Interdisciplinary teams

The “Subjective” – and really hearing


I’m not a physiotherapist. This means I don’t follow the SOAP format because it doesn’t suit me. The first letter is intended to represent “subjective” – and when I look up the dictionary meaning of subjective and compare it with the way “subjective” notes are thought about, I think we have a problem, Houston.

Subjective is meant to mean “based on personal feelings” or more generally “what the person says”. In the case of our experience of pain, we only have our personal feelings to go on. That is, we can’t use an image or X-ray or fMRI or blood test to decide whether someone is or isn’t experiencing pain.

Now the reason I don’t like the term “subjective” when it’s part of a clinical examination is that so often we contrast this section with so-called “objective” findings.  Objective is meant to mean “not influenced by personal feelings”, and is intended to represent “facts” or “the truth”. Problem is… how we determine truth.

Let’s think about how the information we obtain fits with these two ideals, and how we use it.

Subjective information is all the things we ask a person about – their thoughts, beliefs, feelings, understanding and their own experience. Subjective information might even include the person’s report of what they can and can’t do, how they feel about this and what their goals are.

Objective information, on the other hand, is all the things we as clinicians observe and measure. Now here’s my problem. By calling this information “objective” we’re indicating that we as clinicians hold a less-than-subjective view of what we see. Now is that true? Let’s think about the tests we use (reliability, validity anyone?). Think about the choices we make when selecting those tests (personal bias, training variability, clinical model…). Think about the performance variables on the day we do the testing (time of day, equipment and instruction variability, observational awareness, distractions, recording – oh and interpretation).

Now think about how that information is used. What value is placed on the objective information? It’s like a record of what actually was at the time. If you don’t believe me, take a look at what’s reported in medico-legal reporting – and what gets taken notice of. The subjective information is often either overlooked – or used to justify that the client is wrong, and what they can actually do is contained in the “objective”.

Given the predictive validity of a person’s expectations, beliefs and understanding on their pain and disability over time, I think the label “subjective” needs an overhaul. I think it’s far more accurate to call this “Personal experience”, or to remove the two labels completely and call it “assessment”. Let’s not value our own world view over that of the people we are listening to.

How do we really hear what someone’s saying? Well, that’s a hard one but I think it begins with an attitude. That attitude is one of curiosity. You see, I don’t believe that people deliberately make dumb decisions. I think people make the best decisions they can, given the information they have at the time. The choices a person makes are usually based on anticipating the results and believing that this option will work out, at least once. So, for example, if someone finds that bending forwards hurts – doesn’t it make sense not to bend over if you’re worried that (a) it’s going to hurt and (b) something dire is happening to make it hurt? In the short term, at least, it does make sense – but over time, the results are less useful.

Our job, as clinicians, is to find out the basis for this behaviour, and to help the person consider some alternatives. I think one of the best ways to do this is to use guided discovery, or Socratic questioning to help both me and the client work out why they’ve ended up doing something that isn’t working out so well now, in the long term. I recorded a video for the Facebook group Trust Me, I’m a Physiotherapist (go here for the video) where I talk about Socratic questioning and Motivational Interviewing – the idea is to really respect the person’s own experience, and to guide him or her to discover something about that experience that perhaps they hadn’t noticed before. To shed a little light on an assumption, or to check out the experience in light of new knowledge.

Learning Socratic questioning can be tricky at first (Waltman, Hall, McFarr, Beck & Creed, 2017). We’re not usually trained to ask questions unless we already know the answer and where we’re going with it. We’re also used to telling people things rather than guiding them to discover for themselves. Video recording can be a useful approach (see Gonsalvez, Brockman & Hill, 2016) for more information on two techniques. It’s one of the most powerful ways to learn about what you’re actually doing in-session (and it’s a bit ewwww at first too!).

We also really need to watch that we’re not guiding the person to discover what we THINK is going on, rather than being prepared to be led by the client as, together, we make sense of their experience. It does take a little time, and it does mean we go at the pace of the person – and we have to work hard at reflecting back what it is we hear.

So, “subjective” information needs, I think, to be valued far more highly than it is. It needs to be integrated into our clinical reasoning – what the person says and what we discover together should influence how we work in therapy. And we might need to place a little less reliance on “objective” information, because it’s filtered through our own perspective (and other people may take it more seriously than they should).

 

Gonsalvez, C. J., Brockman, R., & Hill, H. R. (2016). Video feedback in CBT supervision: review and illustration of two specific techniques. Cognitive Behaviour Therapist, 9.
Kazantzis, N., Fairburn, C. G., Padesky, C. A., Reinecke, M., & Teesson, M. (2014). Unresolved issues regarding the research and practice of cognitive behavior therapy: The case of guided discovery using Socratic questioning. Behaviour Change, 31(01), 1-17.
Waltman, S., Hall, B. C., McFarr, L. M., Beck, A. T., & Creed, T. A. (2017). In-Session Stuck Points and Pitfalls of Community Clinicians Learning CBT: Qualitative Investigation. Cognitive and Behavioral Practice, 24(2), 256-267.

Live Plan Be


There are times in my work when I feel like I’m banging my head against a brick wall. Even though I’ve been saying most of what I write about on here since forever, it seems to take SUCH a long time for anything much to change! BUT then along comes something totally cool to brush my frustration away, and today I want to talk about Live Plan Be developed by Pain BC in Vancouver, Canada.

A couple of years ago I was given the privilege of being asked to prepare a document analysing the content and approach of self management programmes. I reviewed the Cochrane systematic reviews which all supported a multidisciplinary self management approach as the foundation for chronic pain management. I then turned to the qualitative research to investigate what it’s like to be part of a programme from the participant’s perspective. I found that people attending these programmes enter a journey of self-discovery, that some of the skills don’t seem to make sense at first – but do when the person returns to their own setting. I also found that people living with chronic pain relish the opportunity to feel that their pain is acknowledged, that others on the programmes know what it’s like to live with chronic pain so they don’t have to spend ages trying to explain themselves, and to have the chance to be with others who ‘get it’ means breaking out of the isolation that chronic pain can bring.

I also took a look at the ways these programmes can be delivered. While many programmes are face-to-face, with technology making online programmes increasingly more responsive and flexible, I wanted to see whether there were major differences in the outcomes of each programme. Although it’s difficult to tell because the populations using both approaches are not exactly the same, from what I could find, the outcomes were comparable. This is really exciting because it means more people can get access to approaches that have solid research underpinning them without having to travel to and from, and without the staffing needed for face-to-face programmes.

As a result of my report, I suggested that Pain BC might like to investigate developing a whole new programme for helping people live well with chronic pain, and to make this an online programme with some of the features that the research into online behaviour change programmes has identified as useful. Things like having a discussion forum so participants can connect and share their experiences of the reality of living with chronic pain. Having action prompts so that people don’t just read something – but also get prompted to DO something with that information – and most importantly, have this tied to where the person is currently at in their journey towards making changes to live with their pain. I recommended having some self-assessments so people can track their progress, and a place where they could record the things that worked, and those that didn’t work, so it’s easy to share with other people including health professionals.

I’m SO excited to see how Live Plan Be has come together – and it’s now LIVE!

