Clinical reasoning

Pain science is not a thing


Today’s post is occasioned by reading several discussions on various forums where the term “pain science” and various adjectives to describe this kind of practice. For those who don’t want to read the rest of my ramblings: no, it’s not a thing, science is an approach to understanding phenomena, and I would have thought all health professionals would use a science-based approach to treatment.

I went on to Google, as you do, to find out when this term began its rise in popularity. Google wasn’t particularly helpful but did show that it’s been around since 2004 at least, and seems to have been centred around the US, UK and Australia in roughly May 2004. I can’t grab data from earlier than this, sadly, but I think it’s interesting to take a look at the popularity peaks and troughs…

So, what does “pain science” mean to commentators? I haven’t delved in too deeply to the social media use of the term, but given I’m a social animal and have written my blog since 2007 (which is mainly on “pain science”) I’ve encountered it many times. It seems to be related to using a neurobiological explanation for pain as an experience (referring to the phenomenon and the underlying biological processes involved) rather than focusing purely on biomechanics or tissue damage/nociception as the key force. And it does seem to tie in with the emergence of “Explain pain” as one way of helping people reconceptualise their experience as something they can influence rather than something other people need to “fix”.

Commentators who aren’t in love with the “explain pain” thing have said things like “the pain science camp” or as one person put it “There’s your manual PTs, your pain science PTs, and your just load it PTs etc”

I went on to Twitter and the hashtag #painscience was paired with #BPSModel and #PT and #physicaltherapy (or variations), #chronicpain #exercise #lowbackpain – and so on.

So what do I think pain science means if it’s not a neurobiological approach to pain management? Well – pain science is a lot like cardio-respiratory science, and neurological science, and psychological science – it’s about applying a scientific approach to understanding pain. Science has been defined as “the intellectual and practical activity encompassing the systematic study of the structure and behaviour of the physical and natural world through observation and experiment.” In this instance, Google is your friend. So science is about systematically studying phenomena through observation and experimenting. If we apply this to pain – it’s the systematic study of structure and behaviour of the phenomenon we call ‘pain’ through observation and experiment. For what it’s worth, scientific study of pain has been going on since… oh at least Descartes, but probably much earlier given that pain is a ubiquitous and essential part of human experience.

To me, understanding pain involves multiple disciplines: yes to biology, and especially neurobiology because the experience (as we understand it now) involves neurobiological processing. But it’s also about psychology
the scientific study of the human mind and its functions, especially those affecting behaviour in a given context; sociology – the study of the development, structure, and functioning of human society; the humanities – the study of how people process and document the human experience; politics – the activities associated with the governance of a country or area, especially the debate between parties having power; and Anthropology –  the study of humans and human behavior and societies in the past and present. Social anthropology and cultural anthropology study the norms and values of societies. Linguistic anthropology studies how language affects social life.

So to describe an entire approach to understanding a phenomenon as if it’s a “movement” or “camp” or “dogma” or even “tribe” suggests serious  misunderstanding of both science and of an intervention.

What is “explain pain” then, or pain neurobiology education? – it’s an explanation of some of the biological elements of our nociceptive system as they combine to produce the experience we know as pain. For some people it’s the first time anyone took the trouble to explain why the pain of a papercut feels so bad compared with, for example, the pain of a sprained ankle; and why they still experience pain despite having no “damage” as visible on imaging. It’s an attempt to give people a frame of reference from which to understand their own journey towards recovering from a painful injury/disease/problem. In itself it’s not new: explanations for pain have been used in pain management programmes since the 1970’s (and earlier, if we consider that Fordyce used explanations in his behavioural approaches to pain management), and have routinely drawn on current pain research to help provide explanations that make sense to both the person and the clinician. The distinction between earlier explanations which drew heavily on the gate control theory, and this latest iteration is that the explanations are more complex, pain is considered to be an “output” that emerges from multiple interactions between brain and body, and that’s about it. Oh and it’s been picked up and enthusiastically used by physiotherapists (and other primarily body therapists) around the world.

What’s the evidence for this approach? Well, IMHO it’s not intended to be a stand-alone “treatment” for most people experiencing pain. I see giving an explanation as integral to usual practice, just as we do when we explain why it’s not a good idea to go running on a newly sprained ankle or why we’re suggesting a mindfulness to someone with a panic disorder. So far there have been a lot of studies examining variants of “explaining pain” alone or in combination with a number of other treatments including exercise. A recent systematic review and meta-analsyis of “pain neuroscience education” for chronic low back pain found eight papers (with 615 participants) showing that in the short-term, this kind of education reduces disability (by 2.28 points on the Roland-Morris Disability Questionnaire which is a 24 point scale) in the short-term and a slightly lesser effect in the long-term  (2.18). There were greater effects when this was combined with physiotherapy, though we often don’t know exactly what is included in “physiotherapy”.  There was some evidence that this kind of education helps reduce pain scores (by 1.32) but only in combination with other physiotherapy interventions. The authors pointed out that the strength of evidence for education on pain in the short term was low to moderate, but that it doesn’t have much of an impact on pain-related fear and avoidance, or on pain catastrophising (Wood & Hendrick, in press).

To compare this with another active treatment, exposure therapy for fear of movement/reinjury in chronic low back pain, de Jong, Vlaeyen, Onghena, Goossens, Geilen & Mulder (2005) performed a careful study of six individuals, using a single case experimental design. (If you’re not familiar with this approach to research – it’s extremely rigorous and useful in a clinical setting, this link takes you to a chapter discussing its use).  The aim was to establish which part of treatment “did the work” to change behaviour, but also measured pain intensity, and fear of pain and movement.  The treatments were information about pain and mechanisms, and the activities were those the person particularly wanted to be able to do. Their findings identified that explanations do little to pain intensity, avoidance or fear – but what actually worked was doing graded exposure. In other words, experiencing something different, DOING that something different in the real world, was more effective than talking about why someone shouldn’t be afraid. A much more recent replication of this study was conducted by Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski (2018) and shows the same result: doing trumps talking about doing.

When we sit down and take a cold hard look at what we do in pain management we can see that the field has to draw on a huge range of disciplines and fields of study to understand the problems people experiencing pain have. This is, in fact, why Bonica and colleagues first established the International Association for the Study of Pain, and why multidisciplinary (and now interprofessional) pain management teams and approaches were established. None of us can possibly hold all the knowledge needed to work effectively in the area. At the same time, as health professionals working with people, we do need to have some foundation knowledge about biology, disease, illness, psychology, sociology and anthropology. These areas of study inform us as we work hard to help people get their heads around their pain. Do we need to be experts in all of these fields? Yes – if you work completely in isolation. No – if you work within an extended team (whether co-located or otherwise). Pain research will continue to push our understanding ahead – and to be responsible health professionals, we must incorporate new understandings into our practice or we risk being unprofessional and irrelevant. I would go as far as to say we’re irresponsible and harming patients if we fail to incorporate what is known about pain as a multidimensional experience. It’s time to back away from temporary guruism and move towards a far more nuanced, and perhaps less flighty approach to understanding pain.

