Science in practice

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: https://doi.org/10.1016/j.healthpol.2017.05.011

Cano, Annmarie, Miller, Lisa Renee, & Loree, Amy. (2009). Spouse beliefs about partner chronic pain. The Journal of Pain, 10(5), 486-492. doi: http://dx.doi.org/10.1016/j.jpain.2008.11.005

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: https://doi.org/10.1016/j.tins.2016.03.003

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: https://doi.org/10.1016/j.cobeha.2018.02.006

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: http://dx.doi.org/10.1016/j.pmn.2008.12.003

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: https://doi.org/10.1016/j.neuropsychologia.2015.10.028

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. https://doi.org/10.1177/0269215517709890

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

Cannabis and cannabinoids for persistent pain?


Over the last 12 months New Zealanders have entered into the debate about cannabis and cannabinoids for medical use. In the coming year we’ll hear even more about cannabis as we consider legalising cannabis for recreational use. There is so much rhetoric around the issue, and so much misinformation I thought it high time (see what I did there?!) to write about where I see the research is at for cannabis and cannabinoids for persistent pain.

For the purposes of this blog, I’m going to use the following definitions: Cannabis = the plant; cannabis-based medication = registered extracts (either synthetic or from the plant) in standardised quantities with quality assurance; cannabinoids = substances found in cannabis that may or may not be synthesised into cannabis-based medication.

I’m going to divide this post into two: one part is about cannabis and cannabis-based medication for persistent pain; and the other is about cannabis for recreational purposes.

Recreational use

Cannabis is really popular in New Zealand. Growing up in Gisborne, one of the prime growing regions because of its long, warm summers, cannabis was common. I’ll put my hand on my heart and say I didn’t try it because I was a bit of a nerd and didn’t even try alcohol until I’d left home at 17!

Ministry of Health estimates that eleven percent of adults aged 15 years and over reported using cannabis in the last 12 months (defined here as cannabis users). Cannabis was used by 15% of men and 8.0% of women. Māori adults and adults living in the most deprived areas were more likely to report using cannabis in the last 12 months. Thirty-four percent of cannabis users reported using cannabis at least weekly in the last 12 months. Male cannabis users were more likely to report using cannabis at least weekly in the last 12 months. The NZ Drug Foundation reports that ” In the 2015/16 year, 80% of the adult population reported drinking alcohol once or more – 31% reported drinking at least twice a week.”

The harms from cannabis are real: for vulnerable people, particularly teens with developing brains, the foetus, and those with other mental health problems are more likely to experience adverse effects including psychosis. This risk increases with the greater THC content. The mix of cannabis plus alcohol is nasty… But I’m more concerned about the harms from prohibition.

Prohibition for alcohol didn’t work. Illicit stills, home brewing, fruit-based alcohol concoctions were all readily available during the prohibition era in New Zealand (see this about Hokonui Moonshine). Why would we think prohibition would be effective for cannabis? In fact, the harms from prohibition are this: limited calm and reasoned discussion about adverse effects of cannabis; disproportionate targeting of Maori for possessing cannabis; the use is underground so there is no quality control of the product; gangs use their control of cannabis to threaten purchasers; the real health and addiction problems of cannabis can’t be addressed because it’s illegal while the funding used by police and the justice system could be redirected towards helping the vulnerable. And there are undoubtedly other harms as well.

For my money, I’m quite comfortable with legalising and then controlling the quality of cannabis for sale in New Zealand. With good safeguards around the age required for purchase and redeploying the money currently spent policing and imprisoning people for cannabis crimes to health services, I think we’d do ourselves a great favour. Not quite so happy about commercialising the product because with competition there’s always an increase in efforts to sell more, but with good controls I think it will be far better than our current situation.

Now. Onto cannabis for pain, and cannabis-based medications for persistent pain.

“Pain-related use”

I’ve been reading a LOT of research exploring cannabis and cannabinoids for persistent pain. To limit the extent just a little, I’ve looked only at cannabis and cannabis-based medications for neuropathic pain. This is for a couple of reasons: cancer pain is different from non-cancer pain, and there are often different considerations for cancer pain. Most of the animal research (rats, mice) uses a neuropathic pain model. Neuropathic pain is one of the more difficult persistent pain problems to treat pharmacologically. There’s more, and better quality, research into cannabis, cannabis-based medications and cannabinoids in neuropathic pain than any other pain mechanism. BUT it’s important NOT to extrapolate from findings in rats and mice, and for neuropathic pain, to all forms of pain in humans. That being said, here’s where things are at.

