Physiotherapy

Back to basics about psychosocial factors and pain – iv


Part of the definition of pain is that it is “a sensory and emotional experience” – in other words, emotions of the negative kind are integral to the experience of pain. Is it any wonder that poets and authors have written so eloquently about the anguish of unrelieved pain? As I write this, I’ve been pondering the way “psychosocial” has been used when discussing pain, as if those factors aren’t experienced by “normal” people, as if the way we feel about pain and the way people who struggle with their pain feel are two entirely different things.

Chris Eccleston, someone I admire very much, writes about a “normal psychology of chronic pain” and makes some incredibly useful points: that pain is a normal feature of human life. Pain is an everyday occurrence (watch kids playing in a playground – every 20 minutes kids communicate about pain, Fearon et al, 1996). In New Zealand one in five people report experiencing pain lasting six months or longer. Pain really is all around us – and it’s normal and indeed part of the experience itself, to feel negative emotions such as fear, anger, sadness, anxiety, and such when we’re sore.

So why have emotions been lumped in with “other factors” as part of the negative way psychosocial factors are interpreted today? I personally think it’s partly a hangover, in NZ at least, from the way our stoic forebears viewed “weakness”. There wouldn’t be many families in New Zealand who haven’t heard something like “man up”, or “big boys don’t cry”, or “pull yourself together” with great All Blacks who played on despite broken ribs or arms – who didn’t give in when they were injured being held up as examples we should emulate. At the same time pain isn’t given much space in our health professional training programmes – and when it is, it’s primarily viewed in a neuroanatomical way, as we’re taught about spino-thalamic tracts, and nociceptors, and not much else. In fact, I think the gate control theory is still being taught as the main theory in some programmes (despite it being revised and replaced with more sophisticated models).

So what is normal? I really like Acceptance and Commitment Therapy, as you’ve possibly noticed. Amongst one of the many reasons I like it so much is its view of suffering. Within ACT, being psychologically inflexible is the problem – that is, working hard to avoid or control experiences we don’t want, getting caught up in thoughts as if they’re Truth instead of our mind’s opinion of things, being attached to someone’s idea of who and what we are, living in the past or predicting the future, and failing as a result to take actions that line up with what our personal values are. When we get stuck thinking there’s only one way to deal with a situation, and when we forget about what’s important in our lives because we’re working so hard to avoid certain experiences – these aren’t seen as pathological, but instead are just part of the way our mind/language and experience tangle us up. The beauty is that there are ways out of being stuck but they’re counter-intuitive.

What do I mean? Well if we all have negative emotions about pain, why do only some of us struggle with that experience and get stuck? For some people it’s because they’re trying so hard not to feel pain that they spend time and energy doing things to control it and in the process stop doing things that matter. Think of the many appointments and the ups and downs of hope that it will all go away with this magic thing – then despair as it doesn’t work. Just the amount of time people spend waiting for and attending appointments can take time away from being with family, working, living…Now to me, this is not psychopathology. This is what normal minds do – try to fix a problem using strategies that have always worked in the past.

At the same time, given pain is a negative experience, doesn’t it make sense to monitor what went on last time you tried to lift that box, go to work, drive the car… AND doesn’t it make sense to anticipate what might go wrong if you try it again? This isn’t about being depressed, anxious or any other kind of pathology – this is just what we’ve learned to do, and our minds are trying incredibly hard to make it work again.

When I mentioned that a solution might be counter-intuitive, what I mean is recognising that trying to control or avoid an experience that comes with us wherever we go because it’s part of us, can trip us up. Instead, we might do better if we soften our attempts to control or avoid our experience of pain. Maybe spending time exploring pain and doing things alongside pain is possible – especially if the things we want to do are important to us. Don’t believe me? Think about marathon runners – they feel the pain (hit the wall) and still keep running! Why? Because it’s important to them to get to the end.

Now I’m not suggesting that ALL people will find this approach helpful, and I’m NOT denying that many people with persistent pain experience depression, anxiety, rotten sleep and generally feel demoralised. What I AM saying is that if we approach everyone with the misguided idea that psychosocial factors exist only in “those people”, we’re wrong. Any one of us will experience negative emotions if pain is present – and even more if pain persists. This is a normal response to a challenging and inherently aversive experience. Of course, if we’ve experienced depression, adverse life events, turmoil in our home and work life, and the stigma of not being believed, the potential to then become angry, depressed, and fed up is only greater. Let’s not make a negative experience worse by stigmatising people with the notion that “psychosocial factors” makes them any different from anyone else.

 

Eccleston, C. (2011). A normal psychology of chronic pain. Psychologist, 24(6), 422-425.

Fearon, I., McGrath, P.J., Achat, H. (1996). ‘Booboos’: The study of everyday pain among young children. Pain, 68, 55-62.

Vowles, K. E., Witkiewitz, K., Levell, J., Sowden, G., & Ashworth, J. (2017). Are reductions in pain intensity and pain-related distress necessary? An analysis of within-treatment change trajectories in relation to improved functioning following interdisciplinary acceptance and commitment therapy for adults with chronic pain. Journal of consulting and clinical psychology, 85(2), 87.

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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.