The team that has put this together has done an amazing job, exceeding my wildest dreams of what the programme might look like. It’s sophisticated, easy to use, has lovely graphics and video recordings of real people doing real things, has SO MUCH information on it – and it’s free! If you have chronic pain, or you work with people living with chronic pain, I would love you to take a look at it, and try it out. Then let me know what you think. Whatever feedback you give, you’ll know that the team will work hard to keep on making it better and more useful, so please let them know.

Meantime, I’m hoping that this will bring some hope to people who have struggled with chronic pain, and would like to learn to live well.

Treat the pain… or treat the depression? Carpal Tunnel Syndrome management


ResearchBlogging.org
Carpal tunnel syndrome is a very common pain disorder associated with compression of the median nerve at the carpal tunnel. Approximately 139 women and 67 males per 100,000 people will report this problem over the course of one year, although this depends on the definition used. The problem with CTS is not only that it is common, but also that it affects function – it is really difficult to carry out normal daily life with a numb or tingly hand, poor grip strength (particularly in the fingertips), and disruption to sleep from the ongoing deep achy sensation in the hand. Additionally, some studies show that people with CTS also experience widespread pressure pain hypersensitivity, and an increased response to heat, suggesting that the problem either triggers, or is part of a central sensitisation process.

Diagnosing CTS is conducted using two main approaches – firstly the clinical signs of pain, paraesthesia in the median nerve distribution, symptoms worse at night, and positive Tinel and Phalen signs; secondly, electrodiagnostic testing must show deficits of both sensory and motor median nerve conduction.

In this study, the authors were interested in establishing the relationship between clinical signs and symptoms, physical signs and symptoms (notably CROM and pinch grip force), as well as neurophysiological measures – and they also measured depression. I wish they’d included measures of pain anxiety, or catastrophising, but this was not included in this study.

224 women were included in the study, which carefully screened out individuals with potential confounding contributory causes such as whiplash, pregnancy or diabetes.  The initial and expected findings were that women with higher reports of pain also demonstrated poorer CROM, pinch grip, lower heat pain hypersensitivity, and overall poorer functional hand use.

The first interesting finding was that women in this study reporting only moderate levels of pain also reported poor functioning. The authors suggest that, as a result of this finding “it may not be necessary to report higher levels of pain to find a repercussion in functional activities.” In other words, the impact of CTS on functional use of the hand appears ahead of the pain intensity, although the two are associated.

The study also found that heat pain hyperalgesia over the carpal tunnel as also associated with the intensity of hand pain – they suggest this may be due to peripheral sensitisation which is present from very early on in the presentation.

Looking at depression and the relationship with CTS, interestingly, the women did not demonstrate very high levels of depression, which surprised me a little given they had been selected for inclusion on the basis of having CTS symptoms for 12 months or more. The analysis found that depression was associated with poorer hand function and greater pain, even though the women did not report very high levels of depression. These authors suggest that “perhaps proper management of depressive symptoms in CTS may reduce, not only chronicity, but also induce an improvement in hand pain-related disability.”

Somewhat more controversially for some physiotherapists, these authors also argue that because depressive symptoms resolve during (as a result of perhaps?) physiotherapy treatment in 40% of people with work-related musculoskeletal pain injuries, perhaps those treatments should target mood management as well. So much for “but it’s not in my scope of practice”!

In fact, the authors are very clear that “proper management of individuals with CTS should include therapeutic interventions targeting physical impairments, that is, manual therapies; psychological disturbances (cognitive behaviour), and mechanical hypersensitivity (that is, neuromodulatory pain approaches).” If ever there was a time to get upskilled in a whole person approach to rehabilitation, this paper supports doing so now.

Fernández-Muñoz, J., Palacios-Ceña, M., Cigarán-Méndez, M., Ortega-Santiago, R., de-la-Llave-Rincón, A., Salom-Moreno, J., & Fernández-de-las-Peñas, C. (2016). Pain is Associated to Clinical, Psychological, Physical, and Neurophysiological Variables in Women With Carpal Tunnel Syndrome The Clinical Journal of Pain, 32 (2), 122-129 DOI: 10.1097/AJP.0000000000000241

Taking a peek beneath the hood


What would it be like to lift the hood and take a good hard look at the skills needed to carry out various chronic pain management treatments? You know, take each profession’s jargon away and really look at what a clinician needs to know to conduct safe, effective treatment. Oh I know, this is skating on thin ice – each profession’s treatment paradigm and assumptions are incredibly important and I’m an outsider looking in, so please, before you push me under the cold, cold water, let’s think about the parts that really do the business in pain management.

The first set of skills that are crucial to effective pain management are those to do with communicating. The ability to listen carefully, reflect what’s being said, and to ask questions to genuinely understand what a person believes and feels, and how they got there.  To be able to help the person identify what’s important to them, their main concerns, their values and the direction they want to move towards. To know what to say and how to say it (Bensing & Verhuel, 2010; Hall, 2011; Hulsman, 2009; Klaber & Richardson, 1997; Oien, Steihaug, Iversen & Raheim, 2011).

These skills are generic to all health professionals, although perhaps enhanced and refined in those clinicians who are involved in talking as the therapeutic process.

The second set of skills involve being able to change behaviour. To be aware of operant conditioning, classical conditioning, and to use these principles along with those involving cognitions (eg “education” or providing information).  Interestingly, while these principles are derived from psychology, and perhaps educational research, ALL health professionals use these skills when they’re involved in asking the person to make a change outside of the treatment room.

Unless the clinician is doing something TO the patient, treatments for chronic pain typically involve asking the patient to DO something (Honicke, 2011; Persson, Rivano-Rischer & Eklun, 2004; Robinson, Kennedy & Harmon, 2011).

The third involve being able to progressively grade activities from simple to complex – modifying them so that the demands just slightly exceed the person’s capabilities or confidence.

  1. Those demands might be physical (repetitions, range of movement, loading, isolation to integrated movement),
  2. Cognitive (simple one-step directions through to complex multi-stage decision-making activities),
  3. Social (working alone, in a pair, in a small group, large group, being the follower, being the leader),
  4. Emotional (joyful flow or frustrating, touching on highly important values or those that are not especially relevant).
  5. Contextual (controlled contexts like a clinic room vs highly chaotic like a shopping mall on Christmas Eve)

It’s this latter set that I think we may forget when looking at skills and professionals. There can be an assumption that being able to do an exercise programme in a gym or clinic should lead to greater participation in life outside that setting. Exercises can be prescribed to isolate a small set of muscles, using all the usual suspects to increase strength, flexibility, speed and stamina – and the techniques to progress along this kind of training are, sorry guys, reasonably simple to learn. The challenge is for the person doing them to be able to transfer this training to the real world where movements are integrated, where the environment is complex and the demands and distractions are myriad.

Likewise with graded exposure training – beginning with the least feared movements, progressing to more and more feared situations using a graded hierarchy is something any one of us can learn provided we take the time to understand how and why this approach is used. What’s far more difficult is helping the person doing these activities in new and evolving situations so the skills generalise. Occupational therapists, for what it’s worth, are explicitly and uniquely trained to analyse occupations/activities to do precisely this kind of generalisation.