In neuropathic pain, cannabis-based medications are either a combination of THC + CBD or they’re straight THC. CBD has not been studied on its own for pain. This is important because, according to a study I’ve just been involved in, and from listening to people about their experiences of using cannabis for pain, most people think a CBD-based or CBD-heavy drug is “good for pain”. Recently I reviewed a study of cannabis for fibromyalgia (here) where it was only the plant with THC or THC + CBD that gave people pain reduction. There is some thought that CBD augments the effects of THC, but only in certain proportions – there’s a reasonably small window in which THC + CBD is helpful in pain.

The controlled studies, using reasonable methods (and believe me, there are a LOT of studies using poor methods, and even poorer reporting) show that THC or THC + CBD are the only combinations to provide pain reduction.

The question we should be asking (and always ask before adopting a new treatment) is whether this is more effective than what else is on offer, and whether the adverse effects are fewer.

At this stage I have to say the evidence is pretty skinny. Lots of studies, yes, but not well-conducted or reported, and the change in pain intensity is small. So small that the change in pain scores was a reduction of 4mm on a 1 – 100mm visual analogue scale. And the number needed to treat for one person (to achieve a 30% reduction in pain) were 27 (38.5% response to treatment, 33% response to placebo) (Campbell, Stockings & Nielsen, 2019).

Now this finding conflicts with the many people who report using cannabis (not cannabis-based medications). Again, drawing from the study I have been involved in, many of the participants indicated that they found cannabis helpful – although a good proportion also identified that cannabis didn’t actually take the pain away. And this is interesting. Why is it that people say they use cannabis for pain (and pain is the most common reason given for using “medicinal” cannabis in the US (Kosiba, Maisto & Ditre, 2019)?

Drawing from both the study I’ve been involved, and some hunches, here’s what I think might be happening (more research required):

  • Cannabis promotes a sense of euphoria. Now that doesn’t mean feeling super-high, but it does mean feeling better than before you had it. And if you’re experiencing pain that doesn’t go away, feeling good is such a contrast to what you’re feeling most of the time, I wonder if this explains some of the effect. Particularly as it’s the THC or THC + CBD combo that seems to have greatest effect in research.
  • Cannabis often promotes better sleep, and this is one consistent report from the study I’ve been involved in. Disturbed sleep is, as we know, associated with greater pain the following day, and most people with persistent pain report rotten sleep (Simpson, Scott-Sutherland, Gautam, Sethna & Haack, 2018). Maybe one effect of cannabis use is to help people sleep better – but what are the effects of cannabis on sleep architecture in the long run?
  • Using cannabis involves a ritual. A ritual either of baking, or of preparing to smoke weed. Rituals invoke a meaning response (Blease, Annoni & Hutchinson, 2018; Lindenfors, 2019). They prepare us for what is to follow. In time, we anticipate what happens next. In the case of cannabis, inhaled cannabis takes effect within seconds of inhaling, so it becomes a very potent learned expectation. In baked goods, the effect is far slower – but there’s little doubt that inhaling the scent of freshly baked goodies elicits all sorts of yummy expectations, whether the product is cannabis-laced or not! The meaning response (“placebo effect”) is an incredibly powerful product of our own nervous system – and I have no problems attributing at least part of the reported analgesic effect of cannabis to the meaning and expectations people hold towards its use. Add to the expectation some pharmacological feel-good substances, and it’s potent!
  • Cannabis can be used prn whenever the person feels the need. While some people limit their use of cannabis to an evening toke, from our study some people indicated they used cannabis repeatedly through the day and evening. Because it’s not possible to kill yourself with a dose of cannabis, and because the euphoric effects quickly drop (if they’ve even been a significant part of the experience) cannabis use can be a pick-me-up any time. There are good, and not so good effects from this: prn medication use isn’t thought to be helpful because it can promote increased use over time. That doesn’t appear to be the case for cannabis. Again, prn use of any medication is thought to perhaps address distress rather than pain intensity, so it may mean people are less inclined to use active coping than reach for cannabis. I don’t know, because the research hasn’t been carried out. What does seem clear is that because of its rapid onset and relatively mild side effects as compared with opioids or the usual drugs for neuropathic pain, people are more positive about using cannabis as needed rather than these alternative drugs.
  • Cannabis has fewer strongly sedating effects than many other medications for neuropathic pain. By this I do not mean it has no sedating effects (see above!). But participants in the study I’ve been involved in said they could function, they could participate in things that mattered to them while using cannabis, whereas with opioids or other drugs for neuropathic pain, they couldn’t because they felt groggy, spaced out, or just couldn’t think. I think this is really interesting. Maybe it’s worth being able to think straight is more important to our participants than having better pain reduction. The sedating effects of cannabis effects seem to wear off more quickly, particularly for people who use it a lot.
  • Cannabis can reduce anxiety – but so also can it increase anxiety. People living with persistent pain, particularly weird neuropathic pain, live with the uncertainty of when it will flare up, when the “electric shocks” will start up again, wondering if it will settle down or hang around. This doesn’t engender a state of calm! Some forms of cannabis can reduce anxiety (particularly CBD-heavy forms), but THC-high (see what I did again!!) increase anxiety. It’s a mixed bag especially given that establishing the precise chemical consistency of plant material is pretty difficult – particularly by growers in the illegal market of NZ.

