Science in practice

International Chronic Pain Virtual Summit 2020

I am so happy to be part of this virtual summit especially under our current COVID19 disruptions! It’s FREE and more than 20 speakers from around the world are talking about the things that matter in pain rehabilitation and management. I might even drop in a word or two about occupational therapy….!
Click the link and find out more! – click

Just to give you an idea of the speakers involved, you’ll get to hear from:

Professor Peter O’Sullivan

Professor Tasha Stanton

Lissanthea Taylor

Vidyamala Burch

Dr Stephen Grinstead

Kathy Hubble

Pete Moore

Prof Kim Burton

Prof Ann Taylor

Dr Adriaan Louw

Dr Shilpa Patel

Dr Saurab Sharma

Coronavirus (COVID19), catastrophising – and caution

I don’t often leap aboard a popular topic and blog about it, but I’m making an exception right now because, although COVID19 is new – catastrophising is not.

There are a number of people who really do not like the term “catastrophising”. There are comments that this is a pejorative term, used to deny the validity of a person’s experience. That it means the person is exaggerating or being melodramatic or in some way not believable.

But as I read the many, many headlines about COVID19, including the international toilet paper frenzy, reading about Vitamin C or “anti-inflammatory foods” to combat it, I even saw a serious post about using hands-on therapy to “shift the toxins”…. And I wonder whether we can take a good hard look at ourselves and our response to this virus.

Firstly, getting accurate information about COVID19 has been difficult. There are some authoritative sources “out there” but they’re not necessarily the most sexy sites to visit. Not many memes coming out of our Ministry of Health in New Zealand! Much of the information we read on a daily basis is in the general news media, giving a “personal story” slant on “what COVID19 means”. Some really good information coming from our politicians in NZ – but also some scaremongering from the political opposition.

Does this sound familiar? Where does the good, accurate and evidence-based information about persistent pain come from? And in the absence of readily accessible and “memeific” information, where do people go to learn about pain?

Secondly, it’s not the virus itself that’s causing the majority of trouble for people – except for the small percentage for whom the virus is deadly, mainly because of comorbidity, and health vulnerability. People who are older, already have immune compromise, and who are not able to access good healthcare are most at risk. The rest of us are experiencing the fallout of containment measures, economic insecurity, and lack of toilet paper. Sorry, couldn’t resist that last one. Seriously, most of us are being affected by the cancellation of meetings, by the need to self-isolate, by travel restrictions, by people having less money to spend because suddenly their jobs are less secure – watching my savings melt day by day…

Sounds quite similar to the experiences of people with persistent pain: often it’s not the pain itself that’s so awful, but the effects of losing contact with people you love, of having to take medications to reduce pain that leave you feeling dreadful, of not being able to play sports or do work – the loss of income security, access to healthcare, connection with people who matter. These are amongst the most debilitating aspects of living with persistent pain, let along the pain…

If you’ve found it hard to think of anything else but COVID19. If you’ve had trouble taking your mind off how you’re going to get by if patients can’t come to see you because they’re worried about giving you COVID19, or of catching it from you – that’s rumination, or brooding on it.

If you’ve caught yourself heading to the supermarket to get some extra pantry staples “just in case”. If you’ve found yourself checking in to see what your local health authorities are recommending. If you’ve been wondering if you should shut your business down for a while – and then been wondering what you’re going to do for a income if you do that. If you’ve looked up your bank balance and wondered what you’re going to do if your kids are off school for the next month, while you’re meant to be at work and there’s no-one to look after them…. you’re magnifying, or estimating that the demands of this situation might well exceed your current resources to deal with it.

If it all feels a bit overwhelming and you’re not really sure what to do next. If you’re feeling pretty stuck and getting a bit panicky. If this feels just way too much to handle – that’s hopelessness, or feeling really overloaded.

And each of these three clusters of cognitions, emotions and behaviours are part of the catastrophising construct.

Do they feel normal to you? Do you think you’re exaggerating? Do you think your reaction is over the top? No? Well you’d be (generally) quite right (except maybe the toilet paper hoarding… that’s just weird). Thinking the worst is normal in the face of uncertainty. Some commentators and researchers believe it’s one way we learn to convey our need for social support (Bailey, McWilliams & Dick, 2012; Lackner & Gurtman, 2004; Thorn, Keefe & Anderson, 2004).

At the same time, I want to take a pragmatic and contextual look at catastrophising.

From a pragmatic perspective, right now it’s completely appropriate to be a bit discombobulated by COVID19. And many of us have a lot of things to consider over the next few days/weeks as the situation changes on a daily and even hourly basis. The things we’re doing right now to plan for the worst are largely useful. That’s the point of being able to catastrophise – in the right context, in a rapidly evolving health and economic crisis, being able to consider the various futures and put plans in place to deal with them is probably a good thing. That’s the action part of the catastrophising construct.

The difficulty NOT checking your news media feed, and feeling a bit overwhelmed by it all seems to be a fairly reasonable response to an unreasonable situation. Logic, right?

So, from a pragmatic perspective right now, in the face of uncertainty, most of us are doing exactly what has got humans out of trouble many times in our history.

Now, what if we shift the context to 24 months in the future. COVID19 has now been largely contained, a vaccine is available, the virus hasn’t evolved, and while the economy is slowed, it is gradually picking up. What if, at that time, we have a friend who is still nervously scanning the headlines for the latest information on the virus? What if that friend is still stockpiling pasta and toilet paper and hand cleanser? What if that friend is still feeling like there’s not much they can do except hunker down and hide?

Now, my guess is that many of us would think this is being a bit extreme. Maybe even a bit OTT. Especially given that there’s likely to have been a LOT of media coverage of the COVID19 vaccine, and most economic activity will be returning. We might begin suggesting (gently) to the person doing the stockpiling that maybe it’s not necessary to keep on doing so. We’d think it’s a good idea to give them the new information about COVID19. We’d probably suggest that although they’re freaking out, maybe it’s time to reconsider the threat.

Context matters – catastrophising can be useful right now. In 24 months: not so much. New information will likely help us take a more realistic look at what’s going on with COVID19. It’s not that individual people won’t be personally affected if they get sick, but probably the crisis that’s happening right now will be over.

What about the validity of the person’s emotional response to their feared situation? Would we be dismissive? I hope not – because anyone who is still freaking out about COVID19 in 24 months time is still in distress! But we might be more willing to share the good news about recovery with them, so they don’t continue feeling overwhelmed and distressed. We’d not be likely to let them carry on thinking the worst, and we certainly wouldn’t be telling them their response is perfectly valid and appropriate for the threat.

What of the person experiencing pain and thinking the worst, feeling pretty awful and hopeless? Would we support them to stay in that highly distressed state? Would we say “there, there, you’re really feeling bad, aren’t you, here’s a tissue” – and walk away? Would we hesitate to suggest that perhaps they’re magnifying the problem and that they might have some other options?
Think about it. Catastrophising is a well-validated and studied construct. Hundreds of studies have shown that catastrophising is associated with poorer outcomes in so many situations – childbirth, knee replacements, hip replacements, multi-trauma orthopaedics, discomfort during internal atrial cardioversion, length of hospital stay after knee replacement, use of medications – on and on and on.