When we look at what works in chronic pain management, there are four things:

  1. Placebo or meaning effects which are strongly influenced by the way we communicate, and the person’s expectations from us and our interaction.
  2. Providing accurate information so the pain is “de-threatened” or at least loses a large degree of the threat value even if the pain doesn’t reduce as a result.
  3. Supporting the person to do more, whether that be through exercise or just doing more of what they want.
  4. Generalising those skills so that irrespective of the pain fluctuations or context, the person can remain able to participate in what’s important in their life.

And the skills needed to do these things? They’re the ones I’ve listed above.

What I think this means is the time has come to stop describing various treatments as “belonging” to any single discipline. They don’t “belong” to anyone – they’re generic skills that we ALL use. So I, as an occupational therapist warped by psychologists, will have greater technique in communicating, noticing psychosocial obstacles, and helping a person generalise skills into a range of contexts by virtue of my training. Paul, as a physiotherapist, will have greater technique in prescribing specific exercises for certain muscles, and have more confidence in exercise progression. Scott will have greater expertise in enhancing expectations and helping a person reconceptualise their pain in a way that dethreatens it. We ALL have effective skills across all of these areas, but at the same time we have particular expertise in what we originally trained in.

Finally, what I think this means is that when the call is made for clinicians to work in primary care, or alongside GPs or in ED, to help reduce healthcare use, increase participation in life and so on, it’s time we stopped saying “The (X profession) and the GP should form a team”, I think it’s time for us to say “The allied health team (made up of people with the following skills) should form a team with the person living with pain”.

 

Bensing, J. M., & Verheul, W. (2010). The silent healer: The role of communication in placebo effects. Patient Education and Counseling, 80(3), 293-299. doi:http://dx.doi.org/10.1016/j.pec.2010.05.033

Eakin, E., Reeves, M., Winkler, E., Lawler, S., & Owen, N. (2010). Maintenance of physical activity and dietary change following a telephone-delivered intervention. Health Psychology, 29(6), 566-573.

Hall, J. A. (2011). Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. Patient Education & Counseling, 84(3), 319-324.

Hardcastle, S., Blake, N., & Hagger, M. S. (2012). The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. Journal of Behavioral Medicine, 35(3), 318-333.

Honicke, M. (2011). Acceptance and commitment therapy as a challenging approach for occupational therapists in pain management. Ergotherapie und Rehabilitation, 50(7), 28-30

Hulsman, R. L. (2009). Shifting goals in medical communication. Determinants of goal detection and response formation. Patient Education & Counseling, 74(3), 302-308.

Klaber, M. J., & Richardson, P. (1997). The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13(1), 89-96.

Okun, M. A., & Karoly, P. (2007). Perceived goal ownership, regulatory goal cognition, and health behavior change. American Journal of Health Behavior Vol 31(1) Jan-Feb 2007, 98-109.

Oien, A. M., Steihaug, S., Iversen, S., & Raheim, M. (2011). Communication as negotiation processes in long-term physiotherapy: A qualitative study. Scandinavian Journal of Caring Sciences, 25(1), 53-6

Persson, E., Rivano-Fischer, M., & Eklun, M. (2004). Evaluation of changes in occupational performance among patients in a pain management program. Journal of Rehabilitation Medicine, 36(2), 85-91.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Review of occupational therapy for people with chronic pain. Australian Occupational Therapy Journal, 58(2), 74-81.

Rosser, B. A., McCullagh, P., Davies, R., Mountain, G. A., McCracken, L., & Eccleston, C. (2011). Technology-mediated therapy for chronic pain management: The challenges of adapting behavior change interventions for delivery with pervasive communication technology. Telemedicine Journal & E-Health, 17(3), 211-216.

What is the difference between using cognitive behavioural therapy – and using a cognitive behavioural approach?


My last post generated an enormous amount of discussion about whether clinicians who are not psychologically trained, or who haven’t completed a psychology degree, or indeed, should carry out treatments using a cognitive behavioural approach. This is my answer! But note well, these are not my words, but drawn from two of the most eminent researchers and clinicians I know. And yes, I think you can ALWAYS learn more skills – and apply them within your practice with an eye to optimising the quality of your interactions and outcomes.

The first is from Professor Turk:

Capture

This excerpt is from Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

In this paper, Turk identifies the many influences on our experience of pain, and on subsequent disability, that are amenable to “top down” approaches. As he points out in this excerpt, a cognitive behavioural approach is a way to conceptualise the person and his or her experience. The perspective is as important as the content of therapy. The best way I can put this is to show the following clip from this paper – and ask readers if they agree, based on the findings from pain science research.

assumptions of CBT approach

 

 

 

 

 

 

 

 

 

 

 

 

 

 

So, it’s clear to me anyway, that our modern view of pain as an experience that people go through in the context of their life implies that tissues and nociception are only part of the picture. Along with this is the recognition that our treatments exert their influence not just through the so-called “active ingredients” of whatever modality we choose to use. At the same time as we “treat”, the people coming to see us interpret and place expectations on what will happen in that “third space”. Their understanding of what could and should happen influences their response – and even if we don’t recognise this! What this means to me is that we have a responsibility to be mindful and thoughtful about everything that goes on between the person “treating” and the person “seeking”, because these influences are always happening. For more information on the neurobiology of treatment seeking and relief, Benedetti’s book on The Patient’s Brain should be a mandatory reference, though there are others.

Turning to whether those clinicians who primarily touch people, or advise on movements and bodies (ie physiotherapists) should adopt a cognitive behavioural approach, I’m going to snip from a paper by Harding and Williams (1995). What’s scary is that this paper was written waaaay back then, but some clinicians in this area of practice STILL don’t recognise that this is a legitimate approach for them to take. Back to the snip:

Capture1

Here’s a further snip from that same paper, explaining how and why providing accurate information, and helping people identify unhelpful ways of thinking is an important component, especially within a team environment.

“The cognitive component of a CP management programme involves teaching patients to identify thoughts and beliefs which underpin maladaptive behaviours and which adversely affect mood. There is a particular focus on anxiety and depression. Once patients can identify the very disabling cognitions, they try to use cognitive restructuring to identify and challenge longstanding beliefs and immediate judgements (Turk et al, 1983), with resultant improvement in mood and in practical coping with the pain.
Cognitive restructuring is a task that varies in complexity. Although this complexity sometimes requires the specialised skills of clinical psychologists or others with appropriate training, there are many occasions when less experienced professionals may help patients apply the principles to great effect.
One of the more disabling habits of thinking identified in many CP patients is catastrophising: expecting only the worst to happen and feeling
unable to cope with it. Research shows that patients who use catastrophising frequently cope poorly with CP (Jensen et al, 1991; Keefe et al,
1992). Team members are therefore taught to recognise catastrophising and to help patients to challenge it when it occurs, such as during exercises,
practical activities or planning.”