Summary – and a bit of science

Writing this blog I’m sure will bring out a heap of pro-cannabis people who will argue that I’m ignoring the “strong evidence” for cannabis for pain relief. Before anyone does – believe me, I’ve read a heap of papers, and to be perfectly honest, I’m alarmed at the state of the research. Not only are many studies failing to identify the pain mechanisms addressed (neuropathic pain is the most commonly studied, but it’s also common to find studies with mixed cohorts); studies are often short – for a chronic, ongoing problem like persistent pain, we need to have studies carried out over 12 months or more, 8 weeks or less is completely insufficient; the outcome measures used are primarily pain intensity using a unidimensional index like a numeric rating scale – come on guys, pain is NOT a unidimensional problem, and surely we’ve learned from opioid trials that pain intensity isn’t the best outcome measure for a long-term problem? What about participation in life? What about disability reduction? What about sleep? What about reduced use of healthcare? Many of the studies are in rats and mice and last time I checked, I’m not a rat or a mouse, and my physiology is a little different; the analysis of studies is often awful with no mention of dropout rates, no responder analysis, no description of adverse effects and tiny, tiny sample sizes. Worse, the small sample sizes exclude people with comorbid problems like depression, anxiety, insomnia, drug and alcohol use (and yet these are characteristics of many people seeking help for persistent pain). Additionally, most studies don’t indicate whether the people taking part in the study are naive to cannabis – people who use cannabis regularly are less likely to be bothered by adverse effects, so studies aren’t describing what may happen in people who are new to the effects of cannabis.

I could go on, but I think there are enough questions about the state of the research into cannabis for pain for us to be pretty cautious about asking medical practitioners (who may not have the time I’ve dedicated to reading the research) to sign their name to a prescription for a cannabis-based treatment, or cannabis itself. Doctors should think carefully before prescribing because, in health, we expect that medical practitioners know what substance they’re prescribing, the effects of that substance, what it should be used for, what harms might come from it, what interactions it might have with other medications, and that the product available has consistent quality-assured content.

As for understanding why people continue to use cannabis for pain – I’m keen to study this in more detail. Why is there such a disparity between what research shows and what people tell us? What might explain this? I’m absolutely not doubting the experience of people who say that cannabis helps – I’m just curious about how this is coming about, because it doesn’t look like it’s purely from the pharmacological effects of the plant.

References

Blease, C., Annoni, M., & Hutchinson, P. (2018). Editors’ Introduction to Special Section on Meaning Response and the Placebo Effect. Perspectives in biology and medicine, 61(3), 349-352.

Campbell, G, Stockings, E, Nielsen, S. (2019). Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain. European Archives of Psychiatry and Clinical Neuroscience, 269. pp 135 – 144. https://doi.org/10.1007/s00406-018-0960-9

Kosiba, J, Maisto, S, Ditre, J. (2019). Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis. Social Science & Medicine, 233, pp 181-192. https://doi.org.10.1016/j.socscimed.2019.06.005

Lindenfors, P. (2019). Divine Placebo: Health and the Evolution of Religion. Human Ecology, 47(2), 157-163.

Simpson, N. S., Scott-Sutherland, J., Gautam, S., Sethna, N., & Haack, M. (2018). Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization. Pain, 159(1), 33-40.

Barriers to good pain rehabilitation


This is a long…… read

ooops, sorry, not.

Low back pain is, we know, the greatest contributor to days lived with disability (Rice, Smith & Blyth, 2016). And no-one anywhere in the world has found a good mix of services to reduce the number of days lived with disability as a result of this problem. And yet billions of dollars are used to fund research into the many contributors to a shift from acute low back pain to ongoing disability associated with low back pain.