Catastrophising gets a bad rap. And woe betide anyone who TELLS someone “you’re catastrophising” because you seriously deserve a slap. Sheesh! But take a moment to consider the adverse impact on the person of thinking the worst… sleepless nights, endlessly checking their body, feeling overwhelmed and overloaded, having trouble thinking of anything else, perhaps anxious and depressed… this is not a recipe for recovery.

Call it what you will – over-estimating the threat of something, and under-estimating your resources can act as a galvaniser for preparation and action in the short term and in the context of uncertainty. When there are ways to move forward, and the threat is maybe not so great as you thought, and maybe you can do something to help yourself – then it’s probably time for us to show strong compassion. That’s compassion that cares enough to have difficult conversations, that helps another person consider their response in light of new information, and is willing to be there to help the person re-evaluate their next best steps.

Keep safe. Keep your social distance. Wash your hands. Don’t go out if you’re sick. Be sensible with the toilet paper.

Bailey, S. J., McWilliams, L. A., & Dick, B. D. (2012). Expanding the social communication model of pain: are adult attachment characteristics associated with observers’ pain-related evaluations? Rehabil Psychol, 57(1), 27-34. doi: 10.1037/a0026237

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

Thorn, Beverly E., Keefe, Francis J., & Anderson, Timothy. (2004). The communal coping model and interpersonal context: Problems or process? Pain, 110(3), 505-507.

Undergraduate pain curriculum: What needs to be included and what doesn’t?

One of the prominent themes in social media discussions about pain is that the subjects are not given sufficient attention at undergraduate level. The results of this omission are that many entry-level clinicians don’t have the necessary knowledge, skills or attitudes for working with people who experience pain. (As an aside, it also makes my job as a postgraduate Academic Leader much more difficult: where do I start when developing a programme?!)

Luckily there is an IASP Pain Curriculum. Actually there are many of them, for many disciplines, and they provide educators with great guidance. The problem is, however, there is so much that could be included in this kind of education – and we usually don’t have much room in a programme to include it all.

The main problems with the curriculum are: the content and levels of competency required at an undergraduate level aren’t specified; most research into this area targets postgraduates, with less attention for undergraduate pain education. Most curriculum for pain have been discipline-specific, and while a consensus on the content and desired competencies of an interprofessional pain curriculum at a pre-licence or undergraduate level has been discussed, an a-priori defined competency level across professions for the items in the IASP curriculum hasn’t been established. We need cross profession agreed competencies to allow for good collaboration. (see van Lankveld, Afram, Staal, van der Sande, 2020).

In my role as Academic Coordinator for Postgrad Programmes in Pain and Pain Management, one aspect of the interprofessional curriculum that is quite difficult to navigate is how to turn topic headings into knowledge, skills and attitudes. I’m wary of teaching directly to subject (knowledge) without accompanying this with appropriate skills and attitudes – particularly at postgraduate level, given knowledge (topics) are continuing to change over time. There’s clearly some material that is highly valued by one profession over other professions – and this is normal for every discipline! And I’m not sure we can ever hope to cover every single thing.

One consistent theme in research into attitudes and beliefs among musculoskeletal clinicians is that confidence to assess and then use information from the psychosocial domain is low (Alexanders, Anderson & Henderson, 2015; Buchbinder, Staples & Jolley, 2009; Miki, Kondo, Takebayashi & Takasaki, 2020; Singla, Jones, Edwards & Kumar, 2015). This problem is not isolated to physiotherapists, but cuts across all professions, including psychologists referred patients with “medically unexplained symptoms” (Brittni & Williams, 2020). I wondered if this area has been given sufficient emphasis in our curriculum, and most especially, whether opportunities to develop skills and attitudes that support equitable and effective pain management are developed.

van Lankveld, Afram, Staal, van der Sande (2020) used interprofessional expert panel groups, followed Delphi process, and incorporated a measure of competency (the Dublin Descriptors), to establish which of the many areas of the pain curriculum should be prioritised. This makes for interesting reading, as some of the areas considered integral to better pain management, such as the socio-political and ethical were not considered crucial, while those related to Epidemiology, Development of Pain Theories, and Mechanisms were all thought crucial. I find this interesting as stigma, equity of access to treatment, ethical use of analgesics are all areas of healthcare that directly influence what we do in treatment and in particular, what gets funded and what does not.

Developing a teaching programme from a list of topics considered important involves opinions, values, and an understanding of pedagogy. Given we live in an ever-changing information environment, I think skills and attitudes towards what is today considered “fact” need to be emphasised – how do we learn to think critically? At least part of critical thinking is reading around a topic to become familiar with current and historic models and knowledge. I also think that some of the more complex issues we need to deal with as societies are often those attitudes towards people who violate our assumptions about who is and isn’t “other”. Learning is not only about content, it’s about attitudes towards the subject matter. And some of these attitudes are buried deeply beneath community assumptions and values. To uncover these attitudes, then help people reflect critically on them and their clinical implications is, I think, one of the tasks educators need to address.

For that reason, in my 5th year undergraduate medical teaching, I ask students to undertake a case study where their job is to listen to the person with pain, identify risk factors and protective factors for recovery and return to optimal functioning and participation, and then offer individually tailored recommendations to the person, in language the person will understand. My hope is that these future medical practitioners will have developed some empathy and strategies for caring for and encouraging patients with pain to be less afraid of their pain, and more able to go on with their lives.

What should go in undergraduate training? I think we can weave all the content of these curriculum into our undergraduate training, but we should also leave students with the certain knowledge, skills and attitudes that this area of study is going to change. And that means lifelong learning about pain, people, science and self.

Alexanders, J., Anderson, A., & Henderson, S. (2015). Musculoskeletal physiotherapists’ use of psychological interventions: a systematic review of therapists’ perceptions and practice. Physiotherapy, 101(2), 95-102. doi: 10.1016/

Buchbinder, R., Staples, M., & Jolley, D. (2009). Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976), 34(11), 1218-1226; discussion 1227. doi: 10.1097/BRS.0b013e318195d688

Crawford, C., Ryan, K., & Shipton, E. (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. N Z Med J, 120(1254), U2536.

Cowell, I., O’Sullivan, P., O’Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskelet Sci Pract, 38, 113-119. doi: 10.1016/j.msksp.2018.10.006

Jones, Brittni, & Williams, Amanda C. de C. (2020). Psychological therapists’ judgments of pain and treatment decisions: The impact of ‘medically unexplained symptoms’. Journal of Psychosomatic Research, 131, 109937. doi:

Miki, T., Kondo, Y., Takebayashi, T., & Takasaki, H. (2020). Difference between physical therapist estimation and psychological patient-reported outcome measures in patients with low back pain. PLoS One, 15(1), e0227999. doi: 10.1371/journal.pone.0227999

Singla, Mukul, Jones, Mark, Edwards, Ian, & Kumar, Saravana. (2015). Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Manual therapy, 20(2), 328-334.

van Lankveld, W., Afram, B., Staal, J. B., & van der Sande, R. (2020). The IASP pain curriculum for undergraduate allied health professionals: educators defining competence level using Dublin descriptors. BMC Med Educ, 20(1), 60. doi: 10.1186/s12909-020-1978-z

Did you miss me?

