Research

Modifying pain behaviour (1)


In my post last week I talked about pain behaviour and why pain behaviours are often a good treatment target in pain rehabilitation. I also talked about pain intensity rating scales and how, because rating scales are a form of communication, the numbers we obtain from them aren’t a true measure of pain: they reflect what the person wants to communicate about their pain to someone at that time and in that context.

This week I want to discuss modifying pain behaviour, and believe me, we are all in the business of modifying behaviour even if we think we’re doing something completely different!

Ethics

One of the issues about modifying behaviour is addressed right at the beginning of Fordyce’s chapter on “Techniques of behavioral analysis and behavior change” and this is the ethical issue of informed consent. It’s important because behaviour change using behaviour modification techniques can operate without the person’s awareness (and does so All The Time). As clinicians, though, we have an obligation to ensure we obtain informed consent from our patient/client before we embark on any treatment. Of course, you and I know that this doesn’t happen in the way that I’d like to see it! When I’m a patient, I’d like to have my options laid out in front of me, with the pro’s and con’s over both short and long term clearly explained. Then I can choose the option that I prefer. But actually, most of the time I’ve received treatment from any clinician, I’ve been given little or no information about alternatives – it’s been assumed that I’ll go along with what the clinician has chosen for me. How’s that for informed consent?

Back to behaviour change. Fordyce clearly details the approach he prefers which is clear discussion with the person about what is proposed – that “well” behaviour will be reinforced via social interaction and “praise”, and “unwell” behaviour will either be ignored or redirected.

Behaviour change done badly

Where I’ve seen behaviour modification done badly is where the clinician fails to indicate to the person that this is the approach being taken (ie no informed consent), where this is applied to all people irrespective of their treatment goals and without discriminating the types of behaviours to be modified, and where it’s applied without empathy or compassion. The kind of “one size fits all” approach. More about this in a minute.

Fordyce points out that “almost every behaviour change problem can be analysed into one or a combination of these three possibilities: 1) Some behaviour is not occurring often enough and needs to be increased or strengthened; 2) some behaviour is occurring too frequently and needs to be diminished in frequency or strength or eliminated; and 3) there is behaviour missing from the person’s repertoire that is needed and that therefore must be learned or acquired.”

Behavioural analysis (lite – more to come in another post!)

So we can work out which behaviours to focus on, as clinicians we need to do some behavioural analysis. This is often best carried out by observing the person – best in his or her natural environment because the contextual cues are present there – but at a pinch, in a clinic setting. I like video for analysing behaviour, particularly something like limping or guarding or compensatory movements, but larger repertoires of behaviour can be self-reported. For example, if someone recognises that they’re resting more often than they want (especially useful if the person values returning to work), then the person can time how long they rest for and work to reduce that time. Fitness trackers or movement trackers can be great for monitoring this. Other options include asking the person’s family about the particular behaviours they notice as indicators that the person is having trouble with their pain: people around the person with pain often know what’s happening well before the person has said anything!

Now this raises my earlier point about lacking empathy or compassion. It doesn’t feel normal to ignore someone who is wincing, looking “pained” or talking about how much they hurt. And this is why, I think, many clinicians don’t enjoy using behaviour modification in a deliberate way – it either feels unsympathetic, so we avoid it, or we do a 180 turn and we apply “ignore all pain behaviour” indiscriminately. Fordyce definitely did NOT suggest this!

Being human in behaviour change

So, how do we approach a person who is distressed? Do we ignore them or comfort them or what? In true time-honoured tradition, I’m going to say “It depends.”

First, we need to analyse the function of the distress in this context, and in the context of our treatment goals. Remember informed consent! We need to clearly articulate and obtain agreement for our behavioural target, and if someone is distressed and this isn’t our target, then we need to respond in an empathic and supportive way. If we’ve observed, however, that the person we’re working with is often distressed as we begin a new activity, perhaps one that pulls the person towards doing something unfamiliar or a bit scary, then we might have a conversation with the person about what we’ve seen, and with agreement, begin to modify our response.

When I describe “function” of distress in this context, I mean “what does the distress elicit from us, and for the person?” – what are the consequences of that distress for the person? If we reduce our expectations from the person, or the person avoids doing the new activity, then we can probably identify that the distress is functioning to reduce the demands we’re putting on the person. Our behaviour as a clinician is being modified by the behaviour of the person – and probably unwittingly. Reducing demands reduces anxiety, a bit, and it may be anxiety about doing that movement (or experiencing pain as a result of doing that movement) that’s eliciting distress. I wouldn’t say being distressed in this context is deliberate – but it’s functioning to draw us away from maintaining the treatment goals we developed with the person.