At the same time, treatments that directly target disability, rather than pain (a target considered the most important outcome by Sullivan and Ballantyne, 2016) are difficult to access, by comparison with surgical solutions (or pharmaceutical or procedural). Overuse of unhelpful treatments is thought to occur when treatments are offered that are ineffective, pose high risks of harm, or where the balance between harms and benefits varies considerably (Brownlee, Chalkidou, Doust, Elshaug, Glasziou, Heath et al, 2017). Non-pharmcological, non-surgical, and non-procedural treatments fall into the large amorphous group of treatments often delivered by allied health clinicians.

When asked, clinicians (aka doctors, in this instance) were found in one study, to fall into three groups: Multimodel/Aggressive = 14%; Psychosocial/Nonopioid = 48%; and Low action = 38% (Phelan, van Ryn, Wall & Burgess, 2009). On the face of it, this looks reasonably good except when we have a look at what the numbers mean. The Low action group were more likely to move from prescribing one opioid to another opioid, suggest that patients take their opioids more regularly and at a higher dose, use a short-acting opioid, treat with a long-action opioid on a fixed basis, and order more diagnostic testing. The Psychosocial/Nonopioid group were more prepared to use psychosocial clinical approaches, refer elsewhere, not use opioids, and were happier to discuss emotional assessments, refer for physiotherapy, mental health evaluation, refer to pain specialists and so on. But their rationale was not to prescribe opioids because of their concern about tolerance, diversion and addiction. Finally, the Multimodal/Aggressive group combined the approaches of both the previous groups and the authors thought this most closely represented “the multimodal treatment strategy endorsed by proponents of the biopsychosocial model” (Phelan, van Ryn, Wall & Burgess, 2009, p. 1274).

I’m interested in why these clinicians chose the kinds of treatments they did – The authors analysed various aspects of each group and found the belief that pain has a physical cause (MA: 56%; PNO: 35%; LA: 31%; P chi-square < 0.01) and positive attitudes towards using opioids (MA: 3.5 [0.8]; PNO: 3.2 [0.8]; LA: 3.4 [0.8]; Pf-test < 0.01) differed by class. Added to this, the physician’s concern also different by class: High concern about drug use/abuse (MA: 39%; PNO: 47%; LA: 19%; Pchi-square < 0.001), and Concern about effectiveness of opioids (MA: 3.6 [1.0]; PNO: 3.4 [1.0]; LA: 3.2 [0.9]; Pf-test = 0.02). Adequate consultation/referral resources also differed by class (MA: 59%; PNO: 65%; LA: 42%; Pchi-square < 0.001).

Let’s look at this – inaccurate beliefs about pain and attitudes towards opioids featured in the choices made by doctors, while feeling there were inadequate consultation and referral resources were especially featured by the very group using these resources most readily!

Treatments that are available but are underused are as problematic for our health system (and the people seeking help) as over-using inappropriate treatments. Glasziou, Straus, Brownlee, Trevena, Dans, Guyatt, Elshaug & Janett et al (2017) describe four stages where people may not get or use helpful treatment:

  1. a total or partial lack of access to health care (because the system does not offer coverage or patients are unable to reach or pay for available care, or both);
  2. unavailability of effective services within the local health-care system;
  3. a failure of clinicians to deliver or prescribe effective, affordable interventions; and
  4. a failure of patients to commence or adhere to effective, affordable interventions. ” (p. 171).

As I look at these four stages, I can see that in New Zealand, 1, 2, 3 and or course 4 all apply. The ones that concern me most are the first three. Why are effective treatments not widely available? Think about the lack of pelvic pain services for men and women (yes, men have pelvises too) where, instead of evidence-based treatment, these people are offered repeated ineffective, invasive and non-evidence-based “exploratory” endoscopic surgeries. Who makes decisions not to fund so-called conservative interprofessional pain rehabilitation?

Why are ineffective services available despite evidence showing their lack of usefulness? Who makes decisions to continue funding ineffective treatments? What vested interests, what power relationships value the status quo even when it’s not helping people?

Why are clinicians failing to deliver effective, affordable treatments? Why is that GPs in New Zealand still don’t follow back pain guidelines, continue to offer imaging “for reassurance” (despite evidence that this kind of reassurance is not reassuring, Linton, McCracken & Vlaeyen, 2008), and fear talking about the psychosocial impact of persistent pain on people? (Darlow, Dowell, Baxter, Mathieson, Perry & Dean, 2013).