It’s been a while since I last posted on my blog, as I’ve had other projects on the go this summer. Over this time I’ve been pondering, as I usually do, why pain management/rehabilitation has so many problems. Conceptually, I can understand that pain is a complex experience that we’re a long way from understanding. I get that it’s a philosophically challenging subject. That because it’s subjective (like love, disgust, fatigue or hunger) it’s difficult to examine dispassionately.

I also get that it’s big business. Pain is one aspect of being human that captures the entrepreneur’s imagination. People don’t like pain (on the whole), and even those who seek pain (I’m not thinking fetishes – just sports people!) aren’t inclined to want it to hang around. There’s a ready market for anything that helps “get rid of” pain – even though it’s impossible to fully “get rid of” pain without simultaneously creating other problems!

Some of us clinicians focus almost exclusively on finding a presumed cause. The search can go on for weeks, months, years. Professionals will use tests, investigations, even treatments to see whether they’re on the right track to find what’s initiating the experience. And clinicians can believe, because a treatment was followed by a reduction in pain, that they’ve found it! Happy customer, happy therapist.

Huge arguments are waged across social media platforms. The proponents of one view argue against the proponents of another view. The pendulum is said to swing violently from one side to the other. “Too much bio” “Too much psychosocial” “but what about the bio” “the bio’s always in there, it’s even in the name” – and so on.

I’m a clinician who rarely gets caught up in the “but what about the bio” argument – because I’m unashamedly clear that I don’t treat pain. I don’t attempt to change pain. I don’t try to find the cause. I don’t really look at the diagnosis very much. I don’t try to explain what’s going on. Not because I don’t have some ideas about what might be going on, but because the people I see have usually had “the bio” so extensively investigated that it’s moot. Given that most of our treatments for persisting pain are pretty mediocre, I figure that by the time someone gets to see me (on average two years after the onset) it’s time to focus more on living alongside pain. And if pain does happen to change or go, that’s a total bonus. I’d argue that being able to do that even in the early stages might go a long way towards reducing the overwhelming impact of pain on the daily lives of people.

But in not focusing on pain reduction, not locating the supposed “source” of the problem, some people are horrified. “But look at my success” or “this person suffered for X years and then I solved the problem and their pain went!”. You know, that’s awesome and I think it’s fabulous when someone finds something that reduces pain. It’s just that I don’t think it’s necessary to prioritise pain reduction over living life – I think the two can be done concurrently, albeit with care.

The energy people put in to arguing their position, whichever orientation they prefer, is extraordinary. And it’s this that makes me feel somewhat worried. When we put so much effort into defending a position, we argue ourselves into a stance that’s difficult to change. And we become less sensitive to information that doesn’t fit with our argument. We hold onto our beliefs more strongly, while filtering everything we see and hear through a lens that skews our view of our world.

I’ve argued that clinicians need to hold their beliefs about what we think we know fairly lightly. When we recognise that pretty much all we think we know is provisional and should be subject to more testing, it’s worth remembering that something we assume we know for sure could be wrong.

Take rest for low back pain: from the late 1880’s until around 1986ish, rest for seven days was The Treatment. It’s only through testing and vigorous (really vigorous) arguments that we’ve arrived at the situation we have now, where it’s pretty clear that bed rest isn’t a good option (See the two refs below!). But OH the angst over the years 1975 – 2004! Much argument and rage and frustration and even litigation…

Now we have the era of exercise is good for back pain (well, everything if you read the headlines!). But is “exercise” the panacea? How does exercise help? What are the mechanisms, and can they be activated in other ways? What if you don’t enjoy “exercise” as administered by so many therapists? (see Searle, et al, 2015, below).

I think we’ve learned a great deal about what doesn’t work in pain rehabilitation/management. Mostly, our effect sizes are modest to tiny. And what we haven’t dealt with is how do we help people move from being patients to being people. To being people with lives they want to live. Transferring what seems to help into a person’s OWN life, not the one we think they ought to live.

This year’s blogging is likely to continue my tradition of grasshoppering from topic to topic, but at the heart of my writing is my desire to see people with pain being able to live their own lives, in their own way, with their own priorities and values, and in their own context. Maybe it’s time to step outside our clinic doors, and remember the reason people come to see us: they want to be able to do what’s important in their life. The rest of this philosophical and methodological and factionistic arguing is beside the point.

Hagen, K.B., et al., Bed rest for acute low‐back pain and sciatica. Cochrane Database of Systematic Reviews, 2004(4).

Searle, Angela, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation 29.12 (2015): 1155-1167.

Waddell, G., G. Feder, and M. Lewis, Systematic reviews of bed rest and advice to stay active for acute low back pain. British Journal of General Practice, 1997. 47(423): p. 647-652.

Three letter acronyms and what they mean – CBT, DBT, CFT, ACT – not alphabet soup!

Once you begin to dip your toes into psychological therapies, it doesn’t take long before you begin to see TLAs all over the place. So today I’m going to post on two things: some of the TLAs, and why or how we might consider using these approaches in pain rehabilitation.

The first one is CBT, or cognitive behavioural therapy. CBT grew out of two movements: behaviour therapy (Skinner and the pigeons, rats and all that behaviour modification stuff), and cognitive therapy (Ellis and Beck and the “cognitive triad” – more on this later). When the two approaches to therapy are combined, we have cognitive behavioural therapy where thoughts and their effect on emotions and actions are the focus of therapy, with a secondary focus on behaviour and how behaviour can be influenced by (and influence) thoughts and emotions.

In pain rehabilitation, cognitive behavioural therapy is used primarily by psychologists, while a cognitive behavioural approach is what underpins most of the multidisciplinary/interprofessional pain management programmes. These programmes were very popular and effective during the 1980’s and 1990’s, but have faded over time as insurers in the USA in particular, decided they were expensive and should instead be replaced by what I call “serial monotherapy” – that is, treatments that were provided in a synthesised way within interprofessional programmes are often now delivered alongside or parallel to one another, and typically with very limited synthesis (or case formulation). A question yet to be answered is what effect this change has had on outcomes – my current understanding is that the outcomes are weakened, and that this approach has turned out to be more expensive over time because each discipline involved is seeking outcomes that fit with their priorities, and there is far more opportunity for duplication and gaps in what is provided.

Cognitive behavioural approaches underpin the “Explain Pain” or pain neurobiology education approach. The theory is that people who hold unhelpful beliefs about their pain can become fearful of what the pain means. Once they hold more helpful or realistic beliefs about their pain, that emotional zing is reduced, and it’s less scary to begin moving.

Cognitive behavioural approaches also underpin cognitive functional therapy. In cognitive functional therapy, as a person begins to move, the therapist asks about what’s going through their mind, and establishes through both movement experiments and information, that they’re safe to move, and can do so without fear (O’Sullivan, Caneiro, O’Keeffe, Smith, Dankaerts, Fersum & O’Sullivan, 2018).

When carrying out graded exposure, in the way that Vlaeyen et al describe, a cognitive behavioural approach is integral. In this approach, the classic relationship between avoidance and a stimulus (bending forward, for example), is challenged in a series of behavioural experiments, beginning with movements the person fears the least, and progressing over time to those the person fears the most.