So what can we do? In this instance, we might remind the person of our agreement to stick to our plan of activity, we can acknowledge that they’re feeling anxious (that’s probably why we’re doing this activity in the first place!), we can reassure the person that we trust that they can do this (boosting self-efficacy via verbal encouragement), and we can maintain our treatment goal.

That’s hard!

Yep. Using this approach is not for the faint-hearted. It means we need to be observant, to always be thinking not just about the form of behaviour we’re seeing, but about its function. We need to monitor our own behaviour (verbal, facial expressions, subtle body shifts, all the non-verbal “tells” we make), and we need to change our own responses to what the person does. And often we find this self-awareness difficult to do. Most of our responses are “automatic” or habitual, and behaviour modification means we need to interrupt our habitual responses so we can help our patient/client do what matters to them.

For a brilliant description of Fordcye’s approach as applied in a case study, Fordyce, Shelton & Dundore (1982) is a great example of how a seriously disabled person was helped via this approach. Remember, this was carried out with the person’s full consent! Chapter 4 of Fordyce’s Behavioral Methods for Chronic Pain and Illness gives the best blow-by-blow description of how to go about this. And for a rebuttal to some of the criticisms of a behavioural approach to pain management, Fordyce, Roberts and Sternbach (1985) offer some very helpful points. That paper also offers some of the best analyses of pain behaviour and why it’s needed as part of pain rehabilitation.

Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors. Journal of behavioral medicine, 5(4), 405-414.

Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.

Pain behaviour: what is it and what do we do about it?


I’m re-reading Fordyce’s classic Behavioral Methods for Chronic Pain and Illness and once again I’m struck by how many of the concepts he introduced and systematically investigated are either mis-interpreted and ignored in our current approaches to helping people with persistent pain. Today I’ll explore just a tiny portion of what Fordyce described.

Pain behaviour refers to all the observable actions we do in relation to experiencing pain (NB some people include thoughts as well, but for today I’ll just focus on observable actions). There are roughly two groups of actions: those involuntary ones that we can call nocifensive responses that include reflex withdrawal underpinned by spinal reflexes but including brainstem circuits (see Barik, Hunter Thompson, Seltzer, Ghitani & Chesler, 2018); and those that are developed and shaped by learning (operant conditioning as well as social learning).

When I write about learning, I often have comments about this suggesting people have a choice about what they do, and that this learning must involve conscious awareness – the upshot of these comments is the idea that if we just tell someone that they’re doing something, information alone will be sufficient to change how often they’re doing it. Well, I don’t know about you, but if you’ve ever chewed your nails, changed your diet, decided to go on a social media diet, or do more exercise, you’ll know that there’s an enormous gap between knowing about and being able to follow through. So let me review some of the processes involved in learning and pain behaviour.

Pain behaviour probably has evolutionary significance. What we do when we’re sore acts as a signal to others, whether those actions are voluntary or involuntary. For example, while limping off-loads weight from the sore limb, it can also function to let other people know there’s something wrong. Groaning or sighing also lets people around us know that we’re not OK. Remembering that we’re a social species, being able to let others know that we need help – or not to do what we just did – means we’re more likely to receive attention, and also to warn others about potential danger. Of course, by eliciting help, we’re kinda obligated to help others when they do the same, which may be why when we see someone demonstrating prolonged pain behaviours we tend to feel annoyed: we might be asking ourselves “If they’re not going to reciprocate, why would I help? Dem’s the rules”

Now pain behaviour is also subject to learning principles. In other words, the specific behaviours we do develop in form and frequency depending on context. The underlying analysis goes like this: an antecedent is present (maybe it’s a particular person, location, or occasion), the behaviour occurs, then something in the environment/context occurs – and it’s this “something in the environment/context” that influences whether the behaviour is repeated, and/or the frequency of that behaviour. The easiest example of this is when you watch a three-year-old playing just a little distance from Mum and Dad. When she trips and falls, she’ll probably get up and brush herself down – and then you’ll see her look for Mum or Dad, and if they’re close enough, she’ll probably let out a bit of wail. In the context of Mum and Dad and her falling over, she’s learned that if she cries she’s likely to get a cuddle or some attention, and this is nice. In the absence of Mum and Dad, if she trips she’s less likely to cry because she’s not likely to get that cuddle. Clever huh?