… a little more about Pain Catastrophising subscales


I’ve been writing about the Pain Catastrophising Scale and how to use this instrument in clinical practice these last two posts here and here because the construct of catastrophising (thinking the worst) has become one of the most useful to help identify people who may have more distress and disability when dealing with pain. Today I want to continue with this discussion, but looking this time at a large new study where the subscales magnification, rumination and hopelessness have been examined separately to understand their individual impact on pain severity and disability.

Craner, Gilliam and Sperry looked at the results of 844 patients with chronic pain prior to taking part in a group programme (a heterogeous sample, rather than a single diagnosis, so this group probably look at lot like those admitted to high intensity tertiary chronic pain management services such as Burwood Pain Management Centre here in Christchurch).  Most of the participants were female, European/white and married, and had chronic pain for an average of 10.7 years. Just over half were using opioid medication to manage their pain.

Along with the PCS, participants also completed some very common measures of disability (Westhaven-Yale Multidimensional Pain Inventory – MPI) and quality of life (SF-36), and the CES-D which is a measure of depression.

Now here comes some statistical analysis: multiple hierarchical regression! Age, sex, duration of pain and use of opioids were entered into the equation and found to account for only 2.0% variance of the pain severity subscale of the MPI – but once the PCS was added in (subscales entered separately) an additional 14% of the variance was accounted for, but the helplessness subscale was the only one to contribute significantly to the overall variance.

When Pain Interference was  entered as the dependent variable, all the same demographic variables as above contributed a meagre 1.2% of the variance, but when the Pain Severity subscale scores were added, 25.5% of the variance was explained – while the combined PCS subscales contributed 6.5% of the variance. Again, helplessness was the only subscale to contribute to Pain Interference.

Moving to quality of life – the physical subscale of the SF-36 was used as the dependent variable, and once again the demographic variables accounted for only 1.5% variance in physical QOL, with Pain Severity accounting for 23%. PCS subscales contributed only 2.6% of the variance, with only the magnification subscale being identified as a unique contributor. When the mental health subscale was used, again demographics only accounted for 1.2% of variance, with pain severity accounting for 12.4% of the variance. This time, however, the PCS subscales contributed 19.5% of the variance with both Magnification and Helplessness contributing to the variance.

Finally, examining depression, demographics contributed a small amount of variance (3.3%), with pain severity additing 9.8% of variance. The PCS subscales were then entered and contributed a total of 21% to the prediction of depression with both Magnification and Helplessness contributing to the overall depression variance.

The so what factor

What does this actually mean in clinical practice? Well first of all this is a large group of patients, so we can draw some conclusions from the calculations – but we need to be a little cautious because these participants are a group who have managed to get into a tertiary pain management facility. They’re also a group with a large percentage using opioids, and they were pretty much all European – and from North America, not New Zealand. I’m not sure they look like the people who might commonly come into a community-based facility, or one where they’d be referred directly from a GP or primary care centre.

At the same time, while this group may not look like the people most commonly seen for pain management, they share some similar characteristics – they tend to magnify the “awfulness” of pain, and then feel helpless when their pain is bothering them. Surprisingly, I thought, ruminating or brooding on pain wasn’t a unique contributor and instead the helplessness scale contributed the most to pain severity, pain-related interference (disability associated with pain), poor mental health quality of life, and low mood, while magnification scale contributed to poorer physical health quality of life, mental health quality of life and low mood.

What this means for practice

The authors suggest that the construct measured by the helplessness subscale might be a factor underlying poor adaptation to life’s difficulties in general, leading to passivity and negative emotions. They also suggest that magnification might be a unique contributor to perceiving obstacles to doing the things we need to do every day, while hopelessness might mean people are less likely to participate in enjoyable activities and then in turn contribute to feeling low.

Importantly, the authors state: “We offer that simply collapsing the 3 dimensions of this phenomenon (ie, rumination, magnification, helplessness) may actually conceal nuanced relationships between specific dimensions of catastrophizing and outcomes that would might inform treatment approaches.” Looking at the overall scores without thinking about the subscales is going to give you less information to use for individualising your treatment.

In a clinical setting I’d be reviewing the individual subscales of the PCS alongside both disability and mood measures to see if the suggested relationships exist in the scores this person has given.

I’d be taking a look at the repertoire of coping strategies the person can identify – and more, I’d be looking at how flexibly they apply these strategies. Extending the range of strategies a person can use, and problem-solving ways to use these strategies in different activities and contexts is an important part of therapy, particularly occupational therapy and physiotherapy. Another approach you might consider is helping people return to enjoyable activities that are within their tolerance right here, right now. By building confidence that it’s possible to return to things that are fun we might counter the effects of helplessness, and help put pain back where it belongs – an experience that we can choose to respond to, or not.

I’d also be taking a look at their tendency to avoid feeling what their pain feels like, in other words I’d like to see if the person can mindfully and without judging, complete a body scan that includes the areas that are painful. This approach is intended to help people notice that alongside the painful areas are other nonpainful ones, and that they can successfully be with their pain and make room for their pain rather than attempting to block it out, or over-attend to it. The way mindfulness might work is by allowing people to experience the sensations without the judgement that the experience is bad, or indicates some terrible catastrophe. It allows people to step back from the immediate reaction “OMG that’s BAD” and to instead take time to view it as it actually is, without the emotional halo around it.

