“Exercise” – what does it do for people living with persistent pain?

No, I’m not going to assemble a bunch of papers and point out the effect sizes of exercise on pain and disability! In fact, I’m not even going to point to much research in this post. I want to pose some questions and put some thoughts out for discussion.

See, the people I’ve seen over the years who live with pain have, by and large, not been great ‘exercisers’ before their pain came on, and many haven’t really changed their lifestyle a heap since their pain either. In fact, there is research showing that people with chronic pain don’t change the overall quantity of their activity very much – but instead, change the pattern of that activity over the course of a day (Huijnen et al., . 2011; Tynan et al., 2023). Nevertheless, because of the influence of the ‘deactivation’ idea, along with the pain-related fear and avoidance model, and of course the benefits of exercise on other aspects of health, there would be very few people living with chronic pain who haven’t been prescribed some sort of exercise intervention.

I’ve made my views on exercise known many times – but once again, for the avoidance of doubt, I think movement is awesome, healthy, integral to living well and something to be done regularly and with enthusiasm. I’m less comfortable, however, with people being obligated to ‘do exercise’ with unhelpful explanations, the inflated promise of effects, and in forms that simply do not fit in with the complex lives we all live – now and over our lifespans.

Some of the unhelpful narratives include: that exercise will ‘take away the pain’; that exercise will improve functioning elsewhere in life; that symmetry is crucial; that core strengthening is needed; that ‘form’ must be ‘perfect’ (whatever that is); that progression should follow some formula (and not based on the person’s response to it); that one type of exercise is ‘the right one’; and that exercise must be supervised by a clinician or it doesn’t work. Bah humbug.

So. We do need to move and do that regularly. That’s a given. There are loads of ways to move and people who regularly meet the WHO exercise recommendations do this in a myriad of ways that look a lot like dance, walking, cycling, gardening, playing with the dogs and kids, leaping into the sea or a pool, doing housework, doing hobbies… all the things. Movement and life go together.

What does exercise offer people with pain?

Well, to me exercise is a simplified context for learning what feels OK and what doesn’t. Exercise (or movement practices) don’t have all the contextual factors that make life difficult. For example, when I’m gardening I need to factor in the ambient temperature, the time of year, the lifecycle of my plants, their needs for compost and water and pest removal. I also need to find a suitable time to garden, assemble all my equipment, be aware of all the other things I need to get done in my ‘spare’ time, and what needs doing in my garden. If I’m working alongside other people, I need to bear in mind the bits they want to do, the bits that need doing, and the bits I like to do. We need to coordinate our efforts so we don’t all go to do the same thing. Gardening is always influenced by context.

If, as I suspect, movement practices offer a simplified context to do movement with a person who helps me feel safe (I won’t damage myself when a therapist is present), who can encourage me to nudge in to movements I’m not confident about, who can offer suggestions about how I might change the way I go about doing a movement, or the quantity – then the ‘work’ is much less about the form of movement I do but much more about the ‘work’ the clinician does. And clinicians, it probably isn’t to do with the form or quality of my movements, but so much more about how YOU go about guiding ME to experience what my body is feeling like while it’s doing the things.

If my hunch is on the money, then the skills so often relegated to ‘oh you’d better do some communication stuff’ or ‘those soft skills’ might actually be the most critical ones a clinician can develop. Because, so it’s been found, words are sticky and have power (O’Keeffe et al., 2022) – and the more people listen to the words spoken in a clinical context, the less able they are to notice their own body responses (we can’t do divided attention very well). And those words spoken can act as life-long rules for behaviour (Barnes-Holmes & Harte, 2022). We know this simply by listening to the narratives of people describing no longer doing things they love on the basis of an authoritative word from a surgeon about the state of an osteoarthritic joint, or back pain and the risk of ‘damage’…(eg Stenberg et al., 2014; Christe et al., 2021).

What skills might be needed to facilitate awareness and build confidence?

Guided discovery is an approach used in psychotherapy – this involves the clinician obtaining data (information) from the person using open-ended questions, then guiding the person to pull that information together in surprising ways, testing assumptions and helping them to notice what they already know to be true. In therapies such as graded exposure for phobias, guided discovery helps people notice and be OK to nudge into discomfort, waiting for the symptoms of anxiety to reduce, and then noticing that this has happened even in the presence of the thing the person fears. From ACT, noticing without judgement is an integral process for people to tune in to sensory experiences so they can be in the present moment and become aware of the in-real-time impact of their actions.

I suspect the same skills might be critical for effectively guiding learning in movement therapies. That is, helping the person nudge into previously worrying movements, guiding them to notice what happens, remaining engaged in the movement enough times that the alertness level drops, and then drawing the person’s attention to how that feels. The therapists work is all about guiding the person to notice their own sensory experience, and of course, in structuring the movements so that the intensity and complexity suit where the person is at.

What this kind of approach won’t do on its own, is help that person transfer their learning undertaken in the safe clinic area with a safe clinician, into the complexity of daily life – and this is where occupational therapists should be adding their input. Because learning doesn’t transfer readily from one context to another without this process being structured, and without lots of repetition and exposure to lots of different contexts.

Helping people gain confidence in what their body feels like when it’s moving is a ‘transferable skill’. Learning to trust your own body experience allows you to experiment with different forms of movement practice. Different movement practices allow us to keep moving throughout our entire lives, in different ways to suit time, equipment, location, goals, money and motivation/interest.

You see, I don’t think movement or exercise is much about fitness or other physiological factors, except that when someone has a pain problem, it’s likely to mean a much bigger reaction from the nervous system (ie pain payback or pain flares) than in everyday folks. To counter this, we need to build confidence, awareness, willingness to go gently into these uncomfortable experiences, and then to sustain practice in all the life contexts so we can be able to do the things exercise and movement are supposed to promote: healthy living. If exercise doesn’t contribute to healthy living (note the emphasis on living), then all the health in the world isn’t worth it. If I’m healthy but don’t do the living I want to do, why that sounds a lot like being in prison.

Barnes-Holmes, D., & Harte, C. (2022). Relational frame theory 20 years on: The Odysseus voyage and beyond. Journal of the Experimental Analysis of Behavior, 117(2), 240-266. https://doi.org/10.1002/jeab.733

Christe, G., Pizzolato, V., Meyer, M., Nzamba, J., & Pichonnaz, C. (2021). Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskelet Science and Practice, 52, 102342. https://doi.org/10.1016/j.msksp.2021.102342

Huijnen IP, Verbunt JA, Peters ML, et al. Differences in activity-related behaviour among patients with chronic low back pain. European Journal of Pain 15(7):748-755, 2011.

O’Keeffe, M., Ferreira, G. E., Harris, I. A., Darlow, B., Buchbinder, R., Traeger, A. C., Zadro, J. R., Herbert, R. D., Thomas, R., Belton, J., & Maher, C. G. (2022). Effect of diagnostic labelling on management intentions for non-specific low back pain: A randomized scenario-based experiment. Eur J Pain. https://doi.org/10.1002/ejp.1981

Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2014). ‘I am afraid to make the damage worse’ – fear of engaging in physical activity among patients with neck or back pain – a gender perspective. Scandinavian Journal of Caring Sciences, 28(1), 146-154. https://doi.org/10.1111/scs.12043

Tynan, M., Virzi, N., Wooldridge, J. S., Morse, J. L., & Herbert, M. S. (2023). Examining the Association Between Objective Physical Activity and Momentary Pain: A Systematic Review of Studies Using Ambulatory Assessment. Journal of Pain. https://doi.org/10.1016/j.jpain.2023.10.021

Villatte, M., Villatte, J. L., & Hayes, S. C. (2016). Mastering the clinical conversation: Language as intervention. Guilford Press.