So if that kind of learning occurs from the time we’re little, it’s easy to see how rapidly this pattern of behaving can become habitual, and when it’s habitual it’s unlikely to be something the child is aware she’s doing. Crying, or seeking attention, when we’re sore is something we’ve learned to do from an early age and while the form of that attention likely differs as we mature, the underlying mechanisms still apply (please don’t scream the place down when you go get your Covid vaccination! It’s OK for babies to cry, but not quite so socially appropriate for grown-ups to cry!).

How does the form of that behaviour change? It’s called “shaping” and it is something that occurs naturally through social learning, and it can also occur in a planned way. Take the example of the three-year-old falling and crying: crying is probably OK outdoors where there’s plenty of room and not too much attention being paid to the interactions between parents and child. Take that same behaviour indoors, perhaps in a supermarket or worse – a quiet waiting room – and it’s likely the parents will shush the child more quickly, and be a little more firm about any ongoing wailing. The context is different, the parents respond differently, and the child learns that it’s not OK to cry loudly where there are other people who might not approve. Over time children learn that in different contexts, different ways to attract attention are required. Clearly there’s more technical language we can use to describe this process, but for our purposes this is enough.

Why do we care about this?

Pain behaviour is normal. It’s something we all do. Mostly it functions in a positive way. We signal to others that we need help, we protect the sore body part, and gradually we recover and resume normal life. In some contexts, though, the tendency to continue doing pain behaviours outlives its welcome. In persistent pain it’s particularly problematic, but it’s also problematic in acute pain situations.

Let’s take the example of the dreaded pain rating scale. The 0 = no pain to 10 = most severe pain I can imagine scale. In the context of an emergency room, being asked to rate pain is a quick and very practical way for clinicians to decide how severe the presumed injury/tissue damage is, whether the person needs analgesia, and whether they’re responding to it. Give a number less than 3 or 4 and you’re probably not going to get a lot of pain relief. Give a number closer to 10, and you’ll get something. Give a number greater than 10 and you may get raised eyebrows. In an experiment by Herta Flor (Flor, Knost & Birbaumer, 2002), participants were given an electric shock and asked to rate their pain intensity (also nociceptive detection threshold (aka pain threshold) and pain tolerance). After they’d rated their pain over several trials, they were given one of two conditions: one in which they were given smiley faces and money when their rating was higher than their average rating for the previous trials, and one in which they were given a sad smiley when their rating was lower than their average. Flor and colleagues found that those people who had been given positive smiley faces for higher pain ratings rated their pain intensity significantly higher than those who had been given neutral or negative smileys.

This experiment doesn’t reflect changes in pain intensity. And this is a critical point to note! The stimuli were the same across both groups. What changed was the response offered to participants after they rated their pain. In other words, behaviour associated with experiencing pain and the resultant rewards given for higher ratings was reinforced.

This experiment, along with a large number of others, is one reason why I don’t like pain intensity measures being taken at every treatment session. Pain intensity ratings are behaviours subject to the contingencies that all behaviour is subject to – people learn what to do, and they do it. And they’re unaware of this process.

We often rely on pain intensity ratings in both experimental studies and clinical practice. Unfortunately, while a numeric rating scale or visual analogue scale are quick and dirty, they’re not like a pain thermometer. We just don’t have an objective measure of pain intensity. And we forget this.

Where am I going with this?

A couple of points. I don’t think we can always influence a person’s experience of their pain. This means that we’re often needing to influence what they do about it – because prolonged distress and disability is not good for anyone. Given the social nature of our species, and the involuntary nature of our response to another person’s distress, we’re inclined to try to reduce distress by offering comfort. Nothing wrong with that except where it gets in the way of the person beginning to do things for themselves. As clinicians we need to reinforce actions a person does to increase their capabilities. We also need to limit our reinforcement of illness behaviour, and we need to do this with the consent of the person – being open about why we’re doing this. Remember people learn this stuff without knowing they’re learning it! This means that as clinicians we must stop judging people and what they do in response to pain. Pain behaviour is learned over a loooong time, and it’s reinforced in so many places. People don’t do pain behaviour on purpose. So we can’t judge people as being “non-copers” or having “exaggerated illness behaviour” – we can just gently show the person what happens, why it happens, and what the effect of that pattern of behaving is having on their life.