Before I have a bunch of aggrieved doctors jump on me for “blaming them”, let me assure you that I have incredible respect for general practitioners. They have an extraordinarily difficult job to do – and we don’t really understand why adopting guidelines is so difficult. Except… Webster, Courtney, Huang, Matz and Christiani (2005), Coudeyre, Rannou, Tubach, Baron, Coriat, Brin et al (2006); Crawford, Ryan & Shipton (2007), Hush (2008), Somerville, Hay, Lewis, Barber, van der Windt, Hill & Sowden (2008), Corbett, Foster, & Ong (2009), Finestone, Raveh, Mirovsky, Lahad & Milgrowm (2009), Fullen, Baxter, O’Donovan, Doody, Daly, & Hurley (2009), Phelan, van Ryn, Wall, M & Burgess (2009), MacNeela, Gibbons, McGuire & Murphy (2010), Williams, Maher, Hancock, McAuley, McLachlan, Britt, Fahridin, Harrison & Latimer (2010), Azevedo, Costa-Periera, Mendonca, Dias & Castra-Lopes (2013)…. OK I got tired of listing the many, many studies showing how deficient primary care of low back pain is. And that’s not even up to 2019!

Of course I could point the finger at many other health professionals as well – similar findings for physiotherapy, orthopaedic surgery, even pain services…

So WHY are unhelpful approaches so sticky? Why doesn’t practice change?

Me… wondering why

Here are my off the top of my head ideas (ideas based in reading a lot). Funding and policy for funding is, in New Zealand, governed by two main agencies: ACC (accidental injury) and Ministry of Health but devolved to local DHBs. Who sits on the decision-making committees? How many of these august people come from allied health backgrounds? What is the understanding of pain within these committees?

How do people get to be appointed to the committees and policy-making positions? Who makes those decisions? What are the hidden (and maybe not so hidden) vested interests within those groups? How many have holdings in medical companies? What exposure do these people have to evidence and to allied health?

Why do clinicians carry on with unhelpful approaches? I think there’s a lot to uncover: limited time, the push to replace face-to-face interaction with apps (when people really crave interaction!), lack of funding, fear of how to handle difficult conversations (possibly based on lack of training, but maybe because of a fear that the conversation will be misinterpreted – in turn, maybe that fear is because the clinician still holds a dualist model of pain), limited knowledge of what other clinicians offer, ties between companies stitching up who can be referred where, desire not to be different, and not to take more time….

Disheartened? Maybe it’s winter, but while there is a zeitgeist amongst physiotherapy believing that “we’ve reached a turning point” and aha! we will now move forward as enlightened pain rehabilitation beings! I’m inclined to look at the waves of change that have occurred over my clinical lifetime. The enthusiasm for multi and inter-professional treatments, the fervour for early intervention to prevent disability, the explain pain and it will lead to great outcomes… All good things, yet still the fundamental problem is, I believe, adherence to a mainly biomedical or biophysical model for what is a problem experienced by humans in all their myriad complexity. Until that reality is firmly fixed within the system (not just GPs!) I think change will be incrementally slow.

Either that, or I need to learn how to play the political game and get appointed to one or more of the decision-making committees in ACC, MoH and DHB-land.

Azevedo, L. F., Costa-Pereira, A., Mendonça, L., Dias, C. C., & Castro-Lopes, J. M. (2013). Chronic pain and health services utilization: is there overuse of diagnostic tests and inequalities in nonpharmacologic treatment methods utilization? Medical Care, 51(10), 859-869. doi:10.1097/MLR.0b013e3182a53e4e

Brownlee, S., Chalkidou, K., Doust, J., Elshaug, A. G., Glasziou, P., Heath, I., . . . Korenstein, D. (2017). Evidence for overuse of medical services around the world. The Lancet, 390(10090), 156-168. doi:https://doi.org/10.1016/S0140-6736(16)32585-5

Corbett, M., Foster, N., & Ong, B. N. (2009). GP attitudes and self-reported behaviour in primary care consultations for low back pain. Family Practice, 26(5), 359-364.

Coudeyre, E., Rannou, F., Tubach, F., Baron, G., Coriat, F., Brin, S., . . . Poiraudeau, S. (2006). General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain Vol 124(3) Oct 2006, 330-337.

Crawford, C., Ryan, K., & Shipton, E. (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. New Zealand Medical Journal, 120(1254), U2536.

Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (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

Finestone, A. S., Raveh, A., Mirovsky, Y., Lahad, A., & Milgrom, C. (2009). Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine, 34(15), 1600-1603.

Fullen, B. M., Baxter, G. D., O’Donovan, B. G., Doody, C., Daly, L. E., & Hurley, D. A. (2009). Factors impacting on doctors’ management of acute low back pain: a systematic review. European Journal of Pain: Ejp, 13(9), 908-914.