Pain science. No, it’s not a thing. Pain being examined through multiple scientific lenses: definitely a thing.

NB for the avoidance of doubt: pain is never a “thing” but examining pain through multiple scientific lenses involves many “things”. (Merriam-Webster – click)


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

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.

Wood, L., & Hendrick, P. A. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. European Journal of Pain, 0(0). doi:doi:10.1002/ejp.1314


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From the particular to the general – Clinical reasoning in the real world


From the particular to the general –
Clinical reasoning in the real world

I make no secret of my adherence to evidence-based healthcare. I think using research-based treatments, choosing from those known to be effective in a particular group of people in a specific context helps provide better healthcare. But I also recognise problems with this approach: people in clinical practice do not look like the “average” patient. That means using a cookie cutter, or algorithm as a way to reduce uncertainty in practice doesn’t, in my humble opinion, do much for the unique person in front of me.

I’ve been reading Trisha Greenhalgh’s recent paper “Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines”, where she describes her experience of receiving treatment based on the original description given for her “fall”. The “fall” was a high-impact cycle accident with subsequent limb fractures, and at age 55 years, she was offered a “falls prevention” treatment because she’d been considered “an older person with a fall”. Great guidelines practice – wrong application!

Greenhalgh goes on to say “we should avoid using evidence-based guidelines in the manner of the fabled drunkard who searched under the lamp post for his keys because that was where the light was – even though he knew he’d lost his key somewhere else”

Greenhalgh (2018), quoting Sir John Grimley Evans

When someone comes to see us in the clinic, our first step is to ask “what can I do for you?” or words to that effect. What we’re looking for is the person’s “presenting symptoms”, with some indication of the problem we’re dealing with. Depending on our clinical model, we may be looking for a diagnostic label “rheumatoid arthritis” or a problem “not sleeping until three hours after I go to bed”.

What we do next is crucial: We begin by asking more questions… but when we do, what questions do we ask?

Do we follow a linear pattern recognition path, where we hypothesise that “rheumatoid arthritis” is the problem and work to confirm our hypothesis?

Our questions might therefore be: “tell me about your hands, where do they hurt?” and we’ll be looking for bilateral swelling and perhaps fatigue and family history and any previous episodes.

Or do we expand the range of questions, and try to understand the path this person took to seek help: How did you decide to come and see me now? Why me? Why now?

Our questions might then be: “what do you think is going on? what’s bothering you so much?”

Different narratives for different purposes

Greenhalgh reminds us of Lonergan (a Canadian philosopher), as described by Engebretsen and colleagues (2015), where clinical enquiry is described as a complicated process (sure is!) of 4 overlapping, intertwined phases: (a) data collection – of self reported sensations, observations, otherwise known as “something is wrong and needs explaining”; (b) data interpreting “what might this mean?” by synthesising the data and working to recognise possible answers, or understanding; (c) weighing up alternative interpretations by judging; and (d) deciding what to do next, “what is the right thing to do”, or deliberation.

Engebretsen and colleagues emphasise the need to work from information from the individual to general models or diagnoses (I’d call this abductive reasoning), and argue that this process in the clinic should be “reflexive” and “informed by scientific evidence” but warn that scientific evidence can’t be replaced simply by reflexive approaches.

The reason for conceptualising clinical reasoning in this way is that a narrative primarily based on confirming a suspicion will likely reduce the number of options, narrow the range of options considered, and if it’s focused on diagnosis, may well over-ride the person’s main concern. A person may seek help, not because he or she wants a name or even treatment, but because of worries about work, the impact on family, or fears it could be something awful. And without directly addressing those main concerns, all the evidence-based treatments in the world will not help.

Guidelines and algorithms

Guidelines, as many people know, are an amalgamation of RCT’s and usually assembled by an esteemed group of experts in an attempt to reduce unintended consequences of following poorly reasoned treatment. They’re supposed to be used to guide treatment,  supporting clinical reasoning with options that, within a particular population, should optimise outcomes.

Algorithms are also assembled by experts and aim to provide a clinical decision-making process where, by following the decision tree, clinicians end up providing appropriate and effective treatment.

I suppose as a rather idiosyncratic and noncomformist individual, I’ve bitterly complained that algorithms fail to acknowledge the individual; they simplify the clinical reasoning process to the point where the clinician may not have to think critically about why they’re suggesting what they’re suggesting. At the same time I’ve been an advocate of guidelines – can I be this contrary?!

Here’s the thing: if we put guidelines in their rightful place, as a support or guide to help clinicians choose useful treatment options, they’re helpful. They’re not intended to be applied without first carefully assessing the person – listening to their story, following the four-step process of data collection, data interpretation, judging alternatives, and deciding on what to do.

Algorithms are also intended to support clinical decision-making, but not replace it! I think, however, that algorithms are more readily followed… it’s temptingly easy to go “yes” “no” and make a choice by following the algorithm rather than going back to the complex and messy business of obtaining, synthesising, judging and deciding.

Perhaps it’s time to replace the term “subjective” in our assessment process. Subjective has notions of “biased”, “emotional”, “irrational”; while objective implies “impartial”, “neutral”, “dispassionate”, “rational”. Perhaps if we replaced these terms with the more neutral terms “data collection” or “interview and clinical testing” we might treat what the person says as the specific – and only then move to the general to see if the general fits the specific, not the other way around.

 

Engebretsen, E., Vøllestad, N. K., Wahl, A. K., Robinson, H. S., & Heggen, K. (2015). Unpacking the process of interpretation in evidence‐based decision making. Journal of Evaluation in Clinical Practice, 21(3), 529-531.

Greenhalgh, T. (2018). Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines. Journal of Evaluation in Clinical Practice, 24(5), 1132-1138. doi:doi:10.1111/jep.12925

Myths about exposure therapy


Exposure therapy is an effective approach for pain-related anxiety, fear and avoidance, but exposure therapy is used less often than other evidence-based treatments, there is a great deal of confusion about graded exposure, and when it is used, it is not always well-conducted. It’s not a treatment to be used by every therapist – some of us need to challenge our own beliefs about pain, and whether it’s OK to go “into” the pain a little, or even slightly increase pain temporarily!

Below are some common misconceptions and suggestions for how to overcome them:

Misconception: Exposure therapy causes clients undue distress and has adverse consequences.

Suggestions: Although exposure therapy can lead to temporary increases in anxiety and pain, it is important to remember that these symptoms are not dangerous, and that exposure is generally carried out in a very gradual and predictable way. Exposure very rarely causes clients harm, but it is important to know your clients’ medical histories. For example, a client with a respiratory condition would not be asked to complete an exposure designed to elicit hyperventilation.

I usually begin with a really clear explanation for using this approach, basing my explanation on what the person has already said to me. By using Socratic or guided discovery, I try to understand the logic behind the person’s fear: what is it the person is most worried about? Often it’s not hurt or harm, it’s worrying that they won’t sleep, or they’ll have a flare-up that will last a looooong time – and they won’t be able to handle it. These are fundamental fears about having pain and vital to work through if the person is going to need to live with persistent pain for any length of time.