Pain catastrophising is a useful construct – but I think we need to become more nuanced in how we use the scores from the questionnaire.

Craner, J. R., Gilliam, W. P., & Sperry, J. A. (2016). Rumination, magnification, and helplessness: How do different aspects of pain catastrophizing relate to pain severity and functioning? Clinical Journal of Pain, 32(12), 1028-1035.

What do we do with those questionnaires (ii)


In my last post I wrote about the Pain Catastrophising Scale and a little about what the results might mean. I discussed the overall score suggesting a general tendency to “think the worst”, with the three subscales of magnifying or over-estimating the risk; ruminating or brooding on the experience; and helplessness or feeling overwhelmed and that there’s nothing to be done.  At the end of the post I briefly talked about how difficult it is to find a clinical reasoning model in physiotherapy or occupational therapy where this construct is integrated – making it difficult for us to know what to do differently in a clinical setting when a person presents with elevated scores.

In this post I want to show how I might use this questionnaire in my clinical reasoning.

Alison is a woman with low back pain, she’s been getting this niggling ache for some months, but last week she was weeding her garden and when she stood up she felt a sharp pain in her lower back that hasn’t settled since. She’s a busy schoolteacher with her own two children aged 8 and 10, and doesn’t have much time for exercise after teaching a full day, and bringing children’s work home to grade at night. She’s completed the PCS and obtained an overall score of 33, with her elevated scores on the magnifying subscale contributing the most to her total score.

Her twin sister Belinda has coincidentally developed low back pain at the same time, only hers started after she had to change the tyre on her car over the weekend. She’s a busy retail manager preparing for the upcoming Christmas season, and also has two children just a bit younger than her sister’s two. She’s completed the PCS and obtained an overall score of 34, but her score on ruminating is much higher than her scores on the other two scales, and this is the main reason her overall score is high.

What difference does Belinda’s elevated score on ruminating mean for us as clinicians? What do we do when we see Alison’s overall elevated score?

Common themes

Both Alison and Belinda live busy lives, and have lots of stressors within their lives. While they both have similar presentations, we might go about helping them regain confidence in their bodies slightly differently. I’ll begin with Belinda who might, because of the elevated ruminating score, have trouble getting off to sleep and might spend more time attending to her back pain than her sister. Ruminating is that endless brainworm that keeps on dragging our attention back to the thing we’re worried about (or perhaps the problem we’re trying to solve).  Alison, on the other hand, might be more inclined to monitor her back pain and imagine all sorts of dire outcomes – perhaps that the pain will never go away, that it’s going to “cripple” her, and that it’s going to be a major problem while she’s at work.

While both sisters would benefit from learning to move with more confidence, to relax the muscle tension that occurs when back pain is present, and to return to their usual daily activities, we probably need to help Alison learn more about her back pain (for example, explain that most back pain settles down quite quickly, that it’s helped by moving again in a graduated way, and that we’ve ruled out any sinister reason for her developing her pain). During treatment sessions where we help her learn to move more normally, we might spend more time giving neutral messages about fluctuations in her pain (for example, we might let her know that it’s normal to have a temporary increase in pain when we start moving again, and that this is a good sign that she’s beginning to use her body normally). If we notice her looking anxious during a new movement or exercise we might take a moment to ask her about her concerns and provide her with neutral and clear information about what’s going on so she becomes more realistic in her judgements about what her pain means.

For Belinda I might be inclined to help her deal with her thoughts in a mindful way, so she can notice her thoughts and her body sensations without judging them, bringing her mind back to breathing, or to noticing the equally present but less “alerting” body sensations she may be experiencing. For example I might ask her to do a mindfulness of breath exercise where, as she notices her mind wandering off to worries or concerns, I would ask her to gently notice that this has happened, acknowledge her mind for trying to help solve an insoluble problem, and bring her attention back to her breathing. I might ask her to notice body sensations including those that are uncomfortable and around the area of her most intense pain, taking care to be aware not only of the painful sensations she’s experiencing, but also associated body responses such as breath holding, or muscle tension. I might guide her to also be aware of a neutral but generally unloved area like her left earlobe (when did you last attend to what your left earlobe felt like?), or her navel. Because at the same time as she’s noticing the painful areas of her body, she’s likely to be trying hard to avoid “going there” with the result that her mind (trying really hard to help her protect herself) actually goes there more often! (don’t believe me? Don’t think of a big fat spider crawling down your shoulder – betcha did!!). Belinda can use the same approach when she’s trying to get off to sleep – by non-judgmentally noticing her body and what’s going on, she can be aware of what it feels like – but not get hooked up in alarming appraisals of what “might” happen. In a clinic setting I might ask her to use this same mindfulness approach when we’re doing a new exercise, or returning to a new activity. She could take time to really feel the movements, to be “in” her body rather than her head, and in doing so gradually reduce the tendency for her mind to take off in new and frightening directions.

Using the PCS is not about becoming psychologists: it’s about being aware of what the person in front of us is telling us about their experience, and then tuning into that and responding appropriately while we do what we do. Our job isn’t to replace a psychologist’s contribution – but to use the results of psychometric questionnaires to augment and support the work we do in a setting where people are actively engaged in learning about their bodies. I think that’s a priceless opportunity.