There’s good evidence from psychological therapies, and also from within pain rehabilitation research, that it’s the behavioural aspects of therapy that do the heavy lifting in pain rehabilitation (Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski, 2018).

And, in the words of Wilbert Fordyce, psychologist who first started using a behavioural approach for persistent pain management “Information is to behaviour change as spaghetti is to a brick”.

So don’t expect disability (which involves changing behaviour) to shift too much without also including some strategies for helping someone DO something differently. And if a person doesn’t accept what you’re telling them – sometimes it’s more effective to try helping them do things differently first, and use that experiential process rather than talk, talk, talking.

ACT (acceptance and commitment therapy), and DBT (dialectical behaviour therapy) are both what is known as “third wave” cognitive behavioural therapies. They both involve understanding the relationship between thoughts, emotions and behaviours, but add their own flavours to this. In the case of ACT, the flavour that’s added is “workability” and contextual behavioural analysis, with relational frame theory as the underpinning theoretical model. Instead of directly tackling the content of thoughts, ACT focuses on changing the relationship we have with thoughts, and shifts towards using values as directing the qualities of what we do (McCracken & Vowles, 2014). Dialectical behavioural therapy helps people build social relationships that support them, begin to recognise strengths and positive qualities about themselves, recognise unhelpful beliefs about themselves and shift towards more helpful beliefs, and to use coping strategies to help soothe and calm emotional responses. I draw on ACT as my primary framework for pain rehabilitation (actually for my own life too!), but I haven’t seen as much use of DBT in this area.

Compassion focused therapy, the other CFT, is also a psychotherapy designed to help people become compassionate towards themselves and others. The theory behind this are understanding three main “drives”: the threat and self-protection system, the drive and excitement system, and the contentment and social safeness system. When these are under-developed, or out of balance, unhelpful behaviours and unhappiness occur. CFT aims to help people bring the three systems into balance. Given that many of the people who experience persistent pain have also experienced early childhood trauma, and concurrently endure stigma and punitive responses from those around them because of their pain, CFT offers some strategies to help effect change on an unsettled and fearful system. CFT uses self appreciation, gratitude, savouring, as well as mindfulness (non-judgemental awareness), and compassion-focused imagery to help soothe the system (Penlington, 2019; Purdie & Morley, 2016).

Along with these TLAs, you can also find many others. I think for each approach, understanding the theory behind them is crucial. While some of these approaches appear very “psychological”, whenever we begin unpacking them, we can start to see how most of what we offer in physical or occupational therapeutic approaches require us to draw on them.

Skills like guided discovery, motivational interviewing, goal-setting, values clarification, graded activity, helping people experience difference in their own lives, soothe their own body, become more comfortable with a sense of self that has to grapple with pain – unless we’re knocking our patients unconscious, we’re going to be using these so-called “psychological” skills.

If we are doing good therapy, I think we need to be as excellent as we can in all the skills required. This includes being excellent at the way we thoughtfully and mindfully use communication.

Psychological therapies all incorporate communication, and responses to people who are fearful of something. Most of us are involved in helping people who are afraid of their pain – and as a result are not doing what matters to them. If we don’t help people do what’s important in their lives, what on earth ARE we doing? For this reason, we need to employ the most effective tools (ie psychological approaches) in just the same way we use goal-setting (psychological), respond with encouragement to someone attempting a new thing (psychological), start with something the person can only just do, then grade it up (psychological), help down-regulate an overly twitchy nervous system (psychological), teach new skills (uh, that’s quite right, psychological!). I could go on.

What don’t we do if we’re using psychological strategies? We don’t dig into deep trauma, substance abuse, criminal behaviour, self harm, psychopathology. Though, we do address some psychopathology if we recognise that depression and anxiety both respond quite nicely to scheduling positive activities, and meaningful movement (ie exercise). Perhaps our artificial divide between “physical” and “mental” needs to be altered?

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy, 98(5), 408-423.

Penlington, C. (2019). Exploring a compassion-focused intervention for persistent pain in a group setting. British journal of pain, 13(1), 59-66.

Purdie, F., & Morley, S. (2016). Compassion and chronic pain. Pain, 157(12), 2625-2627.

Schemer, Lea, Vlaeyen, Johan W., Doerr, Johanna M., Skoluda, Nadine, Nater, Urs M., Rief, Winfried, & Glombiewski, Julia A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Toye, F., & Barker, K. (2010). ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability and rehabilitation, 32(21), 1722-1732.

Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.

Who am I? The sense of self in chronic/persistent pain

One of the most pervasive descriptions of what it is like to live with persistent pain is the loss of sense of self. Time after time in qualitative research we read about people feeling they’re in “limbo land”, losing confidence that they can do what matters in their lives, feeling stigmatised and isolated – not themselves any more. An in-depth meta-ethnography of qualitative research showed that pain undermined participation, ability to carry out daily activities, stymied a sense of the future, and intruded on the sense of self (MacNeela, Doyle, O’Gorman, Ruane & McGuire, 2015).

To understand the idea of “self”, I poked about a little in the literature, and found a title I like “Becoming who you are” (Koole, Schlinkert, Maldei & Baumann, 2019). The theoretical propositions of this paper relate more to self-determination than self-concept – but that title “Becoming who you are” resonated strongly with me.

When I read through pain rehabilitation research and theory, especially that dealing with learning how to live well with pain, I rarely see anything written about how we might help people who feel alienated from their sense of self. Scarcely a word. Except in the psychological literature. There’s a bit about self-discrepancy theory (See E. Tory Higgins works for much more about self-discrepancy), where the “imagined self”, the “real self”, the “feared self” and the “ought self” don’t match – but not much about what to do about helping people restore a sense of self, particularly in physical and “functional” rehabilitation.

Silvia Sze Wai Kwok and colleagues (2016) argue that psychological flexibility can play a role in helping people adjust to chronic pain. They found that psychological flexibility mediated between self-discrepancy (how close is my current self to my feared or ideal self?) and pain outcomes (distress, disability and so on). In other words, the degree to which people could flexibly adjust their goals and actions to suit what they could and couldn’t do made a difference.

This seems like common sense. Kinda. As the authors put it: “recognition of self worth and self-values could be attuned through flexible (re)construction of self-concept in response to changing contexts. These adaptations and regulatory functions then in turn may predict the subjective feelings of pain interference, emotional distress and pain tolerance level perceived.”

So my question is: how often does this become openly discussed in pain rehabilitation? Particularly by occupational therapists and physiotherapists – the clinicians who most often work on goals and helping people achieve them?

Whether a person is “motivated” to pursue important goals depends on whether the goals are important to them and whether they think they’ll successfully achieve them. When someone is “non-compliant” it’s because either the rehabilitation activities are not as important as something else in the person’s life, OR they’re not at all confident they can be successful at it. An enormous part of our job as rehabilitation professionals is helping people re-examine what they want to do and helping them adjust how to achieve the underlying values, even if the particular goal isn’t possible – yet. So, for example, if a person really values being a conscientious worker but can’t sustain a full working day, we can either help them fell OK about being conscientious for fewer hours, or we can make the work less demanding. I see this as an especially valuable contribution from occupational therapists.