ACT plus exercise, vs exercise alone…

and what a shame there was no ACT alone group…

No secret here, I like ACT (Acceptance and Commitment Therapy) as an approach for living well with chronic pain. I like it for many reasons, but probably the most compelling ones are that the hierarchy between therapist and person living with pain is minimised (we’re both humans finding our way through life) and that it doesn’t require the person to delve into challenging or disputing thoughts – this in turn enhances adherence to the core elements of ACT: living a life aligned with what really matters to this person. People seem to find using ACT more appealing than other forms of therapy for chronic pain.

Anyway, just recently a new study investigating ACT plus an additional exercise component (for eight weeks of physiotherapy supervised exercise, and ACT led by a psychologist), vs a supervised exercise programme only. This recent publication is a 12 month follow-up from the original (Casey et al., 2022).

The design of this study involved participants referred to an outpatient musculoskeletal clinic living with any chronic pain condition. Participants were excluded from the trial if they needed further diagnosis, experienced a major medical or psychiatric diagnosis, had cancer, an ‘unstable’ inflammatory condition, substance misuse, some kind of surgical or interventional procedure in the previous 3 months, were part of another supervised exercise programme or were taking part in psychological or physiotherapy treatment, or had attended a previous multidisciplinary pain programme – or couldn’t exercise because of some contraindication.

The two approaches were: (1) an ACT programme with exercise – 8 weeks of once a week two hours of ACT, then a 1.5 hour of exercise led by a physiotherapist who had not undertaken ACT training; and (2) 8 in-person supervised physiotherapy exercise sessions that followed the same structure as the ACT plus exercise. The same therapist led both groups of participants in the exercise component.

The primary outcome was pain interference as measured by the Brief Pain Inventory at 12 months follow-up, with secondary outcomes of pain intensity (BPI), the Patient Health Questionnaire-9 for depression, and the General Anxiety Disorder-7 to assess anxiety. Patient satisfaction was measured, along with the Patient Global Impression of Change. “Process” oriented measures (designed to measure factors thought to change over time and influence outcome) of pain self efficacy, pain catastrophising and the TSK were also taken, along with two measures from ACT, the Chronic Pain Acceptance Questionnaire and the Committed Action Questionnaire.

There were some intriguing changes to the original protocol including redefining some of the measures from outcomes into process measures, and the exercise intervention wasn’t fidelity tested.

What did they find? Well, a bit underwhelming for a person who likes ACT, to be honest! Both groups showed the same amount of pain interference, though with a slight tendency towards the ACT + exercise group which became significant only at one year. No other differences between the two groups were identified with the exception of slightly reduced pain catastrophising in the ACT + exercise group. Participants were happy with the ACT + exercise programme vs the exercise only, and the same participants reported positive responses to the global impression of change question.

Interestingly, there were more drop-outs from the exercise-only group, and the authors also report that the therapist contact time wasn’t equivalent. With a very low follow-up response rate (slightly higher for the ACT + ex group), again it’s not really possible to definitively know just how effective either approach was. The authors also point out that participants weren’t encouraged to use ACT approaches during the exercise part of the ACT + exercise programme because the physiotherapist wasn’t trained in ACT.

Some unanswered questions for me from this study, which was well-conducted within the confines of funding and patient availability.

One big question for me is why movement practices aren’t routinely part of ACT for chronic pain anyway. Certainly the way I practice, and the way physiotherapists I know who have learned ACT and use it routintely, wouldn’t add a non-ACT-based movement intervention into the mix. Given we know that movement practices are an ideal context for employing ACT methods, I’m curious as to why the principles that have been part of CBT approaches to pain management (ie all the team adopt the same over-arching model, employ the same strategies) weren’t adopted here. It’s during movement practices that sticky thoughts arise, and when leaning in to discomfort with pain and anxiety and sadness is highly relevant. They’re also a great time to work with self-as-context given how relevant self-concept is when setting movement practice challenge intensity. Of course, I’d still argue that movement practices can be decontextualised from daily life, and there is always a need to get out of the clinic and into the real world, however even in a ‘gym’ or ‘exercise class’ setting there are opportunities for physiotherapists (and other movement practitioners) to apply ACT strategies.

That the team members didn’t share skills across the team raises yet again the problem we have with siloed treatment. Interprofessionalism is sorely needed to ensure consistent practice of any kind of approach, whether it’s a physio using ACT to work with sticky thoughts and mindlessness, or it’s a psychologist understanding enough about movement and bodies to reinforce that movement is a good thing. It’s like the interprofessional nature of chronic pain management hasn’t yet gone very far, and I wonder why given how many decades it’s been since this was first proposed (at least since 2005, see McCallin, 2005).

Arguing for exercise (about which we know a reasonable amount) head-to-head with ACT + exercise feels a bit redundant to me. We know movement is a good thing. We know the effect sizes are small on both pain intensity and disability, and we know these are consistent findings for almost any treatment approach for chronic pain. We also know that ACT for chronic pain is slightly better adhered to than other forms of therapy, and that it seems especially helpful for people who avoid and are freaked out (though not so much as to make us use it everywhere). What we don’t know, and this study, along with many others, can’t tell us, is whether it made a big difference to the unique and individual daily lives of participants.

Some other missing information that I’ve commented on before. We don’t know the regular movement practices of participants prior to entering these programmes. We don’t know whether participants maintained their movement practices beyond the end of the eight week programme. We have no idea whether the movement practices were enjoyed by participants although we do know that people attending the ACT + exercise were more satisfied than those just attending exercise. We don’t know anything about their lifestyles before, during or after the study, so we don’t know whether the gym or hydrotherapy were exercise practices they valued. We also don’t know whether they transferred any of the learning from the movement practices into other parts of their lives – step counts do not equal daily life. We don’t know anything about the participants family life, their sense of curiosity and joy, or even whether participants who weren’t working during this study were able to return to work or find work.

If we are going to be serious about helping people with persistent pain live lives they value, isn’t it important to find out what people want to be able to do in their worlds? If we want to know how well a therapy works, shouldn’t we attempt to find out a bit more about the person’s world so that anything we offer can actually be done long-term? Life is more than a series of exercise programmes and psychotherapy – life is full of surprises, awe, devastation, busy periods, slow times, grief, love, births, deaths and other health problems. While designing studies is hard, I wonder if we’ve come to the end of the usefulness of further studies exploring movement/exercise for chronic pain. The studies don’t seem to be adding much – just that movement practices are good for health. We kinda know that. Let’s get far more creative and work out how people can integrate all sorts of movement practices for the entirety of their life, throughout all of their life contexts, in all that they do. And let’s do the same for ‘psychological’ approaches. In fact, can we move from siloed ‘physio, psychology, OT, nursing’ and into ‘pain therapists’ and remove the death grip we seem to have for ‘our unique contribution.’ We have far more in common than not in pain therapies, and there is considerably more power in a united approach than a fragmented one.

Casey, M. B., Smart, K. M., Segurado, R., Hearty, C., Gopal, H., Lowry, D., Flanagan, D., McCracken, L., & Doody, C. (2022). Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: A randomised controlled trial. Pain, 163, 1158–1171. https:// doi. org/ 10. 1097/j. pain. 00000 00000 002487

Casey, M. B., Takemasa, S., O’Reilly, T., Leamy, M., Mc Kearney, E., Buckley, M., Smart, K. M., Segurado, R., Lowry, D., Flanagan, D., Gopal, H., Hearty, C., & Doody, C. (2024). Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial. European Journal of Pain. https://doi.org/10.1002/ejp.2229

McCallin, A. (2005). Interprofessional practice: learning how to collaborate. Contemp Nurse, 20(1), 28-37. https://doi.org/10.5172/conu.20.1.28

Guarding and flow: an observational study

It’s been a while since I reviewed a paper but this one caught my eye! Amanda C. de C. Williams is one of my favourite researchers because her work captures social and anthropological aspects of pain – and she’s been researching and teaching for a very long time.