Schutze, R., Slater, H., O’Sullivan, P., Thornton, J., Finlay-Jones, A., & Rees, C. S. (2014). Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Frontiers in Psychology Vol 5 Aug 2014, ArtID 839, 5.

Tsui, P., Day, M., Thorn, B., Rubin, N., Alexander, C., & Jones, R. (2012). The communal coping model of catastrophizing: Patient-health provider interactions. Pain Medicine, 13(1), 66-79.

What do we do with those questionnaires?


Courtesy of many influences in pain management practice, you’d have to have been hiding under a rock or maybe be some sort of dinosaur not to have noticed the increasing emphasis on using questionnaires to measure factors such as pain catastrophising, depression or avoidance. The problem is I’m not sure we’ve all been certain about what to do with the results. It’s not uncommon for me to hear people saying “Oh but once I see psychosocial factors there, I just refer on”, or “they’re useful when the person’s not responding to my treatment, but otherwise…”, “we use them for outcome measures, but they’re not much use for my treatment planning”.

I think many clinicians think psychosocial questionnaires are all very well – but “intuition”  will do “…and what difference would it make to my treatment anyway?”

Today I thought I’d deconstruct the Pain Catastrophising Scale and show what it really means in clinical practice.

The Pain Catastrophising Scale is a well-known and very useful measure of an individual’s tendency to “think the worst” when they’re considering their pain. Catastrophising is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al., 2001). The questionnaire was first developed by Sullivan, Bishop and Pivik in 1995, and the full copy including an extensive manual is available here. Keep returning to that page because updates are made frequently, providing more information about the utility of the measure.

The questionnaire itself is a 13-item measure using a 0 – 4 Likert-type scale from 0 = “not at all” to 4 = “all the time”. Respondents are instructed to “indicate the degree to which you have these thoughts and feelings when you are experiencing pain”.

There are three subscales measuring three major dimensions of catastrophising: rumination “I can’t stop thinking about how much it hurts”; magnification “I worry that something serious may happen”; and helplessness “It’s awful and I feel that it overwhelms me”.

To score the instrument, simply sum all the responses to all 13 items, but to get a better idea of how to help a person, the subscale calculations involve the following:

Rumination: sum items 8,9,10, and 11

Magnification: sum items 6,7, and 13

Helplessness: sum items 1,2,3,4,5, and 12

There’s not a lot of point in having numbers without knowing what they mean, so the manual provides means and standard deviations relating to a population individuals with injury leading to lost time from work in Nova Scotia, Canada.

thingClinicians are typically interested in whether the person sitting in front of them is likely to have trouble managing their pain, so the manual also provides “cut off”scores for what could be described as “clinically relevant” levels of catastrophising. A total score of 30 or more is thought to represent the 75th percentile of scores obtained by individuals with chronic pain.

The “so what” question

Cutting to the chase, the question is “so what”? What difference will getting this information from someone make to my clinical reasoning?

Leaving aside the enormous body of literature showing a relationship between high levels of catastrophising and generally poor responses to traditional treatments that address pain alone (including surgery for major joint replacement, recovery from multiple orthopaedic trauma, low back pain, shoulder pain etc), I think it’s helpful to dig down into what the three subscales tell us about the person we’re working with. It’s once we understand these tendencies that we can begin to work out how our approach with someone who has high levels of rumination might differ from what we’ll do when working with someone who has high levels of helplessness.

As an aside and being upfront, I think it’s important to remember that a questionnaire score will only tell you what a person wants you to know. Questionnaires are NOT X-rays of the mind! They’re just convenient ways to ask the same questions more than once, to collect the answers and compare what this person says with the responses from a whole lot of other people, and they allow us to organise information in a way that we might not think to do otherwise.  I also think it’s really important NOT to label a person as “a catastrophiser” as if this is a choice the person has made. People will have all sorts of reasons for tending to think the way they do, and judging someone is unprofessional and unethical.

Rumination

Rumination is that thing we do when a thought just won’t get out of our mind. You know the one – the ear worm, the endless round and round, especially at night, when we can’t get our mind off the things we’re worrying about. If a person has trouble with being able to drag his or her attention away, there are some useful things we can suggest. One theory about rumination is that it’s there as a sort of problem solving strategy, but one that has gone haywire.

Mindfulness can help so that people can notice their thoughts but not get hooked up into them. I like to use this both as a thought strategy, but also as a way of scanning the body and just noticing not only where the pain is experienced, but also where it is not.

“Fifteen minutes of worry” can also help – setting aside one specific time of the day (I like 7.00pm – 7.15pm) where you have to write down everything you’re worried about for a whole fifteen minutes without stopping. By also telling yourself throughout the day “I’m not worrying about this until tonight” and afterwards saying “I’ve already worried about this so I don’t need to right now”, worrying and ruminating can be contained. By being present with the thoughts during that 15 minutes, the threat value of the thought content is also reduced.