The second point is that we can’t treat pain ratings as Truth with a T, and think that we’re getting a pure measure of pain intensity – because rating pain on a scale is a behaviour, and it’s influenced in exactly the same way as all behaviours are. This doesn’t mean ignoring someone’s pain intensity – it just means we need to listen to what the person is trying to communicate.

Barik, A., Thompson, J. H., Seltzer, M., Ghitani, N., & Chesler, A. T. (2018). A Brainstem-Spinal Circuit Controlling Nocifensive Behavior. Neuron, 100(6), 1491-1503 e1493. doi: 10.1016/j.neuron.2018.10.037

Flor, Herta, Knost, Bärbel, & Birbaumer, Niels. (2002). The role of operant conditioning in chronic pain: an experimental investigation. Pain, 95(1), 111-118. doi: https://doi.org/10.1016/S0304-3959(01)00385-2

Musing on “the social” in pain rehabilitation


What do we think about when we consider “the social” as a factor in pain rehabilitation? Do we think of socioeconomic status? Maybe employment status? Perhaps societal attitudes towards pain and recovery? Do we ask if the person has someone they trust in their life? Maybe we even discuss how a relationship is going, whether the person sees their friends and family?

Have we forgotten that possibly the most potent influences on pain behaviour are the people around the person we’re seeing?

It will be no surprise to anyone reading my work over the past 10 or more years (yes, really! it HAS been that long!) that I love reading older pain theorists, researchers and historic approaches to pain. We can learn so much from the pioneers in this area – people like Waddell, Loeser, Main, and Fordyce. While some of the details of theoretical advances may have been superseded, the ideas they promoted remain as potent as ever.

Fordyce, in particular, attracts my interest. Bill Fordyce was a clinical psychologist who pioneered behavioural approaches to reducing disability for people living with persistent pain. Rather than offering repeated surgeries or medications, Fordyce looked to how what we do (behaviour) is reinforced by people and situations around us. From his work, we learned about activity pacing (decoupling the relationship between activity and pain by adopting a quota-based approach to activity), time contingent medication (using medications according to a time schedule rather than “as needed”), and we learned a great deal about how other people’s responses to an individual’s behaviour could inadvertently increase or reduce the frequency of that behaviour.

Why is this important? Well, aside from the way pain behaviours develop from childhood (crying? Mama will cuddle you. Want something? Cry – and Mama will cuddle you), responses from a person’s partner will likely influence both verbal complaints and physical movements (pain behaviours) such as grimacing, bracing and guarding, and in surprising ways. In fact, in an electronic diary study where people with chronic low back pain and their partners (who had no pain) were asked to record responses five times a day for 14 days, researchers found that when a spouse observed their partner’s pain behaviour at one time, they’d be more likely to be critical or hostile towards that person at a later time. If the spouses believed that the person with pain was “trying to influence their feelings” at the first observation, their responses were more likely to be critical or hostile – and it was the attributions made by partners that mediated between pain behaviours and the subsequent criticism leveled at the person (Burns, Gerhart, Post, Smith, Porter, Buvanendran, et al., 2018).

The so what question is sure to come up for some people. Why do we care? It’s not like we can do anything about this, is it? Well… you know me – writing about this stuff isn’t just for fun! The first thing to know is that if something is influencing a person’s behaviour and especially their disability, rehabilitation professionals should be aware of it. Relationship “stuff” is part and parcel of rehabilitation because it’s part of the person’s context. Secondly, it’s not about judging whether this is good, bad or indifferent – it’s about recognising an influence on the person and considering how we might support that person to respond in a way that enhances their recovery. Finally, we need to recognise how behavioural expressions and responses to them influence us. An earlier study by the same researcher (Burns, Higdon, Mullen, Lansky and Wei, 1999) found that expressions of anger and depression by the person influenced the therapeutic alliance with the health professional and this was perceived both by the person and his or her therapist.

Should we, can we do anything to help?

First, to the “should.” Whether we like it or not, these influences are occurring – so they are having an effect anyway, and both on us and the person we’re working with. We are also constantly influencing our patients because we’re inherently social animals. It’s just that we’re probably oblivious to our influence, and consequently are likely to react rather than respond. While I don’t advocate clinicians who haven’t undertaken specific training