This study is an observational study of physiotherapists watching videos of people with chronic low back pain doing movements. The movements are pretty decontextualised (ie they’re not integrated with everyday life activities) but they are the kinds of movement that people can find difficult. They were: reaching forward with arms horizontal in standing position (reach forward), bending down towards the toes in standing position (forward-bend), standing from sitting stand), and sitting from standing (stand-to-sit). The videos were of 10 people with low back pain, and were chosen from a larger set of 16 people all performing each movement twice: choice was based on showing both sexes, a range of ages, and as wide as possible variation in pain-affected movement. Most lasted less than 30 s.

Sixteen physiotherapists were included, and these were working in senior positions in full or part-time work with people experiencing chronic pain. The average time since graduation of these clinicians was about 21 years (10 – 33 years range).

Each physio watched eight videos drawn from the set of recordings, and were asked “How would you describe the movement”, with further probes such as “Would you describe it as guarded, slow?” etc, and “when do you notice the movement being different/abnormal?”, “did the movement have flow?” and “what single piece of advice would you like to give the patient to help with this movement?”

The analysis followed framework analysis method, which is aligned to thematic analysis but with the use of existing theory (eg deductive analysis rather than inductive where the themes are developed de novo from the data itself), carried out by one researcher, while another independently completed an inductive analysis on ‘flow’. The two forms of analysis were compared and found to be very similar despite the different approach to thematic analysis.

What did they find? Well, this is intriguing because we rely on physiotherapist’s observations to understand movement patterns when considering clinical reasoning and ultimately therapy. Guarding was identified but typically qualified by noting its presence in part of a movement, or a body part. Agreement was not high. Ooops.

Guarding was, however, different from ‘stiffness’, ‘slowness’, and ‘bracing’ – stiffness considered to be ‘rigid’ or ‘wooden’, while guarding was considered more in terms of emotion. Bracing wasn’t really identified except for taking weight through the hands (hands on thighs) when moving from/to sitting and standing.

Guarding was described as ‘cautious’, ‘protective’, ‘fearful’ and ‘avoidant’ – a sense of reluctance to move, and participants related this to the part of the body moving at the time such as ‘thoracic spine’ or ‘didn’t want to move the lumbar spine’. Interestingly, participants anxiety about the movement weren’t commented on…

Flow was also not very consistent between the physiotherapists, but what was interesting was that therapists commented on the limited information about the person in context, there seemed to be more curiosity about the person and their beliefs and feelings than in the observations of guarding. Flowing movement was described as ‘lovely’ or ‘intuitive’ or ‘confident’ and seemed to be described as expressing confidence in the movement, even if the actual movements themselves were idiosyncratic.

In the discussion, these authors report that while there wasn’t a great deal of agreement between physiotherapists on the specifics of guarding and flow, once they were asked to elaborate on their analysis they were more consistent when observing and describing tension or apprehension.

Why would this study matter? What does it add?

One of the characteristics of movement in people who are feeling sore is a quality of hesitation or a lack of ‘fluid’ movement – flow. The descriptions from this study suggest that while these therapists, who were highly experienced, weren’t consistent between one another, they did pick up on flowing movement based on movement tempo, and perhaps might represent something described as by Csikszentmihalyi. Not over-controlled, nor un-controlled. Looking effortless, moving freely between positions, no sudden changes in speed between parts of the movement or parts of the body.

The advice these physiotherapists gave also aligned with Csikszentmihalyi’s idea of ‘just-manageable’ (the ‘just-right’ challenge), stopping or altering the movement right at the point just before the guarding or hesitancy occurred.

The authors then discuss what they believe matters from this study. What matters is that movement qualities appear to reflect both emotions and ‘bio’ limitations, and these physiotherapists were able to identify them, albeit not very consistently.

Guarding is a term used often in pain movement rehabilitation. Flow – not quite so much. There’s some good evidence that movements related to a real world activity rather than a decontextualised fragment of a movement are more variable, more accurate (when accuracy is important) and more flowing (see Wulf, G., & Lewthwaite, R. (2016). Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychonomic bulletin & review, 23(5), 1382-1414.). People also try harder when it matters to them – so they’re more likely to walk briskly to catch a bus than when being asked to ‘show me how you walk’ and their gait pattern is likely more variable.

I’m always about understanding the real world and what it is that people need and want to do in their own life context. If movement therapists (a very broad church!) could be more consistent in the way they observe and interpret movement practice in a person’s own daily life, we’d likely have fewer exercise interventions that bear little resemblance to what a person actually wants and needs to do. Getting fitter, while a worthwhile goal, may not help a person feel confident to lift their mountain bike onto the bike carrier on the back of their car, or to carry their wriggling child into bed, or even to manage vacuum cleaning the whole house at the end of the day when they’ve been busy in the garden. The effect sizes of exercise, like almost everything else in chronic pain management, are small on both pain intensity and disability – and I think exercise is over-emphasised by comparison with the other things a person needs and wants to do in their day.

I look at a study like this, and I wonder if the faith that people place in the movement analyses of therapists should be tempered a little with knowing that: 1. The level of agreement between these experienced therapists was quite low, it’s likely to be lower in less experience clinicians. 2. Decontextualised movements don’t look a lot like real world contextually-embedded movements that we need to do. 3. Flow or movement fluidity could be a useful construct to investigate because it seemed to influence these clinicians towards exploring, with curiosity, more about the person than their assumed body movement deficits, while searching for guarding seemed to elicit more focus on biomechanics. 4. The final sentence of the abstract really resonates: “Movement behaviours associated with pain are better understood in terms of their particular function than aggregated without reference to function.”

I have a bunch of methodological questions – like what were the ethnic backgrounds of each of the people in the video? were they sore at the time of the recording? why weren’t real world activities used? why were there two methods to data analysis (this is partly explained)? But for now, this study piqued my curiosity, so I shared it!

Update from one of the authors (Prof Amanda C de C Williams) re the questions I’ve posed: (NB my interpretation, not word for word).

The ethnic/cultural backgrounds of participants were mainly white – and this is an acknowledged limitation of this study. The research team were more diverse however.

All participants reported pain of moderate intensity at least – 5/10, and some found the movements quite demanding.

The reason decontextualised movements were used relates to the equipment available at the time of this study. The monitoring equipment was not wireless, so people were trailing cords and in a shielded environment. A more recent study being carried out is far less intrusive, uses real world activities and people aren’t encumbered with wires and things.

At the time, the purpose was to train machine learning, so standard movements were used – now that this has been achieved, real world and complexity can be added.

Finally, two different forms of analysis were undertaken because this team was not in the one location, and one of the team members was being trained. While it could be considered a weakness in the study, having two forms of analysis converge on similar themes suggests consistency (it would be called triangulation if there was another person in the mix!!).

Williams, A. C. C., Buono, R., Gold, N., Olugbade, T., & Bianchi-Berthouze, N. (2023). Guarding and flow in the movements of people with chronic pain: A qualitative study of physiotherapists’ observations. Eur J Pain. https://doi.org/10.1002/ejp.2195

All by myself… don’t wanna be

Throughout my career, I’ve been interested in how and why people see clinicians about their pain. I’m intrigued by the journey before, during and afterwards.