Magnification

This is the tendency to think of the worst possible thing rather than the most likely outcome, and it’s common! Magnification can really increase the distress and “freeze” response to a situation. If a person is thinking of all the worst possible outcomes it’s really hard for them to focus on what is actually happening in the here and now. There’s some adaptive features to magnification – if I’ve prepared for the worst, and it doesn’t happen, then I’m in a good situation to go on, but in some people this process becomes so overwhelming that their ability to plan is stopped in its tracks.

Once again, mindfulness can be really useful here, particularly paying attention to what is actually happening in the here and now, rather than what might happen or what has happened. Mindful attention to breathing, body and thoughts can help reduce the “freeze” response, and allow some space for problem solving.

Of course, accurate information presented in nonthreatening terms and in ways the person can process is important to de-threaten the experience of pain. This is at the heart of “explain pain” approaches – and it’s useful. What’s important, however, is to directly address the main concern of the person – and it may not be the pain itself, but the beliefs about what pain will mean in terms of being a good parent, holding down a job, maintaining intimacy, being responsible and reliable. It’s crucial to find out what the person is really concerned about – and then ensure your “reassurance” is really reassuring.

Helplessness

Helplessness is that feeling of “there’s nothing I can do to avoid this awful outcome so I won’t do anything”. It’s a precursor to feelings of depression and certainly part of feeling overwhelmed and out of control.

When a person is feeling helpless it’s important to help them regain a sense of self efficacy, or confidence that they CAN do something to help themselves, to exert some sort of control over their situation. It might be tempting to aim for focusing on pain intensity and helping them gain control over pain intensity, but because it’s often so variable and influenced by numerous factors, it might be more useful to help the person achieve some small goals that are definitely achievable. I often begin with breathing because it’s a foundation for mindfulness, relaxation and has a direct influence over physiological arousal.

You might also begin with some exercise or daily activities that are well within the capabilities of the person you’re seeing. I like walking as a first step (no pun intended) because it doesn’t require any equipment, it’s something we all do, and it can be readily titrated to add difficulty. It’s also something that can be generalised into so many different environments. In a physiotherapy situation I’d like to see PTs consider exercises as their medium for helping a person experience a sense of achievement, of control, rather than a means to an end (ie to “fix” some sort of deficit).

To conclude
Questionnaires don’t add value until they’re USED. I think it’s unethical to administer a questionnaire without knowing what it means, without using the results, and without integrating the results into clinical reasoning. The problem is that so many questionnaires are based on psychological models and these haven’t been integrated into physiotherapy or occupational therapy clinical reasoning models. Maybe it’s time to work out how do this?

Sullivan M J L, Bishop S, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychol Assess 1995, 7: 524-532.

Main, C. J., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24(2), 205-217. doi:doi:10.1016/j.berh.2009.12.012

Sturgeon, J. A., Zautra, A. J., & Arewasikporn, A. (2014). A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain. PAIN®, 155(2), 292-298. doi:http://dx.doi.org/10.1016/j.pain.2013.10.007

Why does “doing exercise” work?


Bless all the physiotherapists in the world, they keep us doing exercises. And exercises are good because they get us doing the things we want to do in our daily lives. But how does it work?  This is not an exposition on exercise physiology – I’m not au fait enough with physiology to do that and there are many other people out there with vast amounts of knowledge giving us the benefit of their wisdom who have written at length about exercise and why it’s important. Instead I want to talk about some observations – and maybe pose some critical questions too.

For many years I’ve worked in a chronic pain management centre where people with chronic pain attend a three week intensive pain management programme. Staff members from outside the Pain Management Centre (we were located as an outpatient facility on the grounds of a rehabilitation hospital) always told us they could spot a person with pain the moment they saw them wandering from our building to the main cafeteria: people walking slowly, sometimes limping, but often just walking very slowly towards the cafe.

Over the course of the three weeks, this group of people would go from this slow amble to walking briskly and attending the hydrotherapy sessions, doing a daily exercise session (circuit-style); and in the final week of the programme, catching a bus to the shopping centre, purchasing food, coming back and preparing a shared barbecue for friends and family. What a turn-around!

Now, I said I wasn’t going to talk about physiology and I won’t, but I WILL point out that three weeks is not a long time. It’s so little time that it’s impossible for muscle length and strength to change significantly. And yet movements (measured using the six minute walking test and timed up and go) were quicker. Postures changed. People looked more alert and took more notice of the world around them. The question of how it is that this group of people could go from being recognisably “pain patients” to people who could do everyday activities has to be asked.

There are a couple of points to make before I do my thing. Firstly, while the people attending the programme were undeniably uncomfortable, clearly slow in their movements, and most definitely disabled, they weren’t, by usual measures “deconditioned”. In other words, they were of pretty average fitness – and indeed, many had been attending daily gym sessions at the behest of a case manager and under the supervision of a physiotherapist for months! At the same time they were not DOING much and felt extremely limited in their capabilities.

The second point is that although the programme had two “exercise” sessions each day, these were not high intensity sessions! The aim in most cases was to help people establish a baseline – or a reliable, consistent quota of exercise that they could do irrespective of their pain intensity. Most of the work within the exercise sessions was to help people become aware of their approach to activity, to modify this approach, and to then maintain it. Movement quality rather than quantity was the aim.

Here’s where I want to propose some of the mechanisms that might be involved.