Fullen, B. M., Baxter, G., Doody, C., Daly, L. E., & Hurley, D. A. (2011). General practitioners’ attitudes and beliefs regarding the management of chronic low back pain in Ireland: A cross-sectional national survey. The Clinical Journal of Pain, 27(6), 542-549.

Hush, J. M. (2008). Clinical management of occupational low back pain in Australia: what is the real picture? Journal of Occupational Rehabilitation, 18(4), 375-380.

Linton, S., McCracken, L., & Vlaeyen, J. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1–2), 5-8. doi:http://dx.doi.org/10.1016/j.pain.2007.10.002

MacNeela, P., Gibbons, A., McGuire, B., & Murphy, A. (2010). “We need to get you focused”: General practitioners’ representations of chronic low back pain patients. Qualitative Health Research, 20(7), 977-986.

Phelan, S. M., van Ryn, M., Wall, M., & Burgess, D. (2009). Understanding primary care physicians’ treatment of chronic low back pain: The role of physician and practice factors. Pain Medicine, 10(7), 1270-1279. doi:http://dx.doi.org/10.1111/j.1526-4637.2009.00717.x

Rice, A. S., Smith, B. H., & Blyth, F. M. (2016). Pain and the global burden of disease. Pain, 157(4), 791-796.

Somerville, S., Hay, E., Lewis, M., Barber, J., van der Windt, D., Hill, J., & Sowden, G. (2008). Content and outcome of usual primary care for back pain: a systematic review. British Journal of General Practice, 58(556), 790-797.

Sullivan, M. D., & Ballantyne, J. C. (2016). Must we reduce pain intensity to treat chronic pain?. Pain, 157(1), 65-69.

Webster, B. S., Courtney, T. K., Huang, Y. H., Matz, S., & Christiani, D. C. (2005). Physicians’ initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. Journal of General Internal Medicine, 20(12), 1132-1135.

Williams, C. M., Maher, C. G., Hancock, M. J., McAuley, J. H., McLachlan, A. J., Britt, H., . . . Latimer, J. (2010). Low back pain and best practice care: A survey of general practice physicians. Archives of Internal Medicine, 170(3), 271-277.

Clinical reasoning models: what’s wrong with them?


I’ve been interested in clinical reasoning and models used in clinical reasoning for quite some time. Occupational therapy has several models, including the “occupational therapy problem solving process” by Lela Llorens, the Model of Human Occupation by Gary Kielhofner, and the Canadian Model of Occupational Performance by Polatajko, Townsend and Craik in 2007. All of these models were designed to support occupational therapy clinical reasoning processes, and to capture the essence of what occupational therapy is about.

When it comes to pain rehabilitation, I’ve found the occupational therapy models a little lacking in specificity for my clinical reasoning. I’ve also noticed similar problems with proposed clinical reasoning models for physiotherapy when considering pain.

Here’s the thing: if pain involves so many factors (call them biopsychosocial for want of a better all-encompassing term), and we don’t know which factors are relevant for this person at this time, clinical reasoning in pain rehabilitation is complex. Why? Well the problem with pain is that it’s full of ambiguity. Not so much for the person experiencing them, but certainly for the clinician trying to help.

Bear with me a minute. To me, clinical reasoning models help shape the factors we include and those we omit.

In writing that sentence I realise I’m assuming something crucial: that models are designed to help us predict and control what’s going on. Is that the purpose of a model? I quickly did a search and found this definition: “In science, a model is a representation of an idea, an object or even a process or a system that is used to describe and explain phenomena that cannot be experienced directly. Models are central to what scientists do, both in their research as well as when communicating their explanations… Models are a mentally visual way of linking theory with experiment, and they guide research by being simplified representations of an imagined reality that enable predictions to be developed and tested by experiment.” It’s from here.

OK, so in clinical reasoning what utility does a model need? I think a model needs to generate hypotheses that explain the unique presentation of this person, their problems, at this time. A nomothetic representation of what might be going on for this unique person.

Occupational therapists and physiotherapists, and probably psychologists, are all concerned less about impairment (that’s damage or dysfunction at the body structure level) than we are about the impact this has on functional limitations and on participation. This doesn’t mean we’re not interested in impairment, but our focus is much more likely to be on “and what impact does that have on what you need and want to do”. Occupational therapists, in particular, are concerned about “and how does this affect the way you participate in our world”.

But if we look at clinical reasoning models in our various professions I think there are some gaps. I don’t think our models invite us to generate hypotheses because the various clusters of information don’t seem to link together in a terribly coherent way. Yet – with all the information around us, there are some causal (or bidirectional) relationships we can consider.