Should rehabilitation clinicians be involved in this kind of “self-concept” work? I think so – especially occupational therapists. Occupational therapists are about doing, being and becoming – by doing things, we express who we are, and what we choose to engage in also shapes our perceptions of ourselves. As therapists we can’t help but influence a person’s self-concept – if we’re hoping to increase self-efficacy, we’re automatically influencing self-concept. If we’re working on goals, we’re influencing self-concept. If we’re working on participation in life, we’re working on self-concept.

And physiotherapists? Self-concept? Yep – of course. If we’re helping someone do exercise, that’s going to influence that person’s beliefs about exercise and their capabilities – that in turn is going to influence self-concept. (psst! it might be even more powerful if movements are done in the context of daily life, where feedback is real, meaningful and ever-present).

Persistent pain challenges the automatic assumptions people hold about what they can and can’t do, what they’re good at, what’s important in life, and how to engage with “the world” at large. Our job as clinicians is to be sensitive to just how confronting it is to find that what used to be effortless and meaningful is now daunting and requires more concentration and thought than we ever believed. I think that’s part of our job, irrespective of professional labels.

Koole, Sander L., Schlinkert, Caroline, Maldei, Tobias, & Baumann, Nicola. (2019). Becoming who you are: An integrative review of self-determination theory and personality systems interactions theory. Journal of Personality, 87(1), 15-36. doi: 10.1111/jopy.12380

Kwok, Silvia Sze Wai, Chan, Esther Chin Chi, Chen, Phoon Ping, & Lo, Barbara Chuen Yee. (2016). The “self” in pain: The role of psychological inflexibility in chronic pain adjustment. Journal of Behavioral Medicine, 39(5), 908-915.

MacNeela, Padraig, Doyle, Catherine, O’Gorman, David, Ruane, Nancy, & McGuire, Brian E. (2015). Experiences of chronic low back pain: a meta-ethnography of qualitative research. Health Psychology Review, 9(1), 63-82.

Having The Conversation…

Over the past few weeks I’ve been posing some of the curly questions that I don’t think have yet been answered in pain rehabilitation. In fact, some of them have yet to be investigated in any depth. Today I’m stepping out into the abyss to offer my current thoughts on one question that has been rattling around for some time: how do we have a conversation about pain and its persistence? I want to begin by stating very emphatically, that I do believe pain can change. And that the way a person views or interprets their experience can change, and there is reversibility in pain intensity and quality. Having a conversation about persistence doesn’t mean pain will inevitably hang around. So why talk about it?

One major reason comes from people living with pain. In a recent book (Meanings of Pain) I quoted several qualitative studies where “pain acceptance” and conversations about this were highly valued by people with pain – in fact, in my own research, learning that pain would either likely remain in its current form, or would be a feature in some way, was part of a turning point (Lennox Thompson, Gage & Kirk, 2019). The turning point was away from pursuing pain reduction as a primary goal, and towards living a life. “And then I finally said to myself, nothing’s going to work. I might as well try to live with it, and learn to live with it, and since then I haven’t tried pursuing any type of pain relief” (Henwood, Ellis, Logan, Dubouloz & D’Eon, 2012), “All the previous treatments dealt with taking
away the pain. This is the first time one gets a treatment that focuses on acceptance of the pain, and you really understand that this is chronic pain that will never disappear; it’s the first time one has received the message from this angle”
( Pietilä, Stålnacke, Enthoven, Stenberg, 2018)

I guess I don’t see this as a dichotomous choice. It’s not simply “pain reduction” OR “pain acceptance”. I think we can have more than one goal. It’s a matter of emphasis, where energy gets spent. Mark Sullivan and Betty Ferrell argue that health professionals need to reconceptualise their contribution to health: is it to treat disease, or to “advance the person’s capacity for personally meaningful action?” (Sullivan & Ferrell, 2005).

The issue is, that doing what matters can mean “doing what matters provided that pain isn’t present”, or “doing what matters provided that pain has gone”, or “doing what matters provided that it feels good”.

Back to the conversation. The purpose of the conversation is to allow some wiggle room around the “provided that”. Because, in the pursuit of pain reduction life can pass by. Jobs go, relationships fail, kids grow up and leave home, expertise and capability become obsolete, mates develop new pursuits and meanwhile, as people living with persistent pain have said, they’re living in “limbo land”. Reconnecting with values-based activities as one way to feel more whole again often means navigating the meaning of pain fluctuations. It can mean developing ways to allow pain to be present without trying to change the experience, or escape the experience.

Guiding the conversation

I routinely use guided discovery as my main form of therapeutic communication. My approach to The Conversation is to begin by finding out about the person’s theory of their pain – what do they think is going on? What have they been told and what sense have they made of this? What has it been like to have this experience bring attention to daily movements and activities? How are they going about daily life? What’s helped, what hasn’t? What have they given up? What new things have they had to do? What’s that been like?

I usually jot down the good and not so good of all of this – it helps to have a record both for the person and for me. I like to reassure people that they’re doing their very best in what can feel like an unrewarding endeavour. I also explore the impact of treatments on the person. What is it like to take medications, do exercises, have to make time to attend appointments? What is it like to tell one’s story to so many people – who often don’t reciprocate?

Drawing from both my clinical experience and from what I’ve learned about ACT (Acceptance and Commitment Therapy), I offer people a chance to reflect on the impact of not only pain, but also the process of getting treatment. On the work that goes into rehabilitation. I ask them what sense they make of life at the moment. What do they take from all of this?

And in that moment I also ask about what’s important in life. What matters. And how well is that person able to do at least something of what matters in their life? And is it possible to move towards doing more of what matters in life even in the presence of pain? And what sense does the person make of all we’ve discussed?

If I’m asked about whether pain will go, I am open about the possibility that it will not completely vanish. This reflects my understanding of neuroscience, the many many studies into all kinds of treatments, and from the words of people in qualitative studies who indicate that this is an important acknowledgement. I’m also not suggesting that anyone stop participating in pain reduction efforts, not at all. It’s not my decision. It’s never our decision – it’s the person with pain who must decide. I will point out, though, that I don’t think living well with pain is often offered to people as a positive option. It’s often delivered as “well if this doesn’t work, you can try doing some pain management”. Not exactly a ringing endorsement. Not even a neutral suggestion.

The Conversation isn’t about stopping treatment. It’s not about pain reduction vs pain management. It’s not about pain persistence as much as it is about ensuring rehabilitation focuses on what matters to people. For rehabilitation is not about eradicating the disease that caused the problem, it’s about restoring and optimising capabilities, enabling people to participate in their own lives as much as possible. Sometimes, in the pursuit of restoring capabilities, perhaps participating in life is forgotten.

Henwood P, Ellis J, Logan J, Dubouloz C-J, D’Eon J. Acceptance of chronic neuropathic pain in spinal cord injured persons: a qualitative approach. Pain Manag Nurs. 2012;13(4):215–22.

Lennox Thompson B, Gage J, Kirk R. Living well with chronic pain: a classical grounded theory. Disabil Rehabil. 2019:1–12.

Pietilä Holmner E, Stålnacke B-M, Enthoven P, Stenberg G. The acceptance. J Rehabil Med. 2018;50(1):73–9.

Sullivan, Mark, & Ferrell, Betty. (2005). Ethical Challenges in the Management of Chronic Nonmalignant Pain: Negotiating Through the Cloud of Doubt. The Journal of Pain, 6(1), 2-9.