I know we can argue about the language used here (remember when this was published), but here’s my rationale for physically-oriented clinicians to actively use cognitive and behavioural approaches. When do you think people are likely to think those unhelpful thoughts? When is it most likely they will recall those scary images and immediately experience distress – and then avoid? Is it likely to be sitting quietly in a clinic room where the only expectation is to talk? Or is it more likely to happen when engaged in doing something that represents the thing the person is afraid of? When do you think emotions are most likely to be present? And when do you think it’s most likely that an experiment disproving the unhelpful assumption might best be carried out? I think it’s likely to be when you and the person are beginning to do some movements.

Along with cognitive aspects, there are also behavioural ones. “Changing Behavior: Providing positive consequences for learning a new behaviour such as a previously feared exercise is likely to reinforce it, particularly when the reinforcements are provided immediately and frequently for small achievements in the early stages. The focus is moved away from unhelpful behaviours, and shaping (Becker, 1989) rather than criticism is used to achieve the finally desired exercise or posture. Pain is not denied, only the pain behaviour is not reinforced.”

And further: “Goal Setting: Exercises are seen as part of the ‘building blocks’ to achieve a range of patient goals, so although they may improve local biomechanics, they constitute steps to  achieving activity goals and general fitness, rather than being prescriptive on the basis of the assessment.”–  yet more“Pacing: Since patients’ exercises are learnt with pacing on a quota not pain basis, practices like ’no pain, no gain’ and ‘pushing through the pain barrier‘ are discouraged. They learn to set exercise baselines at what can easily be managed rather than the most they or the therapists think they can do. Patients are thus enabled to challenge and resolve fears (such as bending the back, or weight bearing through a chronically painful knee) rather than to be precipitated into anxiety and avoidance.”

Still more “Education: Patients need information with written back-up to make choices and help them bring about behaviour change…Education is interactive and involves practical experience, not just discussion.”

“Recording Progress: Charts and exercise sheets are used to demonstrate and reinforce a behaviour change (such as regular and increasing exercise rather than pain determined exercise). They are filled in by patients, not therapists, to reinforce patients’ improvement.”

“Challenging Thoughts and Feelings: Physiotherapists who can help patients capture and challenge unhelpful cognitions, when they are confronted with feared situations such as physical activity, are likely to catalyse big improvements in function and mood. Unhelpful cognitions about exercise may be challenged on the basis of realistic estimates of physical capacity and of risk of harm.”

Finally, “Maintenance and Self-attribution: If improvement is seen as the patient’s achievement – ‘I did it’ – right from the start, rather than ‘the physiotherapist cured/fixed me up’, they will have a greater sense of future self-management.”

Further to my post about interdisciplinary working: An inter-disciplinary team is not hierarchical but involves sharing of skills, and it is quite usual, for example, for the psychologist to address the psychological implications of the physiotherapist‘s initiatives and vice versa. The physiotherapist has a lot of patient contact, so mutual feedback with other members of the team is important both in timetabled team meetings and informally. Good team integration helps patients understand how to tackle the complex experience of CP using the techniques, and prevents mixed messages from the staff which may confuse and discourage patients. Where integration is achieved, differences apparent to patients are easily resolved.” So much for concern about scope.

While these papers are old and the language reflects this, the cognitive behavioural approach is now firmly established as a helpful way to conceptualise the experience and problems of people living with pain. As Vlaeyen and colleagues indicated in their recent book “Pain-related Fear”, the skills rather than the professional discipline is what is important. Turk and others say that by using a cognitive behavioural approach, people are able to attribute change to themselves, rather than on any mythical theory about application of hands.

As Harding and Williams state: “When improvement occurs, it is important that it is credited to patients, both my themselves and by staff. Hands-on physiotherapy is tremendously rewarding, and rapid dramatic results produce in therapists quite a buzz of pride in their skills. Patients sense this and physiotherapists will remember being told: “Oh you are wonderful, no one else has been able to help me, such healing hands…etc”. However this is not helpful to patients. The unspoken message is: “I couldn’t do without you”. Physiotherapists guidance can be acknowledged but it is patient’s hard work and the renegerative capacity of their bodies which bring about change, catalysed by professional help” (p. 686).

So, to conclude, I think clinicians of all colours and stripes should be ready to adopt a cognitive behavioural approach. It is a perspective about a person experiencing pain, not a therapeutic procedure or set of actions. It’s a way of seeing people from within a biopsychosocial perspective. All the actions you then take as a professional will naturally reflect your unique clinical scope – but as far as I know, using effective communication (eliciting a person’s understanding of their pain and situation, and reflecting what you’ve heard) and being able to think of people as active participants in their own health doesn’t constitute stepping out of anyone’s scope.

cb perspective

References

Harding, V., Williams, A., (1995). Extending physiotherapy skills using a psychological approach: Cognitive behavioural management of chronic pain. Physiotherapy, 81(11), p681 – 688.

Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

Vlaeyen, J., Morley, S., Linton, S., Boersma, K., & de Jong, J. (2012). Pain-related fear. Seattle: IASP Press.

Scopes, roles, boundaries, contributions: who does what in a brave new healthcare world?


I have been meaning to write a post like this for some time now, but prompted to today by two things: one is an ongoing debate about non-psychologists using “CBT” with people who are experiencing pain, and the other is a conversation with Chai Chuah, Director General of the Ministry of Health in New Zealand. Let me set the scene:

We know there are a lot of people in our communities who have relatively simple pain problems – a temporarily painful knee after walking up hills for the first time in ages, a painful back that “just happened” overnight, a rotator cuff problem that makes it difficult to get dressed or hang out washing. We know that there are some pretty simple things that will help in these situations: some reassurance that the awful thing the person is worried about isn’t likely to happen (no, you won’t end up in a wheelchair because of your back pain, and no it’s not cancer); some pain relief to help with sleeping more soundly and so we can keep doing things; and gradually returning to normal occupations including work even if the pain hasn’t completely gone.

We also know that approximately 8% of people with low back pain will ultimately end up contributing to the most enormous spend in healthcare that we know about – their pain continues, their distress increases, their disability is profound.

BUT before we put all our attention on to this small group of people, I think it’s worthwhile remembering that people in this group are also more likely to have other health conditions, they’re more likely to smoke, to be overweight, to have mental health problems; they also probably come from lower socioeconomic groups, groups including people from minority ethnicities, people who find it much harder to get work, to remain in education and perhaps even people who typically use healthcare more often than the people who get back on their feet more quickly. Data for these statements comes from the 2006 Health and Disability Survey in New Zealand and numerous studies by epidemiologists around the world  –  back pain is only one of a number of problems people in this group have to deal with. I’m also not saying everyone who gets back pain that lingers has all of these additional concerns – but there is a greater prevalence.

What does this mean?

Well, for a while I’ve been saying that people working in this area of health (musculoskeletal pain) seem to be developed a set of common skills. That is, there is more in common between me and Jason Silvernail, Mike Stewart, Paul Lagerman, Alison Sim, Lars Avemarie, Rajam Roose and many others around the world from many different health professions, than there is between me and a good chunk of people from my own profession of occupational therapy. And I don’t think I’m alone in noticing this. (ps please don’t be offended if I’ve left your name out – you KNOW I’m including you too!)