I’m interested in the social factors influencing choices in healthcare. If I’ve been gardening over the weekend and I wake up Monday with a sore back it’s easy to see a physio here in NZ. That visit is likely paid for by our accident compensation system (24/7 no-fault scheme paid for by taxes and levies). And the jolly joy germ in me thinks “Well at least that means people don’t have to see a doctor first” – but there’s also a tiny cynic in me wondering “what if…?”

The ‘what if’ is all about knowing what I know about low back pain trajectories and how little anyone can do to ‘treat’ acute low back pain. It’s about thinking maybe it’s time we took a hard look at what we’re not doing well but seriously need to. And a dollop of “what if we took the market-driven ideology out of healthcare, removed the perverse incentives that create the drive for repeat customers and unnecessary treatments, and gave people more information about how to self-manage?”

If you’re not aware about low back pain trajectories, here’s the thing: repeated episodes of low back pain are more common than not. In fact there have been a good number of longitudinal studies investigating trajectories finding three or four groupings: High intensity and stable; high intensity but gradually decreasing; medium intensity and stable; and low intensity and decreasing (Andersen et al., 2022). Other studies have shown fairly similar and stable paths for people with chronic pain (Glette et al., 2019).

Now my point is that we know this, and we’ve known it a while. My question is: If it’s probable someone will have either ongoing pain, or recurrent pain, what are we doing to help people manage by themselves? Where are our public health messages about self-managing pain? What do our clinicians themselves know about the trajectories and self-management? Could there be a somewhat selfish reason for the lack of attention to helping people help themselves?

Conversely, I know that when you’re feeling sore, especially if the pain is new, intense, or has been grinding on for ages… seeing a clinician seems sensible. Nobody wants to be dealing with pain all by themselves. And there are some people who feel that self-management is essentially dumping the problem back on to the very people who are most vulnerable – almost like self-management is suggested because “Oh the doctor’s not interested”, “On you go, I can’t do anything about this, you deal with it” (Gordon, et al., 2017, p. 213).

Actually, the paper by Gordon, et al., points out that people may be given information during a course of treatment but that nobody follows the person up – even though both people with pain, and those treating them think this is important. It’s worth noting this study was carried out in a publicly funded jurisdiction. We don’t much have that for non-accident-related problems in New Zealand, so there is very little self-management support and no follow-up at all for most.

Supported self-management is the term given to approaches combining self-management (as I defined it here) with clinician support. The clinician support seems to be important, as Svendsen et al., (2022) found, as did Devan et al., (2018). This is because people find self-management hard work (believe me, it surely is – all that planning, judging, deciding, prioritising, fitting it all in to an already busy life!), particularly if pain and low mood and unhelpful others are around. And the time people feel most vulnerable is likely during a flare-up or when other life events demand energy. Supported self-management will only help, however, if the support offered (especially during a flare-up) continues to focus on supporting self-management. It won’t work if the person’s confidence to manage by themselves is eroded by a well-meaning clinician referring them off for another scan or procedure, or bumping up the medications …

Now if I look at the New Zealand setting, where is supported self-management? Despite showing that self-management programmes for pain are cost effective (see Chowdhury et al., 2023), there are few self-management programmes available and there doesn’t appear to be anything for ongoing support – at least, not freely or widely available. Most pain management programmes in NZ are a combination of exercise plus psychology but the content of those programmes is not visible. Self-management strategies need to be integrated into daily life and there’s very limited occupational therapy involvement even though this is what occupational therapy is all about.

There is about to be a new government in New Zealand. The spokesman for health in the National party was a GP. I hope that he chooses to step up to the challenge of implementing supported self-management for pain – and takes the lives and suffering of the 22% of New Zealanders living with chronic pain seriously. I hope he listens to academics who know of good solutions – and doesn’t simply focus on expediency and simplistic notions of ‘quick fixes’ that have not worked. Privatising healthcare has led to wider service availability – but lower quality of care. There is no incentive to pay for a senior experienced clinician when a less expensive new graduate can come in to do the job. It takes time to develop a deep understanding of just how difficult it is to self-manage pain, and it takes time for clinicians to let go of their ideas about ‘what works’ and start to listen to the people they want to help. It takes maturity to say ‘your idea sounds great’ when someone comes up with a plan to help themselves – even if that plan doesn’t look like something learned in undergrad.

The thing is, people with pain want supported self-management – but it takes time to learn why and there’s a process of coming to terms with it. Once someone has learned that pain is likely to hang around, and medical approaches don’t offer very much, the really hard part begins: picking up all the pieces of life, stitching it back together again but differently, and then carrying on with daily self-management.

Andersen, T. E., Karstoft, K. I., Lauridsen, H. H., & Manniche, C. (2022). Trajectories of disability in low back pain. Pain Reports, 7(1), e985. https://doi.org/10.1097/PR9.0000000000000985

Chowdhury, A. R., Schofield, D., Shrestha, R., & Nicholas, M. (2023). Economic analysis of patient-related effects of an interdisciplinary pain self-management program. Pain, 164(11), 2491-2500. https://doi.org/10.1097/j.pain.0000000000002959

Glette, M., Stiles, T. C., Borchgrevink, P. C., & Landmark, T. (2019). The Natural Course of Chronic Pain in a General Population: Stability and Change in an Eight-Wave Longitudinal Study Over Four Years (the HUNT Pain Study). Journal of Pain. https://doi.org/10.1016/j.jpain.2019.10.008

Gordon, K., Rice, H., Allcock, N., Bell, P., Dunbar, M., Gilbert, S., & Wallace, H. (2017). Barriers to self-management of chronic pain in primary care: a qualitative focus group study. British Journal of General Practice, 67(656), e209-e217. https://doi.org/10.3399/bjgp17X688825

Dancing around the hexaflex: Using ACT in practice 6

Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists (remember ACT is open for anyone to use it!) can use ACT in session.

Actions: It’s what we’re about

You know the old saying “All talk, no action”? There are times I think people with pain get much more talk-talk-talk than action, and the actions that get done are those to please other people. Let’s unpack the ‘committed action’ part of the ACT hexaflex.

Actions are either done – or not. No half-actions here! Goals, as I mentioned in Using ACT in practice 5, can take our focus away from what we are doing to what we hope we’ll achieve. In other words, goals can take us away from the intrinsic experiences of moving towards something that matters. If we’re only looking at ticking the goal off our to do list it becomes hard to be in the moment as we journey towards that result.

But if we look at rehabilitation practice, particularly if we’re funded by an insurer who wants to see ‘outcomes’ because they’re paying for it, often we see a list of ‘goals’ the person must achieve for therapy to be considered a ‘success.’ Do these goals help the person move towards what matters long after the therapy programme is done and dusted? Do people still do those things when they’re discharged from our care? And for chronic pain management, surely most of the self-management options are exactly those things the person will need to do for life?

Actions done differently

I hope it goes without saying that actions need to align with a person’s values.
People must know why their actions are important. People also need to know that they can achieve them, or that they can achieve them with a push.

You see, rehabilitation is a scaffolding process. We simplify aspects of a task so the person can achieve it, then we progress the tasks until the person reaches as far as they can. By simplifying, I mean we modify movements, or weight, or speed, or the environment; we remove unpredictability and complexity so the person can focus on just the parts they need to, maybe we include ourselves as a safety net, so the person knows we won’t let them come to harm. We celebrate as they achieve the task. And we always must remember that scaffolding eventually comes down.