For example, we know that if someone is very fearful of their pain, they’re likely to describe elevated physiological arousal, and they’re not as inclined to engage in movements they believe will exacerbate their pain.

A line of reasoning goes from Fear -> Physiological arousal and Fear -> Avoidance.

This simple set of hypotheses generates some ideas about what might help. Firstly we’d test the presence of fear – is it just happening in this moment, or is it something that’s been present consistently? Mostly we ask the person, but we could use a questionnaire measure of fear of pain. We could also test for physiological arousal – is this present? How do we know? We could use various biofeedback devices, or we could simply ask (or use a questionnaire). And of course we can test for fear-avoidance as a combined construct via questionnaire and/or behavioural testing.

This set of steps really just determines whether our hypotheses are present, so now we need to generate some treatments. In this case, we also draw on research and think about providing information – this, we hypothesise, should reduce reported fear. So we embark on some explanations about what’s going on – and we should see a reduction of fear on a measure of pain-related fear. But perhaps not on avoidance because we know that behaviour change requires more than simply information. We might also help the person down-regulate their excitable nervous system, reducing that “fear -> arousal” relationship. And finally we might begin doing some exposure work which acts on reducing fear in the presence of doing something scary (movements) and so reduce the relationship between fear -> avoidance.

What the example above shows us is what might happen once we’ve identified some potential phenomena that may be present. What it doesn’t show, and something I struggle to find in many clinical reasoning models, is how clinicians identify those phenomena. Why would someone think to ask about fear of pain? Especially if we believe that our job is to help reduce pain and pain’s the only reason the person isn’t doing things. And even more – if we think our job is to deal with “physical” and fail to recognise the relationship between “physical” and “feelings, beliefs”.

You see, I think broad “groups of factors to consider” belongs in the assessment, but we need something more tangible when formulating an individualised explanation. We need to be generating hypotheses about how these various factors interact and lead to a presentation – and while much of this will be conjecture initially, by generating various hypotheses we can then go on to test them – and ultimately establish the priorities for treatment in collaboration with the person. That’s much easier to do when we’ve fleshed out why the person isn’t able to do what’s important to them, and we’ve synthesised all the known factors in some explanatory model.

Is this complex? Yes – but who said it had to be easy? This is why we do the work we do, because it’s complex and “common sense” doesn’t cut it. And if our various professions really want to adopt a sociopsychobiological framework for pain, maybe our clinical reasoning models need to synthesise all these factors in some coherent way rather than simply plonking the groups of factors down without integrating what’s known about the relationships between variables from different domains.

Wacker, J. G. (1998). A definition of theory: research guidelines for different theory-building research methods in operations management. Journal of Operations Management, 16(4), 361-385.

Yazdani, S., Hosseinzadeh, M., & Hosseini, F. (2017). Models of clinical reasoning with a focus on general practice: A critical review. Journal of advances in medical education & professionalism, 5(4), 177-184.

Self-management: What do we think about it?


Self-management is all about the person living with their chronic health problem, learning how to maximise their wellbeing and limit the impact of their health problem on their life. The words might be well-known – but how self-management is best carried out, by whom, and when is a vexed question.

I stumbled upon a study carried out by Van Wely, Boiten, Verhoef, Eijckelhof, Van Hooft, Van Staa et al (2019) where, using Q-methodology (more about this shortly), they examined the beliefs about self-management of a group of Dutch physiotherapists.

First of all, why is this something to blog about on a blog about pain? My basic reason is that the only time we as health professionals can directly influence what a person does is when they’re in front of us. That might be about 30 – 60 minutes, maybe once a week if we’re lucky. The rest of the time that person is on their own. How closely the person follows what we’ve discussed in clinic depends on a whole bunch of factors, some of which are values (how important is health compared with everything else in that person’s life?), readiness to take action (maybe just thinking about it hasn’t yet moved to planning or doing), support or not from others, how well we’ve explained things (how many of us learned about teaching as part of our training?), confidence (are they worried they’re doing it wrong?) and so on. We’re a little inclined to believe that because we value health over other parts of life, so too does the person. And we’re familiar with what to do – but what we ask people to do can be very foreign and unfamiliar.

Living with persistent pain is a 24/7 7 days a week job. It doesn’t go on holiday, doesn’t switch off because you’re tired, doesn’t shuffle into the background because you have other things to do. I’ve referred to it as the ongoing burden of micro-decisions made every single moment of the day.