What’s common amongst us? The ability to see and work with complex, ambiguous, messy and multifactorial situations. Recognising that along with all of our individual professional skills, we also need to have

  • effective communication skills,
  • patient/person-centredness,
  • critical thinking,
  • generating a framework to work from,
  • identifying and solving the unique goals and situations the people we work with have,
  • ability to step beyond “this is my role” and into “what can be done to reduce this person’s distress and disability?”
  • And possibly the most important skill is being able to tolerate not knowing without freaking out.

That ongoing cycle of assess -> hypothesise -> test -> review -> reassess -> hypothesise -> test -> reassess ->  review

This is important because when people come to see us with a complex problem (and increasingly this seems to happen), the simple models break down. The tissue-based, the germ-based, the simple single-factor approaches do not fully explain what’s going on, and don’t provide adequate solutions.

What this means is we, ALL health professionals, will need to think about where our skills lie. Are we people who enjoy pumping through a big number of relatively simple problems? If so, that’s great! Your contribution is clear-cut, you know what you need to do, and you refine and practice your skill-set until you’re expert. I think this is awesome. Or, are we people who relish complex, who look at situations and see that it’s messy and complicated but don’t get put off? In this group we probably use skills for researching and planning, operationalising or getting things started, and we’re often the people who network furiously. We do this not because we’re social butterflies (me being the ultimate introvert), but because we know WE CAN’T DO THIS WORK ALONE!

What about clinical skills and scopes and boundaries?

You know, I am not entirely sure that anyone except the health professional him or herself cares who does what they do to help someone get better. It’s not whether a nurse or a speech language therapist or a podiatrist or a medical practitioner, it’s whether the person (or people) treats each person as unique, listens carefully, is honest and straightforward about what can and can’t be done, and knows when his or her skills are not sufficient so calls in the rest of a team for help. There is a time for working beyond your scope, and a time for calling in an expert – but to recognise when an expert is needed requires knowing enough about the problem to know that an expert might be helpful.

What this means in healthcare, I think, is adopting a framework that works across diagnosis and into the idea that people actively process what happens to them, they make their minds up about what’s needed, and they can learn to do things differently. I’d call this self-management, but I could equally call it a cognitive behavioural approach, or behaviour change, or motivational approaches or even patient-centred or person-centred care. The idea that people understand more than we often give credit, that they make sense from what happens to and around them, and that this knowledge influences what they do comes from a cognitive behavioural model of people, and fits beautifully within a biopsychosocial framework.

So, when I advocate getting skilled at cognitive behavioural skills, I could equally use the term “person-centred” or “self-management” – whatever the label, the contributions from each professional involved will ultimately influence the health experience and actions of the person we’re seeing.

Isn’t it time to be excited about opportunities to develop and to extend our skills? And if this doesn’t excite you, isn’t it great that there are a group of people who will respond to the simple and straightforward – but let’s not confuse the two situations.

 

More than something to blame when the treatment doesn’t work


A friend of mine told me that during her physiotherapy training when they discussed “psychosocial” factors it was usually in the context of explaining why a treatment didn’t work.  This still happens. Even well-informed and scientifically savvy people can unintentionally “blame” those pesky psychosocial factors for getting in the way of complete recovery. What do I mean? Well, let’s think about it: when we’ve done the “explaining” or “educating” – and the person still doesn’t understand and/or their pain doesn’t reduce, what’s our explanation?

We know that pain is an experience, not a separate thing to be treated, but the experience an individual has when his or her brain determines there is a threat to the body (and that threat is more important than other competing goals). We also know there are numerous mechanisms underpinning this experience, many of which are biological. But what we are always left with is the fact that we cannot know anything about this other person’s world except through (1) their behaviour and (2) our interpretation of their behaviour.

I’ve emphasised this because recently I’ve heard one registration board suggesting that a profession should not talk about pain, nor consider psychosocial factors because their domain of influence is bodily tissues.

I’ve also emphasised this because in our efforts to become all sciencey and sound (at least) like we know what we’re talking about, I think we may have forgotten that the only reason we know someone is sore is because they are doing something that we interpret as a signal that they’re sore. And that this occurs within a social setting that has emerged from a combination of historical practices and assumptions, and we are part of that social setting.

The biological substrates for our experience of pain have received the lion’s share of research attention and funds. What has received rather less is understanding some of the social aspects – what individuals learn throughout their life, including the assumptions we develop about what is “normal” and what is not. Unique family and cultural factors influence each individual’s experience – what does this person pay attention to? What does this person ignore? When this person recognises something as “not normal” what is the usual way of dealing with it? Who does this person first see for treatment?

More than this, what about the research looking at treatment provider’s decoding and response to the social communication of the person seeking treatment? We know, for example, that healthcare providers who view video vignettes of people displaying pain behaviour with no medical evidence but with psychosocial factors rate those individuals as experiencing less pain and interference, they have less sympathy, expect medication effectiveness to be less, and those individuals were more likely to be rated as potentially trying to deceive the treatment providers (De Ruddere, Goubert, Stevens, Deveugele, Craig & Crombez, 2014). These responses appear to use both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Observers (ie health professionals) also incorporate automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions. We seem more likely to demonstrate instant ‘‘visceral’’ emotional reactions to unintentional, reflexive expression, while controlled expression characterised by purposive (deliberate) behaviour appears more likely to suggest to health professionals (or observers) that we should think a little about the purpose behind that individual’s pain expression (Craig, Versloot, Goubert, Vervoort & Crombez, 2010). The point is: this occurs even when we know about it, and even if the individual is experiencing pain, and even though the individual is only trying to get the treatment provider’s attention!

Pain behaviour as independent from the individual’s experience of pain is one of the key features of the behavioural model of pain. Pain behaviours were what Fordyce and Loeser and Turk and the very great original thinkers about chronic pain management first thought could and should be dealt with. The reason? Because despite all the surgical and pharmacological treatments available in the late 1960’s, 70’s and 80’s,  many people were still left experiencing pain and were also highly disabled by it. By helping people reduce their pain behaviour (eg stop guarding that body part, start moving more quickly and fluidly, be more relaxed, groan less) they noticed that people were also reporting that their pain bothered them less.

Cognitive behavioural therapy (or a cognitive behavioural approach, to be more accurate) incorporated more “education”, or helping people understand the mechanisms involved in their experience of pain, helping them understand the difference between hurting vs doing damage. A CBT approach meant people were acknowledged as being able to think differently about their pain, reduce their distress and begin to do more. A CBT approach combined education with behavioural experiments and encouraged people to get on with life.

Much more recently we have physiotherapists deciding that giving people pain neurobiology education (sounds almost exactly like the CBT education/explanation to me) is really good and reduces the threat value of the experience. And combined with graded reactivation, exposure to doing things that have been avoided, using methods to reduce distress and by avoiding flare-ups of pain, people are helped.

Two or three important points for me:

  1. Health professionals need to be aware of their own psychosocial responses/background/biases when they observe another person who is indicating they are sore.
  2. If we are two people interacting, all the messy psychosocial factors are immediately present – whether we attend to them, or not.
  3. Given how important those factors are in both our response to another person and their response to treatment (eg placebo, expectancy) it is critical that we integrate effective communication skills into every clinical interaction.