  1. Humans like to, and almost need to, compare their performance with other people. It’s not something we choose to do, it’s an innate social bonding mechanism and whether we then modify what we do to match others – or deliberately try to do the opposite to mark out our own stance – we’ve based our behaviour on having observed what’s “normal” around us. And this applies even when people develop disability (Dunn, 2010), but perhaps more importantly, may well be fundamental to how we experience our world – and ourselves (Santiago Delefosse, 2011). When a group of people meet, their behaviour rapidly becomes more similar – similar gestures, similar body positions, and similar facial expressions. I wonder if one of the mechanisms involved in change within a group of people who live with chronic pain is this tendency to mirror one another’s behaviour.
  2. Having proposed that mirroring is one mechanism of change, why don’t groups of people with chronic pain ALL remain slowed and showing pain behaviour? Well, another mechanism involved in behaviour change is operant conditioning. When a group is performing exercise under the supervision of a “wise and caring authority” (ie a physiotherapist), many reinforcements are present. There’s the “no, that’s not quite the right movement” response, and the “oh you did it!” response. The “you can do it, just push a bit more” response, and the “if you can do that, how about another?” At the same time people are set quota or “the number of repetitions” to complete within a timeframe. Simply recording what is happening is sufficient to change behaviour – just ask someone who is on a diet to record their food intake for a week and you’ll likely see some changes! But add to this a very potent response from the wise and caring physiotherapist, and you’ll get warm fuzzies for doing more, and possibly cold pricklies if you don’t try.
  3. And finally, and possibly the most powerful of all, is the process of confronting feared movements – and doing them. Doing them without “safety behaviour” and doing them to specifically confront the thing that makes them scary. And doing them in many, many different settings, so as to alter the tendency to avoid them because they’re scary. A recently published systematic review and meta-analysis of graded activity (usually based on operant conditioning principles, and perhaps on cardiovascular fitness training principles) compared with graded exposure (deliberately confronting feared and avoided movements in a whole range of different contexts) found that graded exposure more effectively reduces catastrophising than just doing graded activation. This shouldn’t surprise us – one of the mechanisms involved in disability associated with nonspecific low back pain is avoiding doing things because people are fearful either of further injury, or of being unable to handle the effects of pain.

Where am I going with this post? Well, despite the face validity of exercise for reducing pain and disability, it’s not the physiological effects that first produce results. It can’t be because tissues do not adapt that quickly. What does appear to happen are a range of social-psychological processes that influence whether a person will (or won’t) do something. What this means is two things:

  • Physiotherapists, and indeed anyone who helps people do movements to reduce disability, really need to know their psychological processes because they’re inherent in the work done.
  • Becoming expert at analysing what a person wants and needs to do, and in being able to analyse then carefully titrate exposure to the contexts in which things need to be done is vital. That’s fundamental to occupational therapy theory, training and expertise.

 

 

Dunn, D. S. (2010). The social psychology of disability. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology, (2 ed., pp. 379-390). Washington , DC: American Psychological Association

Lopez-de-Uralde-Villanueva, I., Munoz-Garcia, D., Gil-Martinez, A., Pardo-Montero, J., Munoz-Plata, R., Angulo-Diaz-Parreno, S., . . . La Touche, R. (2015). A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. doi:10.1111/pme.12882

Santiago Delefosse, M. (2011). An embodied-socio-psychological perspective in health psychology? Social and Personality Psychology Compass, 5(5), 220-230.

Waitangi Day – or how to live together in unity


Today is New Zealand’s Waitangi Day ‘Mondayisation’ – the actual day was Saturday 6th Feb. It’s an important day in New Zealand because it’s the day when two completely different nations signed a treaty allowing certain rights between them – and allowed my ancestors to travel from Ireland and England to settle in the country I call my home. Unlike many country’s celebrations of nationhood, Waitangi Day is almost always a time of turbulence, dissension and debate. This is not a bad thing because over the years I think the way in which Maori (Tangata Whenua, or original settlers) and non-Maori settlers (Tangata Tiriti) relate in our country is a fantastic example of living together well. Not perfectly – but certainly in a more integrated way than many other countries where two completely different cultures blend.

Thinking of Waitangi Day, I’m reminded of the way in which the multidimensional model of pain attempts to integrate biological, psychological and social factors to help explain this experience and how such a primitive response to threat can ultimately lead to adaptation and learning – in most cases – or the most profound misery and disability in others.

Like the treaty relationship in New Zealand, there’s much room for discussion and debate as to the relative weight to place on various components of the model.  And like the treaty relationship, there are times when each part is accused of dominating and not giving the other/s due credit. Truth, at least to me, is, we need all of us (and all the factors) to integrate – not to become some bland nothing, but to express the components fully.

Just last week I was astonished to find that a clinician thought that I believed low back pain is “psychological”. Absolutely astonished because this has never been my position! While this blog and much of my teaching and reading is around psychological and more recently social factors influencing pain and disability, my position has never been to elevate the influence of these factors over the biological. I suppose I shouldn’t be surprised – it’s hard to deal with the state of play in our understanding of low back pain which finds that many of the assumed causal mechanisms (like disc prolapses, poor “core” muscles, the biomechanics of lifting and so on) just don’t apply. It’s also really difficult to know that so far there are no particular exercise treatments that work more effectively than any other. Cognitive dissonance anyone? Just because these factors are less relevant than presumed does not mean that (a) I think low back pain is psychological and (b) that all biological factors are irrelevant. What it does mean is that we don’t know. I’ll say that again. We. Don’t. Know. Most back pain falls into this “nonspecific” group – and by calling it “nonspecific” we are actually admitting that We. Don’t. Know.