Once I’ve understood the person’s reasons for being bothered by the movements and pain, then I work on developing some coping strategies. These must be carefully carried out because it’s so easy to inadvertently coach people into using “safety behaviours” or “cues” that work to limit their contact with the full experience. Things like breath control, positive self-statements, any special ways of moving, or even ways of recovering after completing the task may serve to control or reduce contact with both anxiety and pain. I typically draw on mindfulness because it helps people focus on what IS happening, not what may have happened in the past – or may happen in the future. By really noticing what comes up before, during and after a graded exposure task, and being willing to experience them as they are, people can recognise that anticipating what might happen is often far worse than what does happen.

Finally, I’ll work through the scenario’s – either pictures of movements and activities, or descriptions of the same things. I prefer photographs (based on the Photographs of Daily Activity), because these elicit all the contextual details such as the other people, weather, flooring or surface and so on that are often factors increasing a person’s concerns. We begin with the activity that least bothers the person and consistently work up from there, with practice in the real world between sessions. I’ll go out to the places the person is most concerned about, we’ll do it together at first, then the person can carry on by themselves afterwards.

Misconception: Exposure therapy undermines the therapeutic relationship and leads to high dropout.

Suggestions: If you give your person a clear reason for using this approach and deliver it well,  the person is more likely to achieve success – and this in turn strengthens your relationship. Additionally, there is evidence that dropout rates for exposure are comparable to other treatments.

There is something about achieving a difficult thing that bonds us humans, and if you approach graded exposure with compassion, curiosity, and celebration, you may find your relationship is far more rewarding and deeper than if you simply prescribe the same old same old.

Misconception: Exposure therapy can lead to lawsuits against therapists.

Suggestions: Survey data suggest that lawsuits against therapists using exposure are extremely rare. As with any kind of therapy, you can take several steps to protect yourself from a legal standpoint. Don’t forget to obtain informed consent, ensure your treatment is delivered with competency, professionalism, and ethical consideration.

The best book/resource by far for graded exposure is Pain-Related Fear: Exposure-Based Treatment for Chronic Pain, (click) by Johan W.S. Vlaeyen, Stephen J. Morley, Steven J. Linton, Katja Boersma, and Jeroen de Jong.

Before you begin carrying out this kind of treatment, check you have these skills (from the book I’ve referenced):

Vlaeyen, Johan, Morley, Stephen, Linton, Steven, Boersma, Katja, & de Jong, Jeroen. (2012a). Pain-related Fear. Seattle: IASP Press.

What it means to be a therapist


I wrote the following response to a discussion held recently on a Facebook group Exploring Pain Science – about the term “catastrophising”. It’s a term that elicits great anger and frustration from people living with persistent pain, and I see the term used poorly by clinicians as a judgement about another’s experience. There’s certainly plenty of research showing relationships between high levels of “thinking the worst” about pain, and poorer outcomes – but HOW we as clinicians respond to someone in distress may be more of a problem than the act of a person describing their fears and worries about the future. This is what I wrote:

I’ve been pondering – I think I see people as doing the absolute best they can to make the best decisions they can based on what they know at the time. And “knowing” means all the messy uncertainty, lack of logic, emotion and coercion from others! So whatever a person is doing to manage is the best they can do. All I can do is offer some options that I’ve seen other people use, maybe provide some more information, maybe even more accurate information, support people to be guided by what they see as important (usually values), and be there for them as they make their own minds up about what to do next. I’m a cheerleader, encyclopaedia, visualiser (lay out the options in a way that makes sense), perhaps a guide but only in so far as helping people notice things they hadn’t before.

To me, if someone is thinking the worst, it could be that they don’t have all the information about their resilience that they need, it might be misinformation about what’s happening in their body, it could be conclusions that over-estimate the threat and under-estimate resilience. It might also be difficulty pulling the mind away from sticky thoughts that stop clear thinking, or as one researcher called it “misdirected problem solving” – a way for the mind to remind the person that there’s an unresolved situation. It might also be feelings of helplessness, feeling like there is no point in trying anything new because nothing works anyway, a sense of not having enough energy to keep trying…

Those aren’t necessarily inaccurate thoughts, but they’re certainly not helpful thoughts, especially at 3.00am! So temporarily at least it seems helpful to bear witness to that person’s distress, to make room to be present, not to judge or dismiss but to allow those worst fears to be recognised. Sometimes bringing the worst fears out into the light shows that they can be managed better than expected, sometimes they fade into nothing, and sometimes they allow someone else to be there and support when the person’s run out of puff.

While I can understand how the language of uninvolved clinicians hurts because so often they fail to acknowledge the real distress of the person, I can still recognise that many of the contents of thoughts and beliefs won’t happen, – those scenarios are there wanting recognition, but they may not happen. If they do there will be things to do then – but mostly, when I catastrophise, I use it as energy to recognise how lacking I feel. And that’s not a nice place to be, but it’s simultaneously true (I lack) and untrue (others have what I need).

There’s a process I use for myself called creative catastrophising. I write down my worst fears, get them out on paper, make them visible. Sometimes that’s all I need to do. Other times I begin planning “what if X disaster happened, what would I do” – and when I’m in the right frame of mind, I can figure out a way to get by. I can’t tell anyone else to do that – but it’s a strategy that’s stood me in good stead as I’ve gone through the ups and downs of my life. It’s one way I cope.

Clinicians, if you can bear witness to another’s distress, without wanting to change, fix, judge or DO anything apart from being fully present, you’ll be doing the very best thing you can. The time for doing something “to help” is just around the corner – whatever you do, do NOT tell the person “you’re catastrophising” because this immediately means you’ve moved from being with to judging.

Each time we face our fear, we gain strength, courage, and confidence in the doing – Theodore Roosevelt


I’m not certain Theodore Roosevelt actually said that – but who cares?! It’s a great statement. For the person living with persistent pain, though, it can be the last thing you want to hear. After all, it’s tough enough getting up and just doing the normal things let alone challenge yourself! So… how can a health professional help?

Let’s briefly recap. Self efficacy is the confidence I can do something successfully if I wanted to. It’s a robust predictor of many health behaviours including exercise, stopping smoking, eating healthily and coping well with persistent pain (Jackson, Wang, Wang & Fan, 2014; Williams & Rhodes, 2016). It was first introduced as a concept by Bandura as part of his theoretical model of behaviour change, and further discussed in an experimental study in a paper investigating systematic desensitisation processes, arguing that this approach to treatment created and strengthened expectations of personal efficacy (Bandura & Adams, 1977). Bandura argued that people develop a sense (expectation) of self efficacy from their own performance, watching others succeed, being persuaded by someone that yes indeed you have the skills to achieve, and also awareness of physiological arousal from which people can judge their own level of anxiety.