There are two of us in this…

Today’s post is another one where there’s very little to guide my thinking… Have you ever wondered why we read so much research looking at the characteristics of the people who look for help with their pain – yet not nearly as much about us, the people who do the helping?

There are studies about us – thanks Ben – and others! (Darlow, Dowell, Baxter, Mathieson, Perr & Dean, 2013; Farin, Gramm & Schmidt, 2013; Parsons, Harding, Breen, Foster, Pincus, Vogel & Underwood, 2007). We know some things are helpful for people with pain: things like listening capabilities (Matthias, Bair, Nyland, Huffman, Stubbs, Damush & Kroenke, 2010); empathy (Roche & Harmon, 2017); trustworthiness (Sessa & Meconi, 2015); goal setting (Gardner, Refshague, McAuley, Hubscher, Goodall & Smith, 2018).

We also know that clinicians who are themselves fear-avoidant tend to avoid encouraging people to remain active, tend to recommend more time off work and more analgesia (see Farin, Gramm & Schmidt, 2013; but also Bartys, Frederiksen, Bendix & Burton, 2017). We also know there is very little investigation of our behaviours and attitudes (Henry & Matthias, 2018). It’s not a sexy area of study, sadly.

So, today I want to point out that there are two of us in a clinic room: yes, the person with all their concerns, catastrophising, depression, avoidance and psychological inflexibility, but we are also in the room. Just as we know couples will vary their behaviour in response to words and actions (Ballus-Creus, Rangel, Penarroya, Perez & Leff, 2014; Cano, Miller & Loree, 2009), I’m pretty certain that the same things happen between a clinician and a person with pain.

What if our attitudes towards pain made a difference? (we know it does). What if underneath our talk of helping people with pain lies a shadow-land where actually we are afraid of pain and distress, where we sincerely believe that it’s unethical to allow people to feel pain and distress because it makes us uncomfortable? And if we are uneasy with another’s distress, or if we are uneasy with another’s presumed distress (because we would be distressed in their place), what might this mean for our approach to pain rehabilitation?

We all think we’re being person-centred in our treatment, I’m sure. Yet at the same time, I think there’s a risk of failing to look at our own blind spots. One of these is our motivation to help. Why do we work in this space? Is it out of a hero complex? To be “the one” who can find the cause, fix the problem, reduce the pain and have a happy patient? Is it out of a desire to be loved? Or because it’s an endlessly fascinating area with so much new research and so much complexity?

What if we have to have a hard conversation? What if our conversation confronts OUR belief that pain is bad, that all pain can change if we just try hard enough and avoid “nocebic language”? In the face of seeing people who have done all the therapies, been the model patient, worked really hard to get well but still have intense and intrusive pain, could we be Pollyanna and change the world by suggesting that person do it all again? Or try yet another something?

How we handle this situation is not yet clear. We have so little guidance as to how best to help – in the past (from the 1980’s, 1990’s, 2000’s) the way forward was clear: “Hurt does not equal harm, we will help you do more despite your pain because pain may change but in the meantime life is carrying on and you’re missing out.” Then along came Moseley, Butler and Louw and acolytes telling us that just by explaining neurobiology and doing graded motor imagery or mirror therapy or graded desensitisation, pain could (read = would) change and because neuroplasticity, pain would go! In fact, some in this group have made it clear that a CBT approach to pain, where learning to live alongside pain, learning to accept that perhaps not all pain reduces, is “shortchanging” people with pain. Kind of like giving up.

But here’s the thing for me: what if, in the pursuit of pain reduction, people lose their relationships, their jobs and stop doing leisure things? What if the pain doesn’t change? What if the pain only changes a little? When does a person with pain decide when is enough?

You see, it is not sexy to admit that pain may not change despite our best efforts. Most of our treatments research shows a group of people who get some relief, a smaller group who get a lot of relief, a group who actually get worse, and most who make no change at all. I want to know how clinicians who really, truly believe in a treatment for all pain, and that all pain changes, handle the people who don’t respond? Because even with the very best approaches in all the world, there is nothing that provides a 100% positive response to pain (except death, and we don’t know what that feels like).

While we espouse person-centredness and informed consent, I think the option of learning to live well alongside pain is rarely given air time. What might be happening more commonly is a narrative where, to avoid our own distress and the risk of “nocebo” or giving up, clinicians present an ever-optimistic picture of “life without pain” if the person will only try hard enough. Driven in part by clinician’s shadow-land fear of pain (and assumption that it’s horrible, awful and a fate worse than…), and by the desire to be loved, thought of as heroic, perhaps compassionate – and nice and good person, and maybe even driven by fear of how to handle a disappointed, distressed person who may themselves feel let down because we don’t have easy answers to persistent pain.

We can dress this narrative up in many ways. We can call to neuroplasticity always being a thing (but remember that nerves that wire together, fire together … and remain there for all time, able to reactivate any time the alternate paths aren’t used) (Clem, & Schiller, 2016; Hayes & Hofmann, 2018). And of course, humans have the additional capability of language and the myriad neuronal connections that allow us to relate one word to many different experiences, objects, relationships. We can call it being positive, enhancing the placebo, being encouraging. We can say we’re on the patient’s side, we only want the best. We can say we know they can and will make changes if we’re positive enough, if we’re good at our therapy, if we believe….

But, is it ethical to present only half the picture? To talk about pain reduction as if it’s the only goal worth going for? To not discuss the “what if it doesn’t help?” To keep self-management, and acceptance and adjusting to an altered self concept out of our conversations, so that people living with pain may not ever know that it IS a thing and can be a very good thing? How is that providing informed consent?

In case anyone’s worrying, I’m honest about my stance on pain: it’s not that I don’t care (because I really do), but pain is often not the problem. Instead it’s having a good relationship with a partner, having fulfilling work, being able to relax and be grateful for a beautiful day or a soft dog or a child’s laugh. I encourage people to look not at what they can’t do, but what they can. At what we can make of what we have. At what’s important and how we can do more that’s aligned with our values. And of it being OK to feel sad when we can’t do things, and angry, and withdrawn and frustrated – because all of these emotions, like all our experiences, are part of life. What matters is how we handle these things. I hope we can allow them to be present, then let them fade as they do over time, making room for new and different experiences that will also come, and then go.

Ballus-Creus, Carles, Rangel, M., Penarroya, Alba, Perez, Jordi, & Leff, Julian. (2014). Expressed emotion among relatives of chronic pain patients, the interaction between relatives’ behaviours and patients’ pain experience. International Journal of Social Psychiatry, 60(2), 197-205.

Bartys, Serena, Frederiksen, Pernille, Bendix, Tom, & Burton, Kim. (2017). System influences on work disability due to low back pain: An international evidence synthesis. Health Policy, 121(8), 903-912. doi:

Cano, Annmarie, Miller, Lisa Renee, & Loree, Amy. (2009). Spouse beliefs about partner chronic pain. The Journal of Pain, 10(5), 486-492. doi:

Clem, Roger L., & Schiller, Daniela. (2016). New Learning and Unlearning: Strangers or Accomplices in Threat Memory Attenuation? Trends in Neurosciences, 39(5), 340-351. doi:

Darlow, Ben, Dowell, Anthony, Baxter, G. David, Mathieson, Fiona, Perry, Meredith, & Dean, Sarah. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine, 11(6), 527-534. doi: 10.1370/afm.1518

Farin, Erik, Gramm, Lukas, & Schmidt, Erika. (2013). The patient-physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation. Journal of Behavioral Medicine, 36(3), 246-258.