And probably another important point:

In the enthusiasm for pain neurobiology education and the potential for the person to no longer experience pain, we need to remember that reducing disability is arguably more relevant than reducing pain. Despite the impressive results reported by clinicians and some researchers there are many many people who continue to live with chronic pain. As clinicians we may even inadvertently delay recovery if our focus is inappropriately on pain reduction. I say this because there is SUCH clear evidence that pain intensity is less of a factor in ongoing disability than unhelpful beliefs and avoidance (Froud, Patterson, Eldridge, Seale, Pincus, Rajendran et al, 2014; Shaw, Campbell, Nelson, Main & Linton, 2013; Wilkens, Scheel, Grundnes, Hellum & Storheim, 2013).

To conclude, it seems to me that it’s high time for health professionals to take a hard look at what they consider to be “their” domain of concern. Not only must we avoid “blaming” psychosocial factors for poor outcomes from treatments we provide, we also must begin to recognise our own biases as we work with people living with pain. One of these biases is the temptation to believe that we are not influenced by our own psychosocial factors. Another is to recognise that delicate moment when it’s time to take our attention away from reducing pain and towards reducing disability. We need to elevate the status of effective communication – not just “can I make myself understood” and “can I establish rapport”, but that much more nuanced scope of implementing reflective listening, truly hearing our clients, and responding in a way that upholds client choice and self efficacy. I think this belongs to all health professions, not simply those tasked with dealing with “psychosocial” factors.

 

Craig, K.D. (2015). Social communication model of pain. Pain, 156(7), 1198-1199.

Craig, K.D., Versloot, J., Goubert, L., Vervoort, T., & Crombez, G. (2010). Perceiving pain in others: Automatic and controlled mechanisms. The Journal of Pain, 11(2), 101-108. doi: http://dx.doi.org/10.1016/j.jpain.2009.08.008

De Ruddere, L., Goubert, L., Stevens, M.A.L., Deveugele, M., Craig, K.D., & Crombez, G. (2014). Health care professionals’ reactions to patient pain: Impact of knowledge about medical evidence and psychosocial influences. The Journal of Pain, 15(3), 262-270. doi: http://dx.doi.org/10.1016/j.jpain.2013.11.002

Froud, R., Patterson, S., Eldridge, S., Seale, C., Pincus, T., Rajendran, D., . . . Underwood, M. (2014). A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskeletal Disorders, 15, 50.

Shaw, W.S., Campbell, P., Nelson, C.C., Main, C.J., & Linton, S.J. (2013). Effects of workplace, family and cultural influences on low back pain: What opportunities exist to address social factors in general consultations? Best Practice & Research in Clinical Rheumatology, 27(5), 637-648.

Wilkens, P., Scheel, I.B., Grundnes, O., Hellum, C., & Storheim, K. (2013). Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: A cohort study. Spine, 38(1), 65-74.

Those who expect moments of change to be comfortable and free of conflict have not learned their history ~ Joan Wallach Scott


I’ve been touring North America – Chicago, Toronto, Edmonton and Vancouver. As I’ve toured I’ve been listening to the stories of change and insight as different professions review their contributions to effective pain treatment. Some things change, some things stay the same – but as the quote above indicates, change isn’t comfortable nor free of conflict.

What have I found in my travels?

There’s a great deal to be proud of in our approaches to helping people who live with pain. Allied health practitioners of various backgrounds have adopted and adapted to the discoveries about how people experience and deal with their experience of pain. There’s been enormous change in our views of pain as neither a form of mental illness (or malingering, or imagination, or even simply weakness of spirit), nor a lifelong static state. Allied health practitioners of every kind know that they can contribute to helping people make sense of their pain, perhaps change their experience and reduce the distress and disability that living with pain can bring.

Disturbingly, though, I heard the exact same issues as those I face in New Zealand, when it comes to unrest and disquiet about competence, scope, and funding for effective treatments.

Disquiet because some of the different professions lay claim to certain areas of practice as “theirs”. Disquiet because there are attempts to limit access to learning about aspects of pain that are integral to the experience and management of pain. Concerns that some clinicians might be overstepping their scope when they begin to develop skills in, most notably, psychosocial aspects of our experience of pain. And disproportionate funding given to short-term (primarily) biomedical interventions without a consistent or even logical argument for similar funding levels to be applied to allied health approaches. Or worse – funding given to those working in a single-discipline approach, and loss of funding (or funding not even considered for) approaches where teamwork is a critical part of the treatment.

As a somewhat renegade occupational therapist with a MSc in psychology, PhD in health sciences, and great interest in psychosocial aspects of pain, I know that I don’t sit especially comfortably in one little box. And it was SO refreshing to find that I’m not alone in this. As allied health professionals develop knowledge and skills in a biopsychosocial and neurobiologically sophisticated model of pain, it becomes increasingly difficult to distinguish between the practice of good occupational therapists, physiotherapists, massage therapists, psychologists, nurses and social workers when working with people who live with pain.

Our aims are the same: we want to help people live good lives despite experiencing pain. Some of the ways we ALL do this are to help people reconceptualise pain as something that is not fixed but can be influenced by reducing the threat value of the experience within the context of what we view as important.

We ALL draw on learning theories, influencing beliefs and attitudes, consider contingencies and work at reducing the relationship between experiencing something inherently unpleasant and avoiding that experience.

We ALL help people set goals, work hard to achieve them, use movement and activity to help pursue what is valued and deal effectively with what gets in the way of this.

We ALL use motivational approaches, we ALL consider personal values and choices, we ALL want the people we work with to have the freedom to choose personally-valued goals and outcomes.

We ALL draw freely on the published scientific literature across all the branches of pain research – biological, psychological, and to a lesser extent, sociological. (I’d love to see far more emphasis on the social as I’m sure regular readers know!).

It confuses and perplexes me that each one of our professional groups has, at times, criticised other professions for failing to address or consider the aspects of pain experience that our particular group sees as critical. But what really perplexes me is that once another profession begins to take up the challenge of adopting and integrating learning from “outside” their original knowledge base, some people turn right around and begin to criticise that group for “working out of scope”. It does not make sense.

A discussion that I think needs to begin is to consider the merit of a specialist “certification” if you like, for those people who have taken time to learn about pain in-depth, and who no longer fit as comfortably within their original profession as they once did. As I saw so often in my travels, when we get beyond the simplistic level of learning about pain as a biopsychosocial experience we begin to recognise that the way we work with people changes over time to become so much more similar than dissimilar that our professional disciplinary approaches seem to fade away.

I know that in the years since my original training and graduation as an occupational therapist (waaaay back in 1983) I’ve done so much more learning and development that what I do now is so very different from what I did then. I’m still essentially interested in helping people do what is important in their lives. Doing, or occupation, is integral to my practice. The ways I help people achieve this (thus reducing distress and disability) has changed but my “domain of concern” (old-fashioned language for “what I’m interested in”) is still occupation, or the things people want and need to do in daily life.

The obstacles to participating in occupations might be addressed in slightly different ways, but I draw on the same fields of knowledge that I drew on in 1983. Just as I learned then that biomechanical, kinesiological, anatomical, biological, psychological, social, anthropological – and the rest – ways of understanding human behaviour informed the way I work with people, I STILL draw on those same fields of knowledge. The first three fields might have less influence now than I thought they did when I first started working in pain management, but they all contribute.