Self efficacy is more than a simple “general confidence” construct, however. It’s far more selective than this. For example, although I believe I can successfully dance in my lounge with no-one there and the curtains closed, this does not translate to me dancing on a stage on my own in the spotlights with an audience watching! Self efficacy refers to confidence to succeed and produce the outcome I desire in a given context – and that’s extremely important for pain management, and in particular, exercise for people experiencing pain.

How does self efficacy improve outcomes? There are at least two ways: (1) through the actions taken to manage or control pain (for example, gradually increasing activity levels but not doing too much) and (2) managing the situations associated with pain (for example, people with low self efficacy may avoid activities that increase pain, or cope by using more medication (Jackson, Wang, Wang & Fan, 2014).

To examine how self efficacy affects outcomes, Jackson and colleagues (2014) conducted a meta-analysis of papers examining this variable along with other important outcomes. Overall effect sizes for relationships between self efficacy and all chronic pain outcomes were medium and highly significant. This is really important stuff – we don’t find all that many studies where a single variable has this much predictive power!

As a moderator, the adjusted overall effect size (r=.50) of self efficacy and impairment was larger than the average effect sizes of meta-analyses on relations between disability and fear-avoidance beliefs, and pain as a threat for future damage and challenge for future opportunities. Self efficacy has stronger links with impairment than cognitive factors such as fear-avoidance beliefs and primary appraisals of pain (Jackson, Wang, Wang & Fan, 2014).  Age and duration of pain were the strongest moderators of these associations and suggest that reduced self-efficacy can become entrenched over time. In other words – as time passes, people experience fewer opportunities for success and begin to expect they won’t ever manage their pain well.

An important point is made by these authors: how we measure self efficacy matters. They found that self efficacy measures tapping “confidence in the capacity to function despite pain” had
stronger associations with impairment than did those assessing confidence in controlling pain or managing other symptoms.

Bolstering self efficacy – not just about telling people they can do it!

Given that self efficacy is domain-specific, or a construct that refers to confidence to do actions that lead to success in specified situations, here are a few of my questions:

  • Why are most people attending pain management programmes provided with gym-based programmes that don’t look at lot like the kinds of things people have to do in daily life? It’s like there’s an expectation that “doing exercise” – any exercise – is enough to improve a person’s capabilities.

    BUT while this might increase my confidence to (a) do exercise and (b) do it in a gym – but does it mean I’ll be more confident to return to work? Or do my housework?

  • How often are people attending gyms told to “push on”, or to “stop if it hurts”? And what effect does this have on people?

If their confidence is low, being told “just do it” is NOT likely to work. People need to experience that it’s possible to do things despite pain – and I think, to be able to handle a flare-up successfully. Now this is not going to happen if we adopt the line that getting rid of all pain is the aim, and that flare-ups should be avoided. If we want people to deal successfully with the inevitable flare-ups that occur, especially with low back pain, then we need to (a) be gentle, and grade the activities in an appropriate way (b) have some “ways of coping” we can introduce to people rather than simply telling them they can cope or reducing the demands (c) have other people around them also coping well (and that includes us health professionals)

  • Ensure we attribute change to the person, not to us.

That’s right: not to our sparkling personality, not to our special exercises, not to the machines we use, not to the techniques we have – you get the drift? Progress must be attributed to the person and his or her skills and perseverance. Because, seriously, all this arguing over which exercise regime is best doesn’t stack up when it’s actually self efficacy that predicts a good outcome.

And for case managers who may read this: just because someone has successfully completed an exercise programme, or a vocational programme with exercise as a component, this does not mean the person can manage successfully at work. Well, they may manage – but they may utterly lack confidence that they can. Context matters.

 

Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research, 1(4), 287-310.

Estlander AM, Takala EP, Viikari-Juntura E., (1998). Do psychological factors predict changes in musculoskeletal pain? A prospective, two-year follow-up study of a working population. Journal of Occupational and Environmental Medicine 40:445-453

Jackson, T., Wang, Y., Wang, Y., & Fan, H. (2014). Self-efficacy and chronic pain outcomes: A meta-analytic review. The Journal of Pain, 15(8), 800-814.

Williams, D. M., & Rhodes, R. E. (2016). The confounded self-efficacy construct: Conceptual analysis and recommendations for future research. Health Psychology Review, 10(2), 113-128.

The confidence that you’ll succeed if you try…


Self efficacy. It’s a word bandied about a lot in pain management, and for a group of clinicians in NZ, it’s been a shock to find out that – oh no! They’re not supporting self efficacy with their patients very much! It means “confidence that if I do this under these conditions, I’ll be successful”.

Self efficacy is part of Bandura’s social learning theory (click here for the Wikipedia entry) where he proposed that much of psychological treatment is driven by a common underlying mechanism: to create and strengthen expectations of personal effectiveness. Bandura recognised that we don’t always have to personally experiment through trial and error in order to learn. Self efficacy expectations were thought to develop from personal experience (let me do, and I’ll learn how); watching other people try (show me, and I’ll see if you succeed, then I’ll copy you); verbal persuasion that aims to convince that you have the capabilities to manage successfully (encourage me, let me know I can, and I’ll try); and how physiologically aroused or alert you are (if I feel confident inside, I’ll try but if I feel anxious or stressed I’m less inclined to) (Bandura, 1977).

Bandura and colleagues established that “different treatment approaches alter expectations of personal efficacy, and the more dependable the source of efficacy information, the greater are the changes in self-efficacy.” (Bandura & Adams, 1977, p. 288). The conclusions drawn from this mean that treatments where people DO and succeed are more effective at enhancing their belief in self efficacy, while watching others, or being told how to do something are far weaker at building this effect.

Bandura began working on this theory while pondering how psychological treatments, particularly for systematic desensitisation or graded exposure, generated their effects. Systematic desensitisation aimed to reduce arousal levels and thus avoidance while being in a relaxed state – therefore the person is exposed to increasingly “aversive” stimuli (stimuli you want to avoid) while remaining calm and relaxed. Bandura thought that there were other factors involved in avoidance behaviour, developing his theory that expectations of negative consequences alone can generate fear and defensive behaviour and that this isn’t necessarily reflected in autonomic arousal and actions. Bandura hypothesised that reducing physiological arousal improved performance not by eliminating a drive to escape – but instead by increasing the confidence that the person can successfully manage the situation.

For parents, the idea that if you believe you can do what you set out to do, is embodied in the little book “The Little Engine That Could” (Piper, 1930/1989). Remember? The little engine that couldn’t because all the bigger engines said so, but then tried and tried and believed he could – and he did!

So, what does this have to do with pain management?

Let’s paint a scenario. Allan comes to see a hands-on therapist because he has a sore back. He believes that hands-on therapy is the thing, because others have said it’s really good. He goes, gets his treatment and wow! Things improve! The next time he has a sore back (because, you know, it almost always comes back) what does he do? Well, on the basis of his past experience, he heads to his hands-on therapist, because he’s confident this will help his pain. The problem is, his therapist has moved town. He’s a bit stuck now because in his town there are not many therapists doing this particular kind of treatment – what does he do? He doesn’t believe that anyone else can help, and he has no belief that he can manage by himself. He has little self efficacy for managing his own back pain.