Gardner, Tania, Refshauge, Kathryn, McAuley, James, Hübscher, Markus, Goodall, Stephen, & Smith, Lorraine. (2018). Goal setting practice in chronic low back pain. What is current practice and is it affected by beliefs and attitudes? Physiotherapy theory and practice, 1-11.

Hayes, Steven C., & Hofmann, Stefan G. (2018). Survival circuits and therapy: from automaticity to the conscious experience of fear and anxiety. Current Opinion in Behavioral Sciences, 24, 21-25. doi:

Henry, Stephen G., & Matthias, Marianne S. (2018). Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review. Pain Medicine, 19(11), 2154-2165. doi: 10.1093/pm/pny003

Matthias, Marianne S., Bair, Matthew J., Nyland, Kathryn A., Huffman, Monica A., Stubbs, Dawana L., Damush, Teresa M., & Kroenke, Kurt. (2010). Self-management support and communication from nurse care managers compared with primary care physicians: A focus group study of patients with chronic musculoskeletal pain. Pain Management Nursing, 11(1), 26-34. doi:

Parsons, Suzanne, Harding, Geoffrey, Breen, Alan, Foster, Nadine, Pincus, Tamar, Vogel, Steve, & Underwood, Martin. (2007). The influence of patients’ and primary care practitioners’ beliefs and expectations about chronic musculoskeletal pain on the process of care: A systematic review of qualitative studies. Clinical Journal of Pain Vol 23(1) Jan 2007, 91-98.

Roche, Jenny, & Harmon, Dominic. (2017). Exploring the facets of empathy and pain in clinical practice: a review. Pain Practice.

Sessa, Paola, & Meconi, Federica. (2015). Perceived trustworthiness shapes neural empathic responses toward others’ pain. Neuropsychologia, 79, 97-105. doi:

Big questions in pain rehabilitation

The last 30 years or more of pain research and management have been exciting for us pain nerds. We’ve learned so much about processes involved in nociception, about the psychology of our responses to nociceptive input, about treatments (that often don’t work terribly well), and we’ve discovered that we (mainly) don’t know what we don’t know. There are some big questions though, that have yet to be answered – and don’t yet share the limelight that neurobiological processes seem to hog. Here are a few of my big questions.

  1. How do we alter public health policy to move from an acute biomedical model to the broader and more adequate biopsychosocial understanding of illness, as opposed to disease? To expand on this – our current healthcare funding targets procedures, actions taken against “diseases” like an osteoarthritic knee that can be whipped out and replaced with a shiny new one. The person living with that knee doesn’t really feature because what matters is getting rid of a waiting list of people who want new knees. Government funding is allocated to ensure X number of knees are replaced with the unquestioned belief that this is the best way to deal with osteoarthritic knees. Rehabilitation, or the process of helping a person deal with the effect of a disease on their experience (ie illness), is, by comparison, poorly funded, and the outcomes rather more uncertain and complex. It’s hard to count outcomes that include quality of life and participation in the community. Health managers and policy funders find it slippery and complicated – and because a biomedical model is so much easier to understand, and so much simpler to measure, and those awkward “people” factors don’t need to be accommodated – funding seems to be allocated to procedures rather than outcomes. (see Wade & Halligan (2017) for a much more eloquent discussion of these issues).
  2. When, and how, do we tell someone their pain may be persistent? I’ve scoured the research databases several times over the years, to understand what research has been conducted in the crucial art of communicating to a patient that their pain is either not going to go away, or that it will take a long time before it does. While there is a little research into “giving bad news” this is primarily in the context of telling someone they have a “life-limiting disease”, ie they’re going to die. But nothing, not a single thing, on when we should advise someone, what we should say, what we should do to best help someone deal with the existential impact this kind of message has. In fact, when I’ve raised this question before, people on social media have advised me that if we tell someone their pain is persistent we’re reducing the possibility of recovery – developing an expectation in the person that their pain won’t go, and this will be a self-fulfilling prophecy. I’m not entirely sure that this is true: that suggests our minds can perpetuate pain, when my understanding is that our beliefs and expectations might influence behaviour rather more. And, putting myself in the shoes of many of the people I’ve seen who live with persistent pain, what is it like to be repeatedly told “we have the answer for you, if you’ll just do…[fill in the gaps]” only to find that it has not helped. How demoralising is that? How heartbreaking? And until we have a treatment with a 100% success rate, we will always have to acknowledge that some people will need to live with their pain for the rest of their years. It’s like a dirty little secret: don’t tell people or — and to be honest, I do not know what might happen! (I couldn’t locate a single paper on how to communicate a chronic pain diagnosis – if anyone has found something, please let me know!)
  3. How do we handle those clinicians who firmly believe that psychosocial factors are either irrelevant, or are equivalent to psychopathology? How do we help those people understand that describing someone’s cognitive approach to their situation as “catastrophising” does not negate or trivialise their distress? Neither does it mean we are “judging” the person. It simply recognises an association between one way of interpreting an experience – and outcomes that are not positive for the person. Clinicians who work with people who tend to “think the worst” do their best to understand how someone has developed this understanding of their situation, then offer new information, skills and support to help that person feel more confident and less hopeless. A clinician who simply offers sympathy may feel heroic and kind, but might be cementing disability and distress into place. And those who believe that the only factors that need addressing are depression or anxiety – and that’s not their scope of practice – probably could do with some more education about how humans interact, and the “social” aspects of the biopsychosocial approach.
  4. How do we appraise treatments that might help in the short term, but have unintended consequences? Particularly unintended consequences that occur over time and in areas unrelated to the original treatment. Here’s an example: when someone is offered an injection procedure that reduces pain, yes pain reduces. Yay! This might provide a “window” of opportunity for rehabilitation, return to work, and return to “normal”. And certainly this seems to occur. BUT what happens as the pain returns? If we offer a further procedure, what is the psychological effect of relief on future treatment seeking? Having worked in a pain management service where three-monthly injection procedures were offered, I can say that a core group of people will phone up as soon as their pain returns, and ask for another procedure. If it’s nearly 3 months since the last one, the person gets booked in. Another procedure, another few months go by. This time, it’s 2 months when the person begins to notice pain. Another phone call to ask for another procedure and the person gets booked in – 2 1/2 months since the previous one. Yay! Pain reduces, person goes on… this time six weeks after the procedure the person recognises that the pain is coming back…. phones up and asks for a procedure. This time the person is told “no, you need to wait”. They’re distressed. They’re anxiously waiting, waiting. They see their GP, maybe get some medications. They begin sleeping poorly. Eventually they get another procedure – and oh! the relief! But the experience of distress then relief from a procedure is an incredible learning opportunity. Guess how long before the person comes back for another procedure? And while they’re waiting for it, they’re distressed, not sleeping, disabled – and not ready to “do rehab” because they KNOW there’s a treatment that will “take it all away”. The problems are many, but two strike me: (1) repeated procedures mean those patients can’t be discharged, they remain patients as long as they continue to get the treatments and this eventually takes up so much time and space that fewer new patients can be accepted, and (2) treatments like cortisone injections can only be offered three or so times. What has the person been trained to do when they experience pain? That’s right – seek another procedure. And when this isn’t available, the person has learned to feel anxious about their pain, and to believe there’s little they can do about it themselves. I think this is cruel.
  5. Finally, how do we move from a clinical model where clinicians believe they have the answer, to a model where we appreciate that the person with pain is the one doing the work in all the hours they’re not with us? Maybe the way we do our treatments might shift from doing things to a person, or telling the person what to do (and expecting that they’ll do it just because we said) to being a coach, a facilitator, a cheerleader, a navigator – someone who is willing to work with rather than do to. And when will our funding models and service delivery models shift from valuing procedures (and therefore paying these people more) to valuing interactions (and therefore paying these people more) – and move away from trying to substitute person-to-person interaction with technology? Our communication capabilities need to be highly refined, highly skilled, incredibly nuanced and selective and flexible, and yet the skill to wield a technique (read – scalpel, manipulation, needle, bathboard – the “what” we do) is valued far more, and trained far more intensively than our communication skills. Unless, of course, we’re psychologists. But we use effective communication all the time – and we need to get better at it so we can more effectively help the person in front of us, who will ultimately have a choice about what they do. When will we be comfortable with recognising just how crucial the so-called “soft skills” of empathy, reflective listening, goal-setting, encouraging, challenging, responding to distress – when will these be funded adequately and when will we realise we ALL use these, not just psychologists.