So here’s the thing: if there is so much our different professions have in common with one another, is it time for allied health professionals to work in a united way to demonstrate just how significant our contribution is to the health and wellbeing of people living with pain? Is it time to trust one another just a little more and stop the infighting as to who is working “in” or “out” of scope? Isn’t it time we looked to the people we work with and for, and focused a little more on sharing our expertise with one another? Shouldn’t we trust that if we’re interested in what works well for the people we want to help, we’ll develop effective knowledge and skills rather than thinking, like Gollum “It’s mine! It’s my preciousssssss!”

I truly thing we can do a much more effective job if we remember that while we let go of some things that we think of as “ours” we might have made just a little room to add some new skills to our own repertoire? And perhaps that change might happen more smoothly if we were more accepting of the need to let go some control and trust a little more.

Should we take their word for it? Patient-reported vs observed functional outcomes


Pain is a subjective experience. There’s no direct means to measure what it is like to be in pain. Disability, or the impact of pain on what we do in daily life is, on the other hand, able to be observed as well as reported on by people with pain. A question that has always fascinated me is the relationship between what an individual says they can or can’t do, versus what they can be observed to do.

One of the more common ways to determine disability by observation is the “functional capacity evaluation” – and readers of my blog will know that I’m not especially fond of them when they’re used to determine “work fitness”. There are instances though, where they make sense – particularly if the individual with pain is able to gain confidence about what he or she can do. Just don’t use them to predict whether a person can carry out a full working week.

Alternatively, and for reasons of convenience and cost, self-report measures of disability are often used. These are thing like the Oswestry Disability Index (Fairbank & Pynsent, 2000), or the Oxford Scale for hip and knee function (Dawson, Fitzpatrick, Carr & Murray, 1996).  These pen and paper assessments are completed by patients, have excellent psychometric properties, and are often used for both assessment and outcome measurement.

The question is: do they represent the real world experience of the person with pain? How accurate are they, really?

In the Orthopaedic Surgery Department where I work, physiotherapists conduct a functional assessment of all people who have been referred for hip and knee joint replacement. The activities used are aligned with the Oxford hip and knee questionnaires. What’s interesting is how poorly the two are correlated. Physiotherapists recognise that many people report difficulty performing things like going up steps, kneeling and so on, but when they are asked to do those same movements in the clinic, they have excellent motor function and manage them well. Why? and which version of the “truth” do we use?

I don’t have the answer, because physical performance and self-reported disability are influenced by many different factors, but I am interested that in a recent study conducted by the IMPROvE Study Group in Denmark, researchers found that using AMPS (Assessment of Motor and Process Skills – an assessment approach developed and used by occupational therapists) and the SF-36 Mental Composite Score showed distinct differences in outcomes six months after a two-week interdisciplinary pain management programme for people who met the 1990 American College of Rheumatology classification for fibromyalgia.

What does this mean?

The first point is that the programme these people attended demonstrated good outcomes in the things that matter most: daily activities, self care and motor performance. Participants became more able to do the important occupations that you and I need to do each day.  Group content doesn’t look any different from the pain management programmes I’ve seen around the world. Lots of information, sharing experiences with one another, exercise including how to increase daily exercise, developing ways to return to usual activities of daily living, and some psychology sessions as well as an opportunity to meet with the rheumatologist. Interestingly, two weeks is not enough time to develop changes in muscle strength – yet function and activity levels increased. It’s not a “training” effect, at least not physical training. Two weeks, 35 hours a week, is not an enormous amount of time in which to deliver a programme of this type – but it’s clear it can and does make a difference for people who had fibromyalgia diagnosed roughly 1 – 3 years ago.

The second is that the two outcome measures are not measuring the same thing.  Using the SF-36, change was minimal, and not clinically significant, neither were changes at six months statistically significant. Using AMPS, however, individuals demonstrated a clinically relevant improvement in performance in both motor ability and process ability (ADL). Interestingly, the researchers report that there were large interindividual differences – something that grouped data cannot show.  Self-report measures show what the person believes he or she can do.  AMPS provides external validation of performance, or what the person will do, or does do when observed. And from this study, it looks like AMPS is more sensitive to change, and to individual differences, than the well-known SF-36. AMPS also provides information on the quality of performance, something that is missing from the SF-36.

In terms of the research design, the assessors, all occupational therapists trained in AMPS and who had just recently been recalibrated (checking to see how consistent and how closely they remain true to the original training) did not know which of the two groups individuals had come from (control or programme).

From this study, I draw a couple of conclusions:

  1. Using both observed performance and self-report gives a broader picture of the impact of pain on daily life. That the two measures don’t correlate well is fine – they’re measuring different things. It’s good to be reminded that what a person says they have trouble with doesn’t necessarily reflect what they can do in usual setting, nor the quality of the performance. Both measures are useful, and it might be worthwhile using both. An unanswered question, of course, is what the participants thought. How did they view their performance? It would have been nice to see something like the Canadian Occupational Performance Measure included in the outcome measures.
  2. While group analyses may not show much difference, within the group, some individuals responded very well. It’s worthwhile considering some different analyses that can show the variation within a group – and then start the search to find out the characteristics of those people who responded well, and this is another reason I like the single subject experimental design approach to clinical outcome measurement.
  3. Occupational therapists, trained to understand occupation made a significant and unique contribution to this study. Many disciplines fail to recognise the specialist expertise of occupational therapy: this study shows that by assessing and focusing on activities that matter to individuals, and directly measuring the impact of interventions on occupation, a more detailed analysis of progress is achieved. Time to wave the occupational therapy flag I feel!

In answer to my question, should we take their word for it? I think the answer is – not exactly. We need to spend time understanding the differences between self-report and observed performance, not as a way to ‘catch a person out’, but as a way to more adequately assess what matters to people who experience chronic pain.

Amris, Kirstine, Wæhrens, Eva E., Christensen, Robin, Bliddal, Henning, & Danneskiold-Samsøe, Bente. (2014). Interdisciplinary rehabilitation of patients with chronic widespread pain: Primary endpoint of the randomized, nonblinded, parallel-group IMPROvE trial. PAIN®, 155(7), 1356-1364. doi: http://dx.doi.org/10.1016/j.pain.2014.04.012

 

Dawson J., Fitzpatrick R., Carr A., Murray D. (1996). Questionnaire on the perceptions of patients about total hip replacement surgery. Journal of Bone and Joint Surgery, 78:185-90

Fairbank JCT & Pynsent, PB (2000) The Oswestry Disability Index. Spine, 25(22):2940-2953

Discussions in chronic pain management


ResearchBlogging.orgIt’s pretty clear that for many people with chronic pain, medications just don’t cut it (Turk, Wilson & Cahana, 2011). This leaves very few options available to the many people who fail to respond – and by and large, it means either soldiering on, or getting help from an interdisciplinary pain management programme. And while there are a hardy few who do cope well on their own (roughly 30% of those with chronic pain), there are a mighty lot who could do with a hand. The problem with this is trouble accessing suitable pain management programmes.