Self efficacy is not about whether a person can do certain movements, it’s about believing that the person can organise skills to achieve goals within a changing context – not just what I will do, under duress, but what I can do, what I’m capable of doing, and what I say I’ll probably do.

Self efficacy is not a belief that a specific behaviour will lead to a certain outcome in a certain situation, it’s the belief that I can perform that behaviour to produce the outcome.

So, self efficacy isn’t a generalised attitude – it’s a specific belief about certain actions, certain outcomes in certain situations. It’s not a personality trait like hardiness, or resilience, or general confidence or self-esteem, it’s about being confident that I can generate a solution to a problem in a particular part of my life.

The times when we’re least confident are often when we’re facing a new experience, or we’ve had a bad experience previously. Particularly if we’ve seen other people fail at the same thing, or succeed but do so with much fear and loathing. In the case of pain, there are ample opportunities to have a bad experience in the past, and to learn from other people around us that – oooh back pain is something to be afraid of, and you can’t manage it alone – you need to get help from someone else. Consequently, many people have very low self efficacy for successfully dealing with a bout of low back pain.

And health professionals: we can foster this.

How? By implying that success is due to what we do, rather than being a natural process of recovery. By suggesting it’s something about our “magic hands” or pills, or injections or surgery or special exercises, or “using the core correctly”. In doing so, we’re generating a belief that the person cannot manage alone. That it’s not what the person does, but the magic hands, pills, injections, surgery, special exercises or using the core…

Damush, Kroenke, Bair, Wu, Tu, Krebs and Poleshuck (2016) found that self management approaches to pain increase self efficacy, self management actions, and reduced pain intensity and depression in a group of community patients with chronic musculoskeletal pain and depression. A typically tough group to work with because confidence to succeed at anything is pretty low in depression. Self management aims to ensure the credit for recovery lies with the person doing things that help – creating and supporting a belief that the person has the capability to successfully manage their situation. The techniques? Simple strengthening and stretching exercises, progressive muscle relaxation, and visualisation, in a group setting. Strategies that typically don’t need technology, but do provide support. Information about the natural history of recovery was included – so people were given realistic and optimistic information about their recovery, whether it meant pain reduction, or not. The usual goal setting, problem-solving, and positive self talk were encouraged, and people set goals each week to achieve – maybe based on something from the session, or something the person wanted to do for themselves.

This is not a high-tech approach. This is simple, straightforward pain management as it has been done for years (right back as far as the mid-1970’s and Sternberg!). And through it, these people become increasingly confident that they could successfully manage their own mood and pain independently. As a business model it’s probably not the best for repeat business – but oh how good for those participants who could go away and live their lives without having to think of themselves as patients.

More on self efficacy in the next couple of weeks – we can help people to become confident that they can succeed at managing their pain if it should happen again.

 

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review,  84, 191-215.

Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research, 1(4), 287-310.

Damush, T., Kroenke, K., Bair, M., Wu, J., Tu, W., Krebs, E., & Poleshuck, E. (2016). Pain self‐management training increases self‐efficacy, self‐management behaviours and pain and depression outcomes. European Journal of Pain, 20(7), 1070-1078.

Maddux, J. E. (2016). Self-efficacy Interpersonal and intrapersonal expectancies (pp. 55-60): Routledge.

Managing sleep problems – a medication-free approach (iv)


The fourth step in learning to sleep well within an ACT framework, is build. My previous posts were: Discover and Accept and Welcome.

In build, we’re beginning to build new practices. This is about learning how much sleep you need, and when you need to head to bed and wake up again.

I know when I had trouble sleeping at night (I refused to call it insomnia, but it most definitely was!), I thought I’d tried everything to help. I had used all the sleep hygiene strategies like no devices in bed, no TV in bed, do some relaxation as I lay down, have a regular bed-time and wake-up time – and one of the things I tried to do was eliminate coffee after lunchtime. While most of the time coffee isn’t a problem for me, I learned that when I was vulnerable to not sleeping, coffee and similar substances (including chocolate and alcohol) were not good for me. And today I still don’t drink coffee after lunch and limit myself to three or so cups a day.

So… what’s different about ACT and this stage of learning to sleep again?

Well, people with pain often talk about being interrupted by their pain – of waking up in the middle of the night because of pain and then not being able to get back to sleep. While there is some truth to the idea that we wake because of pain, in fact we all wake up over the course of a night. You’ll know the typical “sleep architecture” (click here for a nice explanation) where we fall into a deep stage of sleep fairly soon after heading to bed, and that we have periods of REM or rapid eye movement sleep (dreaming sleep) at regular intervals over the night. What you may not be as aware of is that in the periods just before and just after REM sleep, we’re actually awake. Not very awake – but awake enough to roll over and get comfy again. If your bladder does what mine does, I usually have a quick trip to the loo around 2.30ish, and go right back to sleep again.

When you have pain, chances are greater than you are more aware of those lighter periods of sleep and, like I do with my bladder, notice that you are awake. If you then start noticing your pain… or your worries… or your mind starts dropping comments to you, then it’s possible you’ll stay awake. Partly this is because the biological drive to fall into a deep sleep at the beginning of the night has been partly satisfied. Partly also because experiences like pain are very salient or important. So are noises (the cry of a baby, that tapping sound on the window, the car roaring down the road) and during the lighter periods of sleep we’re more likely to wake fully rather than just roll over. We’re not actually waking more often as much as waking more fully, and perhaps for longer than normal.

Building new patterns means some basic “rules” – but rules that are held lightly. In other words, it’s fine to change things up a little from time to time (after all, birthdays, travel, having a cold, or getting a puppy are all things that can disrupt sleep), but broadly these things seem to be habits of good sleepers:

  1. Heading to bed around the same time-ish each night (or within 20 – 30 minutes of this time). Same applies to waking up – and to help you wake, an alarm clock (I do use my phone for this), and in winter, I use a bright SAD light, and bump up the temperature on my electric blanket. Light and warmth both tend to make you wake up a bit more quickly, so it’s helpful for me during winter when I have seasonal affective disorder (winter depression).
  2. Knowing that it’s normal to take around 10 – 15 minutes to fall asleep, and being OK with this.
  3. Changing how long you sleep for will take a few weeks – it’s a habit! So don’t go changing your bedtime or wakeup time too often. If you’re using sleep restriction (going to bed a little later than normal, perhaps getting up a little earlier) you can return to a more “normal” length as part of fine-tuning how long you need to sleep for your needs. But, don’t change things too often!
  4. If you have a late night out (or if you’re travelling over a time zone or two), try to get up at your usual time. Yes, this means keeping the same wake time over the weekends as the week days!
  5. Develop a kind of “wind down” habit – but again, hold this lightly because sometimes there are enjoyable events on late, or you have people visiting, that may mean you’re a little more alert than normal. But on the whole, basically spend around 30 – 45 minutes giving your mind signals that you’re heading to bed. This means cleaning your teeth, checking the doors, stopping watching TV or going on devices, maybe get into your jimjams (PJs!) and heading to bed with a book or magazine.
  6. When you’re in bed, just quietly lying there, letting thoughts wander in and out without getting caught up in the content, and you’ll notice yourself quietly falling asleep. This is totally normal. If you do get caught up in your mind chatter, as soon as you notice you are gently bring your attention to your breathing and the sensations of lying in bed, and this should (at this point in your journey) help you fall asleep.