How do people assume that because I point out that we don’t know the causal mechanisms of low back pain but we DO know the critical importance of psychosocial factors on disability associated with low back pain – and the treatments that can mitigate these factors – that I believe back pain is psychological? I think it’s a simple fallacy – some people believe that because a person responds to psychosocial interventions this therefore means their problem is psychological. This is not true – and here are some examples. Exercise (a physical modality) is shown to be an effective treatment for depression. Does this mean depression is a purely biological disorder? Biofeedback provides visual or auditory information related to physical aspects of the body like blood pressure, heart rate, and muscle tension – does this mean that blood pressure is “psychological”? Diabetes management often includes learning to resist the urge, or “urge surf” the impulse to eat foods that increase blood sugar levels – does this mean diabetes is psychological?

Here’s my real position on nonspecific low back pain, which is let me remind you, the most common form of low back pain.

Causes – not known (Golob & Wipf, 2014), risk factors for onset are mainly equivocal but one study found the major predictor of an onset was – prior history of low back pain, with “limited evidence that the combination of postural risk factors and job strain is associated with the onset of LBP” (Janwantanakul, Sitthipornvorakul,  & Paksaichol, 2012), exercise may prevent recurrence but mechanisms of LBP remain unclear (Macedo, Bostick and Maher, 2013), while subgroup analysis carried out by therapists were “underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting” (Mistry, Patel, Wan Hee, Stallard & Underwood, 2014).

My take from this brief review? The mechanisms presumed to be involved in nonspecific low back pain are unknown.

Treatments – mainly ineffective but self-management provides small effects on pain and disability (moderate quality) (Oliveira, Ferreira, Maher, Pinto, Refshauge & Ferreira, 2012), “the evidence on acupuncture for acute LBP is sparse despite our comprehensive literature search” (Lee, Choi, Lee, Lee, Shin & Lee, 2013), no definitive evidence supports the use of orthoses for spine pain (Zarghooni, Beyer, Siewe & Eysel, 2013), acetaminophen is not effective for pain relief (Machado, Maher, Ferreira, Pinheiro, Lin, Day et al, 2015), and no specific exercises are better than any other for either pain relief or recovery – not even motor control exercises (Saragiotto, Maher, Yamato, Costa et al, 2016).

My take from this set of references is that movement is good – any movement, but no particular form of exercise is better than any other. In fact, the main limitation to exercise is adherence (or actually continuing exercising after the pain has settled).

The factors known to predict poor recovery are pretty clear – catastrophising, or thinking the worst (Kim, Cho, Kang, Chang, Lee, & Yeom, 2015), avoidance (usually arising from unhelpful beliefs about the problem – see commentary by Schofferman, 2015), low mood – which has also been found to predict reporting or treatment seeking of low back pain (see this post from Body in Mind, and this one).

What can I take from all of this? Well, my view is that because psychosocial factors exert their influence at multiple levels including our nervous system (see Borkum, 2010), but also our community understanding of what is and isn’t “illness” (Jutel, 2011) and who to see and what to do about it, the problem of nonspecific low back pain is one of the purest forms of an integrated biopsychosocial and multifactorial health concern in human life. I therefore rest my case: nonspecific low back pain is not psychological, but neither is it biomechanical or biological only. It is a biopsychosocial multifactorial experience to which humans are prone.

The best we can do with our current knowledge base is (1) limit and avoid the use of nocebic language and attempts to explain low back pain via biomechanical or muscle control mechanisms, (2) be honest about the likelihood of low back pain recurring and our treatments essentially doing very little, and (3) encourage return to normal activity by doing normal activity including exercise. Being honest about the state of play in our knowledge is a good starting point for better understanding – sounds a lot like race relations, doesn’t it?

 

Borkum, J. M. (2010). Maladaptive cognitions and chronic pain: Epidemiology, neurobiology, and treatment. Journal of Rational-Emotive & Cognitive Behavior Therapy, 28(1), 4-24. doi:http://dx.doi.org/10.1007/s10942-010-0109-x

Golob, A. L., & Wipf, J. E. (2014). Low back pain. Medical Clinics of North America, 98(3), 405-428.

Janwantanakul, P., Sitthipornvorakul, E., & Paksaichol, A. (2012). Risk factors for the onset of nonspecific low back pain in office workers: A systematic review of prospective cohort studies. Journal of Manipulative & Physiological Therapeutics, 35(7), 568-577.

Jutel, A. (2011). Classification, disease, and diagnosis. Perspectives in Biology & Medicine, 54(2), 189-205.

Kim, H.-J., Cho, C.-H., Kang, K.-T., Chang, B.-S., Lee, C.-K., & Yeom, J. S. (2015). The significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 238-246. doi:http://dx.doi.org/10.1016/j.spinee.2014.09.002

Lee, J. H., Choi, T. Y., Lee, M. S., Lee, H., Shin, B. C., & Lee, H. (2013). Acupuncture for acute low back pain: A systematic review. Clinical Journal of Pain, 29(2), 172-185.

Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.

Machado, G. C., Maher, C. G., Ferreira, P. H., Pinheiro, M. B., Lin, C.-W. C., Day, R. O., . . . Ferreira, M. L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials. BMJ, 350, h1225.

Mistry, D., Patel, S., Hee, S. W., Stallard, N., & Underwood, M. (2014). Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: A systematic review. Spine, 39(7), 618-629.

Oliveira, V. C., Ferreira, P. H., Maher, C. G., Pinto, R. Z., Refshauge, K. M., & Ferreira, M. L. (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64(11), 1739-1748.

Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1).

Schofferman, J. A. (2015). Commentary on the significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 247-248. doi:http://dx.doi.org/10.1016/j.spinee.2014.11.003

Zarghooni, K., Beyer, F., Siewe, J., & Eysel, P. (2013). The orthotic treatment of acute and chronic disease of the cervical and lumbar spine. Deutsches Arzteblatt International, 110(44), 737-742.

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

Who can do Cognitive Behavioural Therapy for Rehabilitation?


I have heard many discussions about scopes of practice: the main concern as far as I can see is of people who are trained to work mainly with the body perhaps stepping out of scope to work with thoughts, beliefs, and emotions. There are risks from stepping too far away from what you’re trained to do, I acknowledge this, though I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge.  And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance.

When I read about a post-surgical rehabilitation approach for people who had spine surgery, I was immediately interested and not because of the surgery! This study compared “cognitive-behavioural based physical therapy” with an education programme six weeks after laminectomy for a lumbar degenerative condition. People were included in the study if they reported high fear of movement using the Tampa Scale for Kinesiophobia. Assessments were completed before treatment, after treatment and at a 3 month follow-up, and included the Brief Pain Inventory, Oswestry Disability Index, SF-12, and three performance tests (5-chair stand, timed up and go, and 10 metre walk).

There was no discussion about the physical rehabilitation, but the CBT and education sessions were conducted by phone and participants also received a workbook to take home and follow. Sessions took 30 minutes, except the first session which was for one hour. The main components of the programme are reported as education on the mind-body connection, activity levels, graded activity plan (graded hierarchy) and weekly activity and walking goals. A cognitive or behavioural strategy was introduced in each session, with the therapist helping patients identify enjoyable activities, replace negative thinking with positive thoughts, find a balance between rest and activity, and manage setbacks by recognising high-risk situations and negative thoughts.

The education sessions included the usual contents delivered by a physiotherapist, and featured biomechanics, daily exercise, and ways to promote healing. Information on stress reduction, sleep hygiene, energy management, communicating with health providers and preventing future injury were also provided.

What did they find?

Firstly, only 68% of those eligible for the study agreed to take part, which in itself is interesting. A number of other factors influenced the total number of people entered into the programme – not being treated for a degenerative lumbar condition, not having high enough scores on the TSK were the main reasons. Dropout rates for both programmes were quite low – 7 – 5%, and both programmes had good follow-up outcomes (not too many people missed the follow-up).

Now here’s a thing: 91% of participants also received clinic-based physiotherapy during the treatment phase (roughly 8 visits), and right up until the three-month follow-up (about 6 – 7 visits). No real difference between the groups here.

What did differ was the long-term improvement in the cognitive behavioural group – in terms of back and leg pain, pain interference and disability. The education group still improved in their leg pain and disability, but back pain and pain interference stayed the same. Similarly, the CBT group continued to improve on measures of physical and mental health over time, while the education group’s physical scores improved but mental health scores stayed pretty much the same. The CBT group’s scores improved more than the education group on almost all the measures including the physical performance tests.

What does this mean?

Well, interestingly, the authors of this study suggest that they obtained large and clinically relevant changes because of the specific focus they had on decreasing barriers to functional activity and walking rather than focusing solely on resolving pain symptoms. I think this is very interesting indeed. Although this study used physiotherapists, the clinician was naive to using CBT and was trained specifically for this study. Participants received concurrent physiotherapy in a clinic – the CBT (and education sessions) were additional to what was delivered in the clinic setting. To me the results suggest that the occupational therapy focus on creating opportunities for people to do more within their own environment might be a potent tool in post-operative rehabilitation.

Once again, it also suggests that the professional discipline of the clinician delivering a CBT approach is far less important than the fact that the CBT approach is tailored to the concerns of the patient, and that the treatment targets factors within the real-world context.

Important points to note: these patients were selected on the basis of high levels of pain-related fear and avoidance. I don’t think the outcomes would be nearly as fabulous in a general or undifferentiated group. This approach, while relatively inexpensive to implement, is an added cost – though if we look at the effect on patient outcomes, I would argue that the financial cost is far outweighed by the positive human results.

Finally, I think this study also shows that addressing thoughts, beliefs and emotions is a part of what every health professional should be doing: it’s unethical not to learn to do this well.

Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips S, George SZ, McGirt ML, Spengler DM, Aaronson OS, Cheng JS, Wegener ST, Cognitive-behavioral based physical therapy
for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.09.013.

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.