I like the way FACT therapists are taught to establish actions. They’re called ‘behavioural experiments’ – opportunities for the person to do an action and observe the result. The way this is done is pretty cool.

Firstly the person has identified what matters to them. The therapist has carried out a case formulation and identified the person’s strengths and vulnerabilities on the three pillars (Openness, Awareness, and Engagement), and with the person develops two actions they can choose from. One action has less effort and less risk and has more certain results, while the other requires greater effort and potentially can promote more radical change.

Now these actions can use SMART features (you know – specific, measurable, achievable, relevant and timely), but the key is that they’re tied to helping the person move towards what matters, to enhancing psychological flexibility – and the best part is that the person can choose which one they’d like to do.

Importantly, obstacles to doing these actions are always discussed and there’s a good deal of problem-solving about how to make sure they do fit in to the person’s life. At the same time, the person is invited to draw on the other parts of the hexaflex (or three pillars) as they do this action. They’re asked to notice (mindfulness), to be willing (even if it’s a bit scary), to put their mind’s chatter to one side so they can choose for themselves (defusion), and to be willing to take a different perspective as they give it a go.

More than this, when they’ve tried the action, they get to debrief. They’re supported to review what they did (action), how it felt (mindfulness/noticing), whether the action took them towards or away from what matters (values), how else they could do it (variation), and what their next step might be.

Even more cool: if the person ‘didn’t do it’ this is not a failure! Instead, it’s an opportunity to:

• Give credit to the person for being willing to show up and tell you they didn’t do it (it’s an unpleasant feeling to know you’ve not followed through)
• Establish what mattered more, what was it about the action or the context, or other parts of the hexaflex that might have either hindered or helped
• Reconsider the values underpinning that action – and did you as therapist mistake what was important
• Be flexible about what the action looked like. How else could the person do it? There is always more than one way to move towards…

A bit far from the old ‘do what I advise because I’m the therapist’!

Actions are ongoing

An action is one event, and life is usually not isolated into single events. If we want to go towards the mountains, there’s often a river or a swamp to get through before we start going uphill. We need to make decisions about how we’re going to get through the river or swamp – and some of the actions we subsequently take look like they’re moving us away from getting to the mountain. We could choose to wade thigh-high across the river to head directly to the mountain, or we could do a detour and go over the bridge, then head towards the mountain.

This is life. Therapists will need to help people keep their eyes on the prize – and often to help funding agencies recognise that getting towards the mountain without wading across the river means doing a detour. It’s part of the journey. If we have a bird’s eye view or we’ve used a map, we can see why doing the detour is important. We have a different perspective – and sharing that perspective both with the person and their whānau/family and the funding agency – can help them see why the detour is relevant and necessary.

When the person finds the journey hard, the detour weird, can’t see the mountain because the swamp reeds are way too high, our job as therapists is to help them see the map. Remind the person of their values – why they wanted to go towards the mountain. It’s not our job to just advise on the next road to take, or that the detour is necessary. It’s our obligation to help keep the person’s eyes on the prize while also helping them savour the journey getting there.

In other words, while we might offer advice about how a person moves towards what matters in their life, it’s not our job to focus only on that. We’re there to help them do what matters to them. Sometimes that means we need to recognise we’re not the right guide for this part of the journey. This is where teamwork comes in.

Points to take home

• Actions are what we do – we can’t predict outcomes, but we can decide to do, or not do, actions.
• A move towards what matters is progress, even if it’s small.
• Notice what happened when taking that action. Bring awareness to all that happens when doing the action – even the uncomfortable, awkward newness of it.
• Draw on why that direction is important.
• Take a bird’s eye view if it feels like you’re taking a detour. Get someone else’s perspective because they might have a bigger map.
• It’s OK to drop an action if it no longer serves you. If it’s not helping you move towards living your values, and you can’t see how it fits in – maybe it’s scaffolding you don’t need any more. You can always pick it up again if you find that it was helping.
• There are usually lots of different ways to move towards what matters. You don’t have to be stuck doing the same old, same old – try some variations!

For some thought-provoking papers on goal-setting in rehabilitation, this one by Gibson and colleagues makes me ponder: Gibson, B. E., Terry, G., Setchell, J., Bright, F. A. S., Cummins, C., & Kayes, N. M. (2020). The micro-politics of caring: tinkering with person-centered rehabilitation. Disability & Rehabilitation, 42(11), 1529-1538. https://doi.org/10.1080/09638288.2019.1587793

This paper by Crawford and colleagues details barriers and facilitators for person-centred goal-setting: Crawford, L., Maxwell, J., Colquhoun, H., Kingsnorth, S., Fehlings, D., Zarshenas, S., McFarland, S., & Fayed, N. (2022). Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review. Clinical Rehabilitation, 36(12), 1694-1704. https://doi.org/10.1177/02692155221121006

The series:

Hexaflex 1 – Mindfulness

Hexaflex 2 – Self-as-context/perspective-taking

Hexaflex 3 – Cognitive defusion

Hexaflex 4 – Willingness

Hexaflex 5 – Values

Dancing around the hexaflex: Using ACT in practice 4

Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists can use ACT in session (remember ACT is open for anyone to use it!).

Willingess (Acceptance) – Choosing to experience it all

Do you remember the poignancy of a beloved pet dying? ‘Crossing the Rainbow Bridge‘ was written by 82-year-old Edna Clyne-Rekhy, who wrote the poem at age 19 in 1959, at the passing of her beloved dog, Major (Wikipedia entry) and tells of the reunion of pet and pawrent years later when the pawrent dies. It’s sweet and sad at the same time, and while I’m not convinced there is a Rainbow Bridge, the loss of a pet is a time of heart-wrenching grief. And yet the years of unparalleled love of a pet leads inevitably to this time. If you love, you hurt when that love isn’t there any more.

Willingness is like that. It’s about recognising that for every ‘up’ emotion, there are equivalent ‘down’ emotions. And that by feeling all the feels that life offers, we move through life moment by moment.

Willingness for pain

Willingness in pain management and rehabilitation often focuses on people being willing to experience pain. Willingness in this sense being quite different from resignation to, or giving up, or resenting, or ‘getting on with it despite’. Willingness is about choosing to make room for pain to be there without trying to change, control or avoid it – because it’s worth it. And like all ACT processes, willingness is a process we can work towards, titrating the difficulty to suit where we’re at in the moment.

By drawing on what is important to the person (their values) and using the other processes, being willing to do things with pain along for the ride is possible. We use this a lot in acute pain: people volunteer to have surgery (painful) so that a better health outcome is possible; women go through childbirth (painful) so they have a new life to raise; runners train (painful) so they can enter races or keep fit. The ‘so what’ gives meaning to pain and people are willing to do what it takes, even if it’s painful, so they can achieve it.

In persistent pain, it’s not quite as straightforward. The pain may not change a lot, so the promise of ‘do X to get Y’ isn’t quite as clear cut, especially if as a clinician you don’t feel terribly confident that it’s OK to experience pain. Some people really don’t want to experience pain even though they can do all the things they need and want to do. That can be confronting especially if there is no certainty that pain will reduce or go. I’m not sure I have a remedy for that, because it’s predicated on the idea that pain should not be present. And yet, there it is in at least 22% of New Zealanders, and there are many painful problems for which we have very little we can do to reduce pain. Willingness acknowledges the reality that pain is there.

Willingness is a yes or no thing.