You can see it’s not too different from what I hope you’ve been practicing all along – just that instead of fighting with those thoughts, or getting all tangled up in them, you’ve got skills to let them go, and just be there in the darkness, resting.

There are a lot of specific issues you may also encounter – things like your partner who snores like a chainsaw, or twitches all night long (I’m the guilty party here!); or when you have a cold or a stuffy nose – the former might take a little longer to deal with, but the latter is usually just for a week or so and I tend to be happy using decongestants just for those few nights when I cannot breathe…. As for the partner noise or twitching, like dealing with your thoughts this is probably about you dealing with your thoughts about the noise or twitching! Again, try welcoming or being willing to listen to or feel those habits. Making some room for them rather than getting caught up in thoughts of smothering him or her! And go back to your usual mindfulness practice.

Finally – the last step is living! We tend to put life on hold when we try to control rotten sleep patterns.  Now it’s time to know that while sleeping badly can come again from time to time, you have skills to roll with it – you know you can manage if you avoid fighting with it or trying to control it. Take those steps to build your new sleep habit, and go out there and DO again!

 

Managing sleep problems – a medication-free approach (iii)


More on sleeping the ACT way. Step one was discover – all the things you’re doing to help yourself sleep, but in your attempts to control the uncontrollable (thoughts, feelings, memories, worries, sensations, the environment and so on). And hopefully you’ve seen that these things can be counter-productive. That flash new pillow and bed is pretty useless if you travel somewhere. The pills need to be stopped at some point – and then you have to withdraw from them. And the thoughts, and sensations (including pain) just carry right on there not matter what you do.

So step two is to accept: accept what you can control, and what you can’t. Radically, this means changing some of the things you do to get to sleep – like pills (but get medical help for this process), doing relaxation, wearing your eyeshades and earplugs, getting up and doing things when you can’t sleep. It usually means a bit of mind chatter!

The common mind chatter is “I’ll fail”; “I know I won’t sleep and then I’ll be useless the next day”; “if I can’t sleep with my pills and earplugs, how will I sleep without them?”; “I’ll feel lousy the next day”; “I’ve slept this badly my entire life, it’s too late for me”; “why me? It’s a punishment”; “but I’ve got [a new job, a baby, a puppy, going on holiday]”; “I’m too tired”

It’s likely, as you begin doing this, you’ll be in bed wide awake – and it’s at this point you can choose. In that moment, you can decide to listen to your mind – or think of your mind as holding an opinion, but one you do not have to follow. In ACT language, what you’re doing here is learning to accept, or be willing to sit with (lie with), to make room for not sleeping rather than struggling to control it. You can’t control your risk factors, you can’t control that you’ve learned to be awake at this time. You can’t control your thoughts about this – but you can lie there and just notice the things your mind is dumping on your doorstep. This isn’t “giving up” – this is radical willingness to come alongside and be with your own sleeplessness.

The best way to learn to do this is – you guessed it, mindfulness.

Now mindfulness is NOT about getting you to fall asleep. You may fall asleep or feel drowsy which is cool, but if you try to use mindfulness “to fall asleep” you’re again trying to control the problem and mindfulness can then become an empty process. You ARE allowed to let your mind wander… just gently bring it back to where you want it to be. Practicing mindfulness can be done anywhere and everywhere – for a few short seconds while cleaning your teeth, sitting in the car, walking through a door – or longer, like at the end of the day, or in the morning.

Some ways to be mindful: notice your senses by bringing your mind to sounds, sights, smells, tastes, touch. Just list all the things you experience – like “a bird chirp”, “the weight of my legs on the seat”, “the smell of coffee”…and as your mind wanders off, as it will, bring it back gently to what you want to focus on.

Another one to try: close your eyes for a few seconds and notice any thoughts or images that pop into your mind. List it – thought, image, work worry, dinner planning.

This skill is one of the most important and useful skills when you’re learning to sleep again. When you lie in bed wide awake, it’s easy to get caught up in the content of what your mind is bringing to  you, rather than just noticing that you are thinking. The problem is, thoughts your mind brings often lead to that heart thump and dry mouth that keeps you wide awake! Instead, directing your focus on to your breathing, or your body contact on the bed, are simple things that help you just notice and be in the present.

If you have pain, mindfulness is one way of letting you experience the ache without that “Oh no, it’s really bad tonight” judgements of that ache. Gently letting yourself notice where you’re sore – and equally, where you’re not sore – and guiding your mind around your body, noticing every part, the painful and the non-painful – allows you to be present with your pain, without fighting against it. Practicing this skill many times during the day really helps you develop this skill. And don’t be surprised if your mind starts trying to either judge or solve the problem of pain, because that is simply the mind doing what it’s done since forever. Be kind to your mind, and bring your attention back to your breath, or your left earlobe, or your belly button, or your little toe…

At night, in bed, mindfulness is not about helping you relax and fall asleep. What it’s there for is to help you guide your mind away from being caught up in the content of your thoughts or feelings or sensations, and back onto just noticing that you are thinking, and bringing your attention onto something like your breath. It can be scary doing this at night because we often want to get out of bed or control what we’re thinking and force ourselves into sleep. And you know it doesn’t work! What mindfulness does is let your brain and mind know that being awake isn’t a threat – remember the flight, fright, freeze response? By letting your mind know you’re not buying into the horror stories, and instead you’re being OK with simply lying there noticing, you’re teaching your mind to let go of the struggle.

  • Start with feeling the sensation of the bed against your body, from the toes to the head. When your mind begins “minding”, bring your attention to your breath. If you get the urge to move or get up (actually, your mind brings the urge), notice it and choose to stay in bed, and bring your attention back to your breath or touch.

Welcome: You’ll find your mind will have a good go at dumping scary thoughts on you when you decide to be present and stay. Remember it’s your mind’s opinions – and be gentle with your thoughts, feelings and yourself. Stay with it, notice your breathing, make room to feel a bit tired (because you were going to be tired anyway, right?!), and be kind, but firm, with your mind, and bring your attention to your breath yet again. You’re resting your body while you’re lying down, and that’s a good thing.

If you find you have a frequent flyer – a thought or worry or sensation that comes visiting when you’re trying to sleep  – you can simply name it “Hi worry”, or “thinking”, or “here you are scared”, or “back again, pain”. Welcoming the thoughts or feelings may feel odd –  but once you’ve noticed it, labelled it, and then welcomed it, go back to your breathing or noticing your body. You can become quite creative with this process – if you have a vivid imagination for visual images, try projecting your thoughts onto a movie screen, or turning them into cartoon letters, or characters from a movie (my pain is a grumpy witch!), or a ball of string all tangled up, or a scrunched towel.  Some people have taken to imagining their thoughts as different voices – squeaky “I’m scared” or deep “I’ll never sleep tonight” – these strategies are ways to help you step back from the content of what your mind is telling you, and see your thoughts as simply thoughts made by your mind.