For some reason, interdisciplinary pain management has been gradually falling into space. There are fewer and fewer programmes around (Loeser, 2006), an d various people have argued that they’re expensive, cumbersome, people don’t like going to them (they’re not sexy and they take hard work!), and they’re hard for clinicians who work in them.

Amongst the arguments around interdisciplinary programmes are discussions about how long or intense a programme should be (the “dose”), the content and what is or isn’t necessary within them, and personnel or who should or shouldn’t be involved. I thought I’d take a little look at some of these arguments.

First of all, what should go into a programme?

Unfortunately, although there is a great deal of literature on interdisciplinary programmes, what is far less clear is the content. Content varies widely from well-documented manualised treatment protocols like some of the ACT or acceptance-based programmes, to rather loosely combined topics. Some programmes have no hands-on treatment, while others include massage, hot pools and mud packs (truth!). What is common about programmes are the following (at least from what I’ve deduced):

  • information about pain mechanisms and psychology (appraisals, mood etc)
  • exercise, usually focusing on graded reactivation
  • activity management (how much activity, daily planning, “pacing”)
  • goal setting and problem solving

Other topics may or may not be incorporated including returning to work, intimacy and relationships, communication, pain behaviour – you name it, you’ll probably find it.

I do have opinions (yes, I know I always have opinions!) about content of programmes, but at this stage I think it is truly opinion not researched evidence-based. With ongoing arguments about what “pacing” is, how it should be conducted, the purpose of it, it’s not surprising to me that there doesn’t appear to be much consistency nor consensus about the content. It surprises me, though, that in all the literature on pain management and coping that there is so little known about what “works” within a programme. It almost makes me wonder whether it’s the content that matters – perhaps there’s something else working?

Adherence

The next question is whether results differ for people who are diligent about using what they’ve learned in a programme as opposed to those who don’t. Again, I think the literature is a bit murky.

If you ask Prof Mike Nicholas, he’d say that adherence was a predictor (Nicholas, Asghari, Corbett, Smeets, Wood, Overton, Perry et al, 2012). But as we know, there is an enormous difference between what people do when they’re observed and what they do when they’re on their own, and Nicholas and colleagues studies of adherence were carried out during the programme rather than estimating what people do “in the real world”.

This means there is no clear evidence that people use coping strategies in daily life after a pain management programme. In fact, Curran, Williams and Potts showed in 2009 that there was very little difference in outcome between those who self-reported adhering to strategies, and those who didn’t.

Programme Intensity or “dose”

The programmes I’ve worked on came in three main forms. The first was the “traditional” three week full day programme where a group of people (usually up to 8) attend daily from 8.30 to 4.30 for three full weeks, with a follow-up around six weeks later. The second was a six week part-time programme, where people (again a group of around 8) attended two to three half days a week for six weeks, then returned for a six week follow-up.  Finally, the third variant was an “individualised” programme for roughly 12 weeks, attending alone usually once a week. This latter format became the default for most people attending the Service where I worked, and I’m not sure why.

The situation is that we don’t know how much of a treatment is needed, although there are some suspicions that the more intense a treatment (ie the more sessions, the closer together) the better the outcome, and that programmes of less than 100 hours duration are not particularly helpful.

The problem with examining “dose” is that definitions are very unclear – what might be “multimodal”, as in Waterschoot and colleagues (2014) definition can range from two types of approach to many different approaches, as long as they include medical or physical or psychological or a combination. Additionally, outcome measures differ greatly, with some programmes measuring psychological outcomes, some using “real world” outcome such as returning to work, and others incorporating physical performance measures.

Once again, I’m not sure we have any answers.

Who should facilitate programmes?

Naturally, among the discussions is the question of which health profession should be involved in facilitating such programmes. And once again the situation is pretty murky, but I think there is sufficient evidence to show that it’s not a matter of which discipline, but more about teamwork (especially maintaining a consistent team rather than changing personnel), and about using a cognitive behavioural approach. So, it’s possible to find nurses (Broderick, Keefe, Bruckenthal, Junghaenel et al, 2014); clinical psychologists, physiotherapists, rehabilitation advisors and medical pain specialists (Nicholas, Asghari, Sharpe, Brnabic, Wood, Overton et al, 2014); occupational therapists (Shannon, 2002; Persson, Andersson & Eklund, 2011; Keogh, McCracken & Eccleston, 2005) – and a whole bunch of others including social workers, psychotherapists, massage therapists, vocational counsellors and so on.

If you ask any of the professionals involved, I can bet they’ll argue for their own type of professional – but seriously, I graduated in 1983, and I think I’ve learned one or two things since then – so perhaps my original training is less influential than whether I use what the literature finds useful.

Conclusion?

Actually, I don’t think there is any conclusion that I can draw from the literature as it stands today. I think there is so much more to learn about what works for whom, and why, and when and how chronic pain management programmes should be used. Pragmatism probably rules in most areas. If a programme is perceived to be difficult to organise, hard to staff, tiring for clinicians and expensive, I don’t think it’ll be supported – and  I think that might be the case for interdisciplinary pain management programmes.

It’s high time some of the ingredients within the “black box” of interdisciplinary pain management got unpacked and sorted, lest we see more and more single discipline, usually biomedical approaches dominating – and we know that biomedicine just doesn’t address the “what it is like” to have lived with chronic pain.

 

 

Broderick, J., Keefe, F., Bruckenthal, P., Junghaenel, D., Schneider, S., Schwartz, J., Kaell, A., Caldwell, D., McKee, D., Reed, S., & Gould, E. (2014). Nurse Practitioners can effectively deliver Pain Coping Skills Training to osteoarthritis patients with chronic pain: A randomized, controlled trial PAIN® DOI: 10.1016/j.pain.2014.05.024

CURRAN, C., WILLIAMS, A. C. & POTTS, H. W. 2009. Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13, 178-188.

Kaiser, U., Deckert, S., Kopkow, C., Schmitt, J., & Sabatowski, R. (2014). Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179-189 PAIN® DOI: 10.1016/j.pain.2014.06.002

KEOGH, E., MCCRACKEN, L. M. & ECCLESTON, C. 2005. Do men and women differ in their response to interdisciplinary chronic pain management? Pain, 114, 37-46.

LOESER, J. D. 2006. Comprehensive Pain Programs Versus Other Treatments for Chronic Pain. The Journal of Pain 7, 800-801.

NICHOLAS, M., ASGHARI, A., CORBETT, M., SMEETS, R., WOOD, B., OVERTON, S., PERRY, C., TONKIN, L. & BEESTON, L. 2012. Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16, 93-104.

PERSSON, D., ANDERSSON, I. & EKLUND, M. 2011. Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18, 188-197.

SHANNON, E. 2002. Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA. Australian Occupational Therapy Journal, 49, 48-52.

TURK, D. C., WILSON, H. D. & CAHANA, A. 2011. Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377, 2226-35.

Waterschoot, F., Dijkstra, P., Hollak, N., de Vries, H., Geertzen, J., & Reneman, M. (2014). Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systematic review PAIN®, 155 (1), 179-189 DOI: 10.1016/j.pain.2013.10.006