This means that knowing what helps, and what doesn’t, being able to decide what to prioritise in this moment on this day in this place, being able to communicate plans and negotiate with others, being “selfish” enough to prioritise what helps with wellbeing over what might feel important in the moment but drains.

So, turning to the study by Van Wely and colleagues, what did they find out?

Q-methodology is an approach to help establish correlations between participants’ beliefs and values by ranking a series of statements, and gradually reducing the list to one by forcing decisions about which statements to omit. Often there is an interview accompanying a Q-methodology sort, and in this case it was used to help participants explain their choices. 37 statements about self-management were sorted by participants into (1) agree (2) disagree or (3) neutral. The “agree” statements were then rank ordered starting from the right “strongly agree”, then moving to the left “strongly disagree” and finally, the neutral statements were sorted. For more information on q-methodology, this site is gold!

Statistical analysis was carried out using a by-person centroid factor analysis with varimax rotation. This process was used to identify the number of data-driven factors, factors representing people who sort the statements in a similar way to one another (ie they share similar beliefs). The qualitative material was then coded to identify topics related to self-management support, and clustered into themes which the authors then labelled.

39 physiotherapists were involved in this study, approximately 50% women, aged between 22 – 64 with an average age of 41 years. Most participants held a Bachelor degree, and the majority worked either in priamry care or nursing home settings.

Results – and what do they mean?

Three dimensions explained how the therapists ranked the statements – the physio’s role perception, the physio’s drive, and collaboration with the patient. The authors therefore coded the four perspectives (from the factor analysis) as (1) externally driven educator (2) internally driven educator (3) client centred coach and (4) client initiated coach.

(1) Externally driven educators thought self-management “ought” to be done to cut down health-care costs, or to reduce the need for clinical input. They thought of themselves as motivators and experts, and didn’t allow much autonomy for the person. Adhering to what is “prescribed” was important – while life goals were considered important, these physio’s thought treatment goals were more important.

(2) Internally driven educators thought self-management is best encouraged by identifying intrinsic motivation in the person, and support self-management by education within consultations. Unlike externally driven educators, they weren’t as motivated by healthcare system issues, and thought that self-management should be supported as an integral part of every session. These participants recognised the person’s autonomy and own expertise to find solutions, and also identified the need for them to obtain additional training to be able to provide support in this way.

(3) Client-centred coaches were influenced by their own internal drive for self-management support and focused on the person’s freedom to choose. Goals of reducing professional care and cost weren’t considered part of the equation, and they aimed to collaborate in a partnership with the people they were seeing. They believed in shared-goal setting, and thought they should be available when needed, but encouraged people to find solutions for their own problems. They particularly thought that healthcare reorganisation was needed to support this approach to healthcare.

(4) Client-initiated coaches also had an internal drive to support self-management but believed the person should ‘take the initiative’ to ask for help, and essentially passed the responsibility for maintaining self-management over to the person, rather than integrating either the environment or physiotherapy input. This group of participants thought distance technology would be useful to support people at a distance.

Overall, the physios in this study thought self-management was not a new concept, nor as something that was difficult or time-consuming. They recognised that self-management promotes the person’s freedom to choose – and that treatment should address the person’s needs so they could self-manage.

The authors were pleased that participants in this study thought of self-management as “business as usual”.

I thought it was interesting that the “educator” perspective was a strong theme. This tends to elevate the clinician above the person seeking help – although these participants did aim for shared decision-making mainly via providing education. I also thought it interesting that factors such as the need for healthcare reform and financial impact of self-management (to reduce cost) were important and I wonder what this study would look like in New Zealand where private practice physiotherapy, dependent as it is on (usually) ACC funding, might be less inclined to support an autonomous self-managing patient.

I think self-management is something all people with persistent pain engage in, whether it’s supported by clinicians or not. We don’t spend all our time “in therapy” which means the rest of our time is all about those decisions. Supporting people to be able to make thoughtful choices about what and how and when to do things that help promote well-being is, I think, something health professionals must do as equal partners. And I think it needs to be made explicit and part of every consultation. That means learning how to work alongside people, listen carefully to their priorities and values, help them develop skills to problem solve and find their own solutions – but most importantly, to have the confidence that people living with pain can make choices themselves.

Van Wely, L., Boiten, J. C., Verhoef, J., Eijckelhof, B. H. W., Van Hooft, S. M., Van Staa, A., & Roelofs, P. D. D. M. (2019). Perspectives of Dutch Physiotherapists on Self-Management Support: A Q-Methodology Study. Physiotherapy Theory and Practice, 35(4), 318-326. doi:10.1080/09593985.2018.1443182