Click to the next post

Managing sleep problems – a medication-free approach (i)


I’ve recently completed two posts on assessing sleep problems in people experiencing persistent pain, and today I turn my attention to strategies for managing sleep problems – without medication. Why without medication? Because to date there are no medications for insomnia that don’t require a ‘weaning off’ period, during which time people often find their original sleep problems emerge once again… I’m not completely against medications for sleep or pain – but I think they need to be used with care and full disclosure about the effects, side-effects, and the need to eventually withdraw from them.

The approach I’m advocating is a modified form of cognitive behavioural therapy for insomnia (CBTi). CBTi is a form of treatment that is now considered to be first line therapy by both the British Association for Psychopharmacology (Wilson, Nutt, Alford, Argyropoulos, Baldwin, Bateson et al, 2010), and the American College of Physicians (Qaseem, Kansagara, Forciea, Cooke, Denberg et al, 2016). It includes sleep hygiene, cognitive therapy for the thoughts and beliefs associated with sleep, and sleep restriction for those who clinically need it. The modified version I advocate is based on Dr Guy Meadows ACT-based approach and I’ll cover that next week, but I’ll describe the classical CBT approach first.

Basic principles

The basic idea behind a CBT approach to insomnia is that although the initiating event may be out of our control, it’s unlikely to be maintaining the problem – and the factors maintaining the problem are typically the habits people have, and the thoughts and beliefs about their sleep problem.

Sleep is a behaviour that is infinitely malleable, as anyone who has travelled far enough on long-haul flights will know (and parents of small babies as well!). There are cues we use to decide when we should head to bed, and how long we should stay asleep. Bodies in turn respond to these cues and modify automatic processes such as digestion, urine production, and body temperature to ensure we stay asleep for as long as needed. When those cues change – for example, we’re in a new time zone when it’s light at the “wrong” time, and we’re hungry at the “wrong” time, we have trouble staying asleep until the body adjusts. Some people say we can manage a two-hour time zone shift every 24 hours, but in some sensitive people even a one-hour daylight savings change can upset the apple-cart!

If sleep is a habitual behaviour, then we can manipulate the cues to our benefit when sleep is elusive. We learn to associate things like the routine we follow prior to going to bed, light in the room, the “winding down” process we use, and even the timing of our snacks and drinks as a way to signal to the body/mind that we’re sleepy/tired.

There are three basic steps in CBTi: stimulus control (aka sleep hygiene), cognitive therapy, and sleep restriction – with the usual relapse prevention steps an essential part as well.

Sleep hygiene (stimulus control)

The basis of sleep hygiene is to control the stimuli associated with going to sleep so that we clearly indicate to the body/mind that it’s time to get to sleep. That means some basic “rules” around what we do in the time preceding getting into bed, and what we do when in bed trying to sleep.

The golden rule is that the bed is for sleep and sex – not for worrying in, not for watching TV or using the computer or phone or tablet, not for arguing in, not for talking on the phone. If you’re awake in bed for longer than 20 minutes, it’s time to get out of bed until you’re sleepy/tired (more on this in a moment), keeping the lights down low, doing something tedious or boring, then returning to bed to actually sleep.

Simple, commonsense things like keeping the room dark and warm, blocking out the worst of the noise, NOT using a TV or radio or any other noise-making device to go to sleep, ensuring caffeine intake is limited, having a regular bedtime and wake-up time, not taking naps through the day and timing when exercise and relaxation are undertaken are all part of sleep hygiene and most of us are aware of these steps. If they’re not familiar to you, this site is a good one – click.

Cognitive therapy

The cognitive therapy part is about managing the thoughts and attitudes that can exacerbate the sleep problem – things like having a busy mind, worrying about not being able to sleep, believing that it’s crucial to have a certain number of hours of sleep or the next day will be awful, getting that sinking dread as bedtime approaches, following any number of almost (and sometimes actual) obsessive rituals to achieve sleep – and so on…

As usual, with any conventional CBT, dealing with these thoughts involves firstly reality testing – Is it true that you must have a certain number of hours of sleep or the next day will inevitably be terrible? Must the room be absolutely silent or sleep will elude you? Then challenging or disputing those thoughts – “It’s possible I’ll feel tired tomorrow, but I can still function even if I’m not at my best”, “It might take me longer to fall asleep but I’ll get to sleep even though I can hear a clock ticking”.

These simple approaches are reasonably easy to implement – and they are effective. But if sleep is still a problem, and the person isn’t getting more than 4 hours sleep a night, it’s time to bring in the big guns.

Sleep restriction

There are two parts of altering sleep habits that are particularly challenging: getting out of bed after 20 minutes of being awake (especially in the wee hours of the morning!); and using sleep restriction. Neither are easy, yet both are effective.

The idea behind sleep restriction is to reduce the amount of time being in bed while not actually being asleep. Simple huh? So that period from when you first hop into bed and until you actually fall asleep is called sleep latency – and the longer your sleep latency, the less sleep you actually get. You become inefficient at sleeping, and worst, your body/mind learns that it’s OK to be in bed wide awake, and as I mentioned earlier, people begin to associate even going into the bedroom as a negative thing which revs up the autonomic nervous system making it even more difficult to fall asleep.

The nuts and bolts are to work out what time you actually fall asleep, and only go to bed at that time. So if you stay awake until 2.00 or 3.00am, you only go to bed at 2.00am. And you keep your morning wake-up time the same as normal. Yes, this means you end up being only able to sleep for the time between 2.00am and 7.00am! Ouch!

The idea is to extinguish the “habit” of being awake while in bed, reducing the association between being in bed and wide awake, while getting you absolutely tired and sleepy that you fall asleep into a deep sleep quickly. Once this falling asleep part happens regularly (usually for a week or so) then it’s possible to begin a very gradual process of bringing the bedtime back to a more reasonable hour – I usually suggest 15 minute increments, returning to the previous step if falling asleep begins to be difficult.

The process is reasonably difficult – not because it’s hard to stay awake (after all, the person has been practicing it for some time!) but because of the mind chatter. It’s truly tough when your mind starts having a go at you, suggesting you can’t sleep, or you’ll be so incredibly tired you won’t cope, or you’ll be cranky and that it’s dangerous and how on earth  will you go at work without any sleep? And this is where having access to a really good clinician can be helpful, although there are apps that provide a pretty good alternative if a human isn’t available.

For a detailed examination of the literature on sleep restriction therapy, Kyle, Aquino, Miller, Henry, Crawford, Espie & Spielman (2015) provide a really good systematic analysis of how sleep restriction is employed in research trials.  For a plain language version of CBTi, this is a good description – click

As I mentioned above, I’ll be going through a slightly different version of CBTi – an Acceptance and Commitment Therapy approach to insomnia that is also gaining popularity and an evidence base. Come right on back next week for that exciting episode!