Big questions, uncertain and complex answers. Can we have meaningful conversations about these without research? And yet these questions are hard to study. But isn’t it time to?

Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come. Clinical Rehabilitation, 31(8), 995–1004.

Uncertainty: perennial controversies in pain understanding

As I write this post today, yet again there are new theories being proposed for that most common of experiences: pain. Not only theoretical controversies, but even the definition of pain is being debated – is pain an “aversive” experience? An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury. Some researchers have recently “found” a new nociceptive fibre (though they persist in calling it a “pain fibre” – once again perpetuating the idea that pain is one and the same with nociception).

One of the conversations is whether pain is a sensation, or an emotion, or something else. When I went to University and studied psychology, sensation was defined as “information transmitted by sensory receptors” – in other words, activity in the sensory receptors prior to perception is classified as sensation. Emotions are also defined in psychology, and depending on the theory being followed might be defined as “a complex reaction pattern, involving experiential, behavioral, and physiological elements.” Perception involves recognising and interpreting sensory information, and invokes the idea of awareness as an essential feature. (This is a good place to begin searching for definition – click)

The term aversive indicates “a physiological or emotional response indicating dislike for a stimulus. It is usually accompanied by withdrawal from or avoidance of the objectionable stimulus.” So pain, unlike most sensory experiences also contains an intrinsic element of distaste and avoidance – even people who pursue painful rituals like body suspension will acknowledge that the experience of being pierced is not pleasant but do it to achieve something else, often a feeling of achievement, accomplishment, meeting a challenge. Doesn’t sound too different from people who enjoy running a marathon, or lifting heavy weights.

The new proposed definition also includes the phrase “caused by, or resembling that caused by actual or potential tissue damage” – because we learn to associate the experience we call pain (or whatever word we use in our first language) with what happens when we graze our skin, get pricked by a needle, or knock our shin. For potential tissue damage, think of those staring contests we used to do as kids: who will blink first? Or consider how long we can sit before we’ll move to relieve the numbness-then-ouch on our buttocks! I prefer the term “associate” than “caused by” because we don’t always perceive pain at the time of tissue damage (think about the bruises we find in the morning after a sports game – but we don’t recall exactly how we got them).

So, for what it’s worth, pain isn’t simply a sensation (the experience is always aversive, and invokes an emotion alongside the sensory characteristics) and it’s not simply an emotionit’s a perception, an interpretation of sensory input via nociceptors in the context of current goals (and consequently, attentional focus), social meaning and values, and past experiences (both personal and vicarious). These latter aspects are really important because it’s not uncommon to fail to perceive “ouch” during an important sports game when the attention is elsewhere, and some beautiful experiments have shown that our perception of a potentially painful experience is influenced by what we’re told about the stimulus (Arntz & Claassens, 2004).

The controversies over a definition of pain matter because after the original definition of pain was agreed upon, it was finally possible for researchers, clinicians and commentators to distinguish between the experience and its sensory apparatus. This is important because it enables a focus beyond what goes on in the tissues, to the person’s experience. Prior to defining pain in this way, if a person claimed to have pain but there was no nociceptive activity, he or she was considered lying or mentally unwell. Traces of this attitude continue to this day, sadly.

Focusing on the person’s experience has allowed treatment to shift beyond “issues in the tissues” to help the person deal with what has happened. Even in the absence of current tissue damage and pain, people can continue to be fearful of potential tissue damage and potential pain. Should anyone question this, I usually point out the extraordinary lifestyle changes made by people who have had angina. These people may not be currently experiencing any chest pain at all – but yet protect themselves from the potential of chest pain because “it might happen again.”

A shift away from addressing sensory stimuli towards helping a person who is experiencing pain involves moving away from a biological-only model of disease. We usually call this a biomedical model where what goes on in the body is considered separately from the person who is the subject of “disease”. Of course, this is a straw man argument because biomedical models have been extending to include the person for at least 30 years. Most medical practitioners would want to address the “why has this person fallen and fractured their neck of femur” alongside “fixing the neck of femur fracture with a plate and pin.” But, it troubles me greatly when I hear people say “but what about the bio?” when it comes to incorporating a broad, multifactorial understanding of people experiencing pain into pain rehabilitation. A multifactorial model (call it biopsychosocial if you will) has never negated the biological contributing factors – but has instead placed those factors into relative importance with psychological and social contributions. And psychological and social factors seem to have more to contribute to our experience of pain and resultant disability than, in particular, what happens to a tendon or disc.

And this leads me to the perennial problem of what do we do if pain doesn’t settle, despite our best efforts. This problem is a real and ongoing challenge for both the person experiencing pain, and his or her health. I think it’s a question many health professionals shy away from. Are we afraid we’ve let the person down? Let ourselves down? Failed somehow? What is it like for the person with pain – constantly wondering if this next treatment will do the trick? Or the next? Or whether they’ve failed? Or is it something sinister? There’s no doubt that pain is aversive and it can invade so much of life – but if so much of our experience of pain is related to how we interpret it, what if we were able to re-interpret this experience as less sinister, less distressing?

Health professionals are powerful attitude shapers. Could we use this influence to help people be a little less afraid of pain, and maybe a little more confident that although pain is inherently aversive, humans are infinitely creative and resourceful and can make peace with pain’s presence?

“‘Specialized cutaneous Schwann cells initiate pain sensation”. Abdo H, Calvo-Enrique L, Martinez Lopez J, Song J, Zhang MD, Usoskin D, El Manira A, Adameyko I, Hjerling-Leffler J, Ernfors P.
Science. doi:10.1126/science.aax6452

Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain. 2004;109: 20–25. pmid:15082122