And we’re willing (yes or no) depending on context. I’m willing to have a flare-up after gardening at the beginning of the season because:

(a) I know it’s not a sign of harm (cognitive defusion)

(b) It’s worth it getting my garden ready for spring (values)

(c) I’ve set my target intensity to something I can handle (committed action)

(d) I’ve done it before and I know I’ll get over it (self-as-context)

(e) Along with the achey bits, I also have the sensory experiences of freesias blooming, the texture of compost as I spread it over the garden, the tiny pink buds of blossom just starting to show, the birds (except the blackbirds and thrushes digging my poor wee seedlings up!!), and at the end of the day I savour the achievement. AND I know that as I keep gardening my tendency to flare will settle.

I’m less willing to hurt just to vacuum the house.

Willingness isn’t just about pain

But it’s not just about being willing to experience pain. It’s also about being willing to experience other negative emotions that show up because we have to adopt new and different ways of doing to accommodate pain. For example, I don’t weed my entire garden in one day. That’s frustrating – and I would rather not be frustrated! Willingness means being OK to do less – and feel frustrated – because I know I want to do other things this week, such as write this blog.

Willingness means being OK to be vulnerable enough to ask people for help – and risk rejection. To say no to things – and risk censure. To take time for yourself – and risk criticism for ‘being selfish’. To do new and unfamiliar practices like meditation, or take medication regularly, or develop priorities, or seek accommodations at work. People need to be willing to do things differently at work – and face negative comments from colleagues. They may be repeatedly asked why they haven’t been asking for an MRI – when they’ve been told it’s not needed.

ALL of these actions might be uncomfortable, even lead to negative consequences at first. Any time clinicians ask someone to do something that’s not familiar to the person in their life, that person risks feeling uncomfortable and needing to be willing to stick to their guns. This means clinicians, we need to look at ways to help the person use the other processes in the hexaflex, and titrate the demands, so they can do the things. And we need to be oh so careful not to assume that the person is ‘unmotivated’ if they struggle to do the things.

Tips for beginning willingness

• Remember it’s a process, so start by dipping in to willingness: 5 minutes of being willing to do a body scan and experience pain; one request for help today; 5 minutes break having a coffee (instead of continuing to work at your desk); a 5 minute walk
• Rehearse what to say, if it’s about asking someone to do something, or make accommodations for you, or to say no to something.
• Dig deeply into the values doing this thing draws on: remember the why! “It’s important to do only this part of the garden because I want to make tea for my family tonight”
• Use cues to remember how much, how long, why – and if you like monitoring yourself, these can be great progress reports so you can see that you are moving forwards.
• Give yourself permission to do things differently because ‘It’s part of your rehabilitation’ (self-as-context AND cognitive defusion).
• Nudge into new things gently – it’s OK to start, monitor, review and repeat.
• Acknowledging that this is not easy helps you remember and be compassionate towards yourself. You are bravely being present with what is. This is courage.

An exercise for willingness is here: click

Some cool web-based resources:

Willingness Skills for More Regulated Emotions

Willingness in difficult times: Holding the cactus gently

Thompson, M., & McCracken, L. M. (2011). Acceptance and related processes in adjustment to chronic pain [Review]. Current Pain & Headache Reports, 15(2), 144-151.

Foulk, M., Montagnini, M., Fitzgerald, J., & Ingersoll-Dayton, B. (2023). Mindfulness-Based Group Therapy for Chronic Pain Management in Older Adults. Clinical Gerontology, 1-10. https://doi.org/10.1080/07317115.2023.2229307

Pester, B. D., Crouch, T. B., Christon, L., Rodes, J., Wedin, S., Kilpatrick, R., Pester, M. S., Borckardt, J., & Barth, K. (2022). Gender differences in multidisciplinary pain rehabilitation: The mediating role of pain acceptance. Journal of Contextual Behavioral Science, 117-124. https://doi.org/10.1016/j.jcbs.2022.01.002

Dancing around the hexaflex: Using ACT in practice 3

Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists can use ACT in session (remember ACT is open for anyone to use it!).

Cognitive defusion

I’m guessing that for psychologists and those who primarily work with thoughts, it feels natural to begin here, but maybe all humans jump to talking rather than doing because this is the biggest distinction between us and other animals.

Cognitive defusion refers to making some space between a thought or belief, and what we do next. It’s not just about actions we take, but also how seriously we hold on to the opinions of our mind.

The language theory underpinning ACT is relational frame theory. This theory explains how humans rapidly acquire an understanding of relationships between concepts, and why these learned relationships become so ‘sticky.’

For a full description of RFT, this is a great place to begin [Youtube playlist]. If you’re a reader, not a video watcher, I love the paper by Beeckman and colleagues (2019) (listed below).
The topic is pretty technical, so I’ll simplify it and just say that humans learn to relate to one concept (stimulus) based on how it is related to another stimulus (concept). We do this directly through our personal experiences, but we also do this by arbitrarily relating concepts (stimuli) to other concepts using language, and from these relationships we develop relationships between those associations to even more associations that have never been experienced or been talked about!

Some of these verbal rules make sense – in some contexts. For example we know that Geoff, going for knee surgery might be told ‘walking is not as painful as cycling, and cycling is not as painful than climbing a ladder.’ Geoff has surgery, and the knee is painful during initial mobilising. Because Geoff has also been told that cycling will be more painful than walking, and that climbing a ladder is even more painful than that, during his recovery he will avoid both cycling and walking. Why? Because he’s combined the ideas of ‘walking=ouch‘ with ‘cycling=OUCH‘ and ‘ladder climbing=OUCH.’ Even though cycling and ladder climbing don’t look like walking, and even though he hasn’t ever personally experienced pain while either cycling or climbing a ladder since his surgery. AND it makes sense not to go nuts and cycle or climb ladders in the early days of recovery.

Some of the verbal rules hang around longer than helpful. If Geoff follows the rule of not cycling or climbing ladders – it’s initially helpful, but if he’s later advised it’s OK to now go cycling and climbing ladders but his wife is worried and instead keeps telling him not to do these things, he may not try them out and continue avoiding. Following the rules that were relevant early after surgery helped, but the negative consequences of annoying Geoff’s partner stops him from ‘disobeying.’ And Geoff never experiences what really happens if he tries cycling or climbing a ladder: the verbal rules win!

What can we do about these really sticky verbal rules?

One of the most popular approaches to getting people on board with pain rehabilitation is explaining pain neurobiology and the poor relationships between pain intensity and what’s going on in the tissues. Information, like ‘explaining pain’ or drawing a network diagram showing links between thoughts, emotions, physiological arousal, pain and activity can help give people a bit of distance between their immediate thoughts (based on initially useful rules), and being OK to begin therapy. It’s pretty helpful, has been part of pain management and rehabilitation ever since Fordyce and Main and the early pain psychology researchers. It doesn’t change pain very much, but then it wasn’t intended to! It’s meant to help people feel more confident about doing their movement-based therapy.

So that’s one thing we can offer. But what do we do if the person just does not believe us? If the rules the person’s learned are really sticky – like ‘I have a disc prolapse and that jelly stuff is oozing out of my disc’, or ‘I have a weak core and if I don’t hold it in my vertebrae will go out of alignment’? What do we do then?

Doing beats talking

This is where therapists can draw on strengths the person has in other processes of the hexaflex. For example, I often use values (and I’ll bet many of you do!). We might say ‘Geoff, if you want to recover, we’ll have to do these exercises first – they’ll be in the ‘orange zone’ where they’re a bit uncomfortable, but you’ll be safe.’ We’re drawing on the value Geoff places on recovery to help him be willing to something that goes against the ‘rule’ he’s learned, and making the initial actions relatively easy to do so he achieves success and the anxiety isn’t too high, using ‘behaviour under appetitive control.’