 

Kyle, S. D., Aquino, M. R. J., Miller, C. B., Henry, A. L., Crawford, M. R., Espie, C. A., & Spielman, A. J. (2015). Towards standardisation and improved understanding of sleep restriction therapy for insomnia disorder: A systematic examination of cbt-i trial content. Sleep Medicine Reviews, 23, 83-88.

Manber, R., Simpson, N. S., & Bootzin, R. R. (2015). A step towards stepped care: Delivery of cbt-i with reduced clinician time. Sleep Medicine Reviews, 19, 3-5.

Qaseem, A., Kansagara, D., Forciea, M., Cooke, M., Denberg, T. D., & for the Clinical Guidelines Committee of the American College of, P. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine, 165(2), 125-133. doi:10.7326/M15-2175

Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., . . . Wade, A. (2010). British association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. Journal of Psychopharmacology, 24(11), 1577-1601. doi:10.1177/0269881110379307

Assessing problems with sleep and pain – ii


Last week I wrote about my approach to assessing sleep problems in those with persistent pain. As an ex-insomniac I’ve spent a while learning about sleep so I can understand what’s going on, and why sleep can be such a problem. In this week’s post I want to dig a little deeper into what’s going on with poor sleep, as well as some of the unique features of sleep in people experiencing persistent pain.

Having reviewed the five main areas that are fundamental (and can/should be assessed by anyone working with people who experience persistent pain), the next area I want to look at with people is mood. There are two primary psychopathological contributors to poor sleep: the first we’ve dealt with last week (Question 4 – what’s going through your mind…) which is by far and away the most common initiator and maintainer of insomnia, and it doesn’t even need to be a diagnosable anxiety disorder! The second, you’ll probably have guessed, is depression.

Depression is common in people with both rotten sleep and ongoing pain (Boakye, Olechowski, Rashiq, Verrier, Kerr, Witmans et al, 2016), and there are some suggestions that pain and depression may be related and similar neurobiological processes may be involved for both (increased limbic activity being one of them). In depression, there is increased activity in the HPA Axis, reduced BDNF (brain-derived neurotrophic factor), and reduced 5HT with increased pro-inflammatory cytokines . In persistent pain, there may be activity in the HPA Axis, there is certainly reduced BDNF except in the spinal cord, and reduced 5HT, along with increased pro-inflammatory cytokines. And in sleep disturbances there is also increased activity in the HPA Axis, redced BDNF, reduced 5HT and guess what… increased pro-inflammatory cytokines. And all three interact with one another so that if you happen to be depressed, you’re more likely to experience pain that goes on, and your sleep will also reduce your mood and increase your pain. And the reverse. All very messy indeed!.

What this means is that assessing for low mood and the impact on sleep is important – if someone’s describing waking well before they usually do, in the wee small hours (anywhere from 3 – 5am if they usually wake at 7.00am) I’m ready to screen for low mood. To be honest I always assess for that anyway! Depression is also associated with low motivation and loss of “get up and go” so this is likely to interact with poor sleep, creating a very tired person.

There are three other very important aspects of sleep I like to assess for: sleep apnoea, where someone stops breathing for seconds to minutes at a time, often snorting awake, and this may be associated with snoring and daytime sleepiness. Often the person won’t be aware of their sleep apnoea, so it can be helpful for a bed-partner to let you know whether this is a feature of your patient’s sleep.

The next are a group of movement disorders of sleep, many of which are associated with the third area I assess, which are medications.

Movement disorders of sleep include restless leg syndrome – that feeling of absolutely having to move the legs, usually at night, and relieved by getting up to walk around, but in doing so, making it difficult to sleep. Another is periodic limb movement disorder of sleep, which can be every 5 – 30 seconds of leg twitching all night long, and in some cases, whole body twitching though this is less frequent and less rhythmic. This latter problem may not be noticed by the person – but their bed-mate will know about it! – and this problem may be associated with both sleep apnoea and restless leg, AND some doses of antidepressants. Another common contributor to these problems is low iron levels – worth checking both iron and medications!

Finally with medications, I like to understand not only what the person is taking, but also when they’re taking them. Several points are important here: some medications are usually sedating such as tricyclic antidepressants but in some people nortriptyline can paradoxically increase alertness! If that’s the case, timing the dose is really important and should be discussed with either the prescribing doctor, or a clinical pharmacist. Opioids depress respiration (ie slow breathing down) so can be problematic if the person has sleep apnoea AND is taking opioids, the drive to inhale may be less, causing more frequent and deeper periods without breathing normally. For restless legs and periodic limb movement disorder, some antidepressants (venlafaxine is one of them) in high doses can cause the twitching and once the dose is reduced, this fades away, at least a bit.  There is a very small amount of research suggesting that NSAIDs can influence sleep quality in some people also.

The effects of poor sleep are many: anything from micro-sleeps during the day (problematic while driving or operating machinery!), to more irritability, sluggish responses, less concentration and more difficulty solving problems. Pain is associated with more frequent micro-wakenings during the night (Bjurstrom & Irwin, 2016) but findings with respect to whether deep sleep, REM sleep or light sleep were consistently more affected weren’t clear.

Having completed my assessment, more or less, I can also use a few pen and paper measures: Wolff’s Morning Questions (Wolff, 1974), Kryger’s Subjective Measurements (1991), Pittsburgh Sleep Quality Index (Bysse, Reynolds, Monk et al, 1989) and the Sleep Disturbance Questionnaire (Domino, Blair,& Bridges, 1984) are all useful. Speaking to the partner is an excellent idea because I don’t know about you but I never snore but my partner swears I do! Who do you believe?!

People experiencing insomnia are not very reliable when describing their own sleep habits – we’re terrible at noticing when we’re actually asleep or awake in those early stages of sleep, so we typically think we’ve slept less than we actually have. We also do a whole lot of things to avoid not sleeping – and these can actually prolong and extend our sleeplessness!

We’ll discuss what to do about the factors you may have identified in your sleep assessment in next week’s instalment, but you can rest assured it’s not crucial for you to do anything yourself about some things. For example, if someone has sleep apnoea, referring for a sleep study is important, but not something YOU need to do! But please make sure a referral is suggested to someone who can make it happen. Similarly with medications and sleep movement disorders, it’s not something you should tackle on your own – please discuss managing these with a specialist sleep consultant, psychiatrist, or the person’s own GP. Mood problems – treat as you would any time you find someone with a mood problem.

Next week – off to the Land of Nod: A roadmap?!

 

Boakye, P. A., Olechowski, C., Rashiq, S., Verrier, M. J., Kerr, B., Witmans, M., . . . Dick, B. D. (2016). A critical review of neurobiological factors involved in the interactions between chronic pain, depression, and sleep disruption. The Clinical Journal of Pain, 32(4), 327-336.

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