidence-Based Healthcare, 17 Suppl 1, S29-S31. https://doi.org/10.1097/XEB.0000000000000180

Spencer, K. L. (2018). Transforming Patient Compliance Research in an Era of Biomedicalization. Journal of Health and Social Behavior, 59(2), 170-184. https://doi.org/10.1177/0022146518756860

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