We might use mindfulness, as I suggested in the first article in this series. We might say ‘Geoff, would it be OK to mess about with attention for a bit while we start experimenting with some little movements – can you bring your mind to your breathing? And can you step up on this wee box? What do you notice in your breath right now?’ In doing this, we’re bringing his attention away from the rule he’s learned and towards his own sensory experience. This helps anchor him to the here and now, and with our guidance, helps him to use his own experience to guide both his actions and how closely he follows the rules he’s learned.

We can also draw on self as context by reminding him that during the early days of his recovery, he was a patient, and now he is becoming himself again: see how far he has come from the early days after surgery!

The cool thing about using the other parts of the hexaflex is that we’re not arguing with them and instead we’re helping them develop a different relationship to those thoughts. So it can be fun to give the thoughts names: ‘ooh that’s my mind being my dictator!’ , ‘the devil on my shoulder’ or ‘the parrot’. Some people think of what their mind tells them as a lot like an off-station radio, or the passengers in a car all having an opinion but the driver gets to make the decision about whether their conversations are worth listening to.

Literally hundreds of metaphors and ways of developing a different relationship with thoughts have been written about in ACT. Some great resources include the Big Book of ACT Metaphors (Stoddard and Afari, New Harbinger Press, 2014); examples from Radical Relief by Joe Tatta , and content on the ACBS website .

But I have two wishes: 1) that we stop reverting to talking just because it’s easy and doesn’t make us feel too uncomfortable and instead 2) we draw on experiential learning and use the other processes in the hexaflex. Doing is so much more potent than talking, and from my experience, transfers to life outside the clinic much more readily. And that, folks, is where life is lived.

Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., & Goubert, L. (2019). How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain. Journal of Pain, 20(10), 1141-1154. https://doi.org/10.1016/j.jpain.2019.02.013

Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865. https://doi.org/10.1136/pgmj.60.710.865

Kendall, N. A., Linton, S. J., Main, C. J. (1997). Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, NZ

Waddell, G., Main, C. J., Morris, E. W., Paola, M. D. I., & Gray, I. C. (1984). Chronic Low-Back Pain, Psychologic Distress, and Illness Behavior. Spine, 9(2), 209-213.

Dancing around the hexaflex: Using ACT in practice 1

Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists (remember ACT is open for anyone to use it!) can use ACT in session.

Mindfulness – messing about with attention

Thanks to Kevin Vowles, I’m adopting the term ‘messing about with attention’ for the ‘present moment awareness’ or ‘mindfulness’ part of ACT. We can get caught up in how we define mindfulness – they all have value – but make the doing of mindfulness less practical.

Why use present moment awareness? Paying attention, on purpose, and without judgement (one of many definitions! This one from Kabat-Zinn, 2003) serves to disentangle us from thoughts about the past and predictions for the future; has been shown to reduce cortical arousal (Day, et al., 2021); and importantly for this post, comes in many forms.

We know that repeated practice, especially over extended periods of time (say, for 20 – 40 minutes or longer) results in alterations in how parts of the brain respond both when anticipating pain, and during painful experiences (Lutz, et al., 2013), but getting to where extended practice is even achievable can be difficult (Birtwell et al., 2019). ‘Messing about with attention’ can be used, however, anywhere and any time. I’m definitely not suggesting clinicians dissuade people from using long meditations because the results are pretty profound for most people (and most RCTs use around 40 – 45 minutes), but we shouldn’t ignore the usefulness of briefer forms of mindfulness.

During movement or occupation (daily activity)

If you’re a physio, osteo, chiro, exercise physiologist or occupational therapist, you have the most awesome opportunity to bring mindfulness into your sessions. It requires a shift in your thinking, though, because mindfulness used during movement or occupation isn’t quite the same as the usual sitting or even a ‘movement’ meditation. For one, it’s not scripted!

Your mindset

Mindfulness is about noticing, paying attention and being curious, but in many movement practices the aim is to develop ‘proper’ form. To move in a pre-determined manner. Perhaps to strengthen, or to relax, various muscle groups. To create a body movement that conforms to some ideal.

If you’d like to bring mindfulness into your movement session, would it be possible to put these ideas to one side for a moment?

Would you be willing to explore what it feels like to move – maybe in one way, and then in another? Would you be willing to experiment? To play with movement and notice how it feels in the body?

The invitation

To create an environment for practicing this kind of paying attention, the person will need an invitation. The invitation might be something like “I wonder if you feel OK to bring your mind to this part of your body for a moment?” or “If you were to close your eyes right now, what part of your body would you notice first?”

You may want to have a quiet environment, one that’s not distracting, no music or other people talking, somewhere where it’s OK to focus on how the body feels.

The guidance

If the person you’re working with hasn’t used mindfulness like this before, you might want to offer them some guidance about what to pay attention to. Something like “You’ve brought your mind to this part of your body, and as you move, what do you notice changing?” or “As you move, where does your weight shift through the soles of your feet?” or “As you move, can you bring your attention away from that part of your body [the first part you suggested they notice] and on to your breathing?”

Bring their attention to any shifts in position, changes in weight distribution, changes in breath, head position, stance, contact with the floor….

Throughout, your job is NOT to suggest what the person might notice, or experience. Your job is to help them explore, with purpose, and without judging. Guide them to play with movements as they do this: perhaps make tiny movements, or shift weight forward and back, or make big movements, speed up or slow down, add ‘purpose’ by making the movement purposeful – if they’re reaching forward, add in reaching for a cup, a pen, a book, a flower, a cloth. Ask them to notice what happens as they reach for these items. Let them repeat or alternate or otherwise change the way they do the movement.

The closure

End this by returning to the breath. It’s not a rule, and you can end in another way if you like, but I find giving some space to stopping and just breathing gives room for people to let their attention go back to something very familiar (and portable!).

Debrief

Your choice: you can ask the person “what did you notice?” or you can let them spontaneously tell you (or not). During the debrief your approach is to model acceptance of their experience, again without judgement. Let their experience be their experience.

If they say “Oh my mind wandered all over the place” ask them “were you able to bring your mind back?” and if they were (and they usually do!) let them know that’s all that’s needed.

You may want to explore which movement was most free, fluid, comfortable, stable. Which felt best, and can the person replicate it?

It’s not about what you think is ‘good’ form, this approach is about the mindful experiencing for the purpose of experiencing.

Rationale

While there are a billion reasons for using mindfulness, in today’s post my intention is to show that mindfulness offers a way for people to pay attention to their own bodily experiences, and to draw their own conclusions about how their body responds to movement.

My argument is that when people leave our care, they will probably have periods where their body ‘reverts’ to how it was when they first sought treatment. If our job is only to help people return to ‘normal’ without also furnishing people with skills to build resilience, we’re only doing half a job. It might be great for repeat customers, but I believe healthcare has enough to do without searching for ways to get people to come back – and failing to help people get in tune with what their body likes to do and how this feels, seems pretty unhelpful to me.

Showing people ways to really inhabit their own body, becoming skilled at noticing how their body feels during movement, being able to experiment and play with different movement patterns, to adjust and notice how it feels: these are powerful tools for helping people gain confidence in how incredibly versatile their body is. Our job might be less about ‘physical fitness’ or ‘strength’, ‘flexibility’ or even ‘function’, it might be about teaching people meta-cognitive skills of noticing and reflecting on what happens as they move throughout the various life contexts they inhabit.

Birtwell, K., Williams, K., van Marwijk, H., Armitage, C. J., & Sheffield, D. (2019). An Exploration of Formal and Informal Mindfulness Practice and Associations with Wellbeing. Mindfulness (N Y), 10(1), 89-99. https://doi.org/10.1007/s12671-018-0951-y

Day, M. A., Matthews, N., Mattingley, J. B., Ehde, D. M., Turner, A. P., Williams, R. M., & Jensen, M. P. (2021). Change in Brain Oscillations as a Mechanism of Mindfulness-Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain. Pain Medicine, 22(8), 1804-1813. https://doi.org/10.1093/pm/pnab049

Kabat-Zinn, J. (2003). Mindfulness-Based Interventions in Context: Past, Present, and Future . Clinical Psychology: Science & Practice, 10(2), 144-156.

Lutz, A., McFarlin, D. R., Perlman, D. M., Salomons, T. V., & Davidson, R. J. (2013). Altered anterior insula activation during anticipation and experience of painful stimuli in expert meditators. Neuroimage, 64(1), 538-546.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Learning ACT (acceptance and commitment therapy)

Around 2001 I read what I believe is the first randomised controlled trial of ACT for people living with chronic pain (McCracken, 1998). I quickly dived into this ‘new’ therapy – it appealed to me because it resonated with my own experiences with psychological therapies for depression, and in the way I had learned to live alongside my own pain. For those who don’t know, I developed chronic pain around the age of 22ish (dates are hard to remember!) and after seeing a pain specialist was given those fateful words ‘I’m sorry, there’s nothing we can do from a medical perspective.’

Why did ACT resonate so well? Because I’d tried to do the things that CBT offered. All the ‘maladaptive thoughts’ (stinkin’ thinkin’), the reframing (no, life doesn’t suck completely, it just sucks here, and here…), the behavioural activation (just keep on doing, even though it’s not rewarding) – all the things I was supposed to do to ‘fix’ my depression and my pain, but actually made me focus more on my thoughts, and more on the reality of being a single mother with two small children working full-time, studying part-time, and yes, feeling overwhelmed and at times pretty desperate.

ACT was different. ACT focused on noticing first. Noticing what was here and now. And when I was being present in the moment I could see my children as wonderful, quirky, loving kids (who also made a horrendous mess that I could never keep on top of!). I could see the colours in the flowers and trees in the nearby Botanic Gardens. I could notice my left earlobe (it doesn’t get sore – neither does my belly button!).

Learning ACT was not easy. ACT is a slippery therapy for anyone who wants a step-by-step protocol. There are common parts to ACT as an approach, like creating a sense of ‘these things don’t work – but it’s not for want of trying, it’s because humans don’t work this way’ (because the harder we struggle to control a thought or a feeling, the more it sticks to us), like being present and noticing, choosing actions that align with what matters: these were relatively familiar to me because of my occupational therapy background. Occupational therapists often start by asking people about what they want and need to do, then begin by setting actions that help the person do those things, but ACT can start anywhere on that darned hexaflex.

How might I go about learning ACT today? Because I know me, I would begin by looking at the end. What’s the end goal with ACT? It’s about being able to continue doing what matters (making our lives count in the ways we want them to), despite what life throws at us. I take this to mean that although the form or outer expression of what matters to us might change over our lives, the intent or values underpinning those actions is retained. And sometimes the values might change a little as we focus on one for a time, and others step back.

The thing is, changing how we do things is hard! I’ve often said to people with pain that I can teach the skills of pacing, for example, in an hour. What’s difficult is dealing with what our minds say, the reactions from other people, our own feelings about making changes and dealing with these other reactions, and the inner sense of wrongness that can come up – like ‘what kind of a person stops half-way through a task just to go take a break?’ And this is why ‘education’ for pain has to go beyond telling someone what to do.

As a total nerd, I like to know the theory or the organising structure supporting a therapy. ACT is based on solid science and I don’t just mean relational frame theory! ACT is a cognitive behavioural therapy, with the major distinction between ACT and CBT being how language is viewed. This means knowing about behaviour change from a Skinnerian perspective. It really does help to understand classical and operant conditioning. It moves us away from working hard to avoid things we don’t like, and towards things that are rewarding to us. The influence of moving in the direction of things we want has a different flavour from avoiding things we don’t want.

For example, if I work hard to avoid feeling my pain, I'll notice my pain whenever I do anything. This makes pain so much more present to me! If, instead, I want to enjoy the delights of what my body can do because I love to move to music, there are so many ways I can do this! I can tap my toes and my fingers in time to the music. I can hum along. I can chair dance. I can sit and internally dance to it. I can stand up and do a wiggle. I can even get up and dance! I can walk in time to the music, I can choose the tempo of the music I move to... the world opens up to me. 

I do ACT as I understand it. I try to use ‘doing’ as the vehicle for working through the various processes because how we do anything is how we do everything. I try not to just talk about ACT. ACT is a doing therapy where, by paying attention to what happens in the moment and bypassing the commentary our minds make (and the stories we hold onto about who we are), the effects of what we do become the guidance we need.

For example, if I feel better in my body by doing chunks of activity then doing a stretch or a walk or a dance or a body scan, my mind can leap in and tell me I'm being lazy, ineffective, sloppy, and never get anything done. Following the guidance of my mind would lead me away from relishing the lightness and reduced pain I get from chunking my day into bits. If I'm willing to notice how my mind likes to nag AND to notice how wonderful my body feels, guess which one is a better guide? Especially if what really matters to me is how I can be calm at the end of the day when I spend time with my partner! By noticing how my body is, and letting my mind do its thing without buying into the content, I'm much more likely to keep doing the pacing. 

There are many courses teaching ACT, and loads of freely accessible material on ACT throughout the interwebs. That’s due in large part to the ethos of ACT and those researching and using ACT-aligned approaches. Unlike CBT which can be tightly regulated, particularly in the USA, ACT is far more generous and open. Anyone can use ACT, it’s intended to view people as people, not bundles of psychopathology. I like this, especially in pain where so many people have already been given unhelpful names and treated with disdain and stigma. It won’t breach your scope of practice because it is about humans being practical about how our minds work, and what trips us up when we hit a life snag. Life snags are everywhere, and being human is, well, who we are!

The challenge for therapists not familiar with psychological approaches is to learn ACT from the perspective of your profession. If you’re a physiotherapist, ACT is done differently from when ACT is used by an occupational therapist or a social worker or a psychologist. We might deal with the same stuff, but our entry point to ACT is often different from a psychologist. I like to begin with actions aligned with values and watch what happens as people begin to do the things. It’s once people begin doing that our minds, beliefs about who we are, our desire not to feel uncomfortable, our memories and expectations all begin to wreak havoc on being guided by what actually happens in real time.

This is why I’m preparing my own online ACT course for therapists who work with people living with pain. The solid foundations of ACT will be there – but we’ll begin by doing the doing. ACT is a different way of being with people, and the best person to experiment with is —– yep, yourself. Keep watching for ACT for pain therapists, coming soon!

BTW this study by Lai et al., (2023) shows 33 ACT RCTs (bearing in mind my reservations about RCTs), with 2293 participants, showing (as usual) small to medium effect sizes for physical function and pain intensity at follow-up; and on depression, anxiety and improved quality of life. Interestingly, people with difficult-to-treat pains like chronic headache and fibromyalgia showed greater benefit than those wioth nonspecific or mixed pain, and again as usual, results were smaller over time. ACT is helpful – so let’s do it!

Lai, L., Liu, Y., McCracken, L. M., Li, Y., & Ren, Z. (2023). The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials. Behav Res Ther, 165, 104308. https://doi.org/10.1016/j.brat.2023.104308

McCracken, L. M. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74(1), 21-27. https://doi.org/10.1016/s0304-3959(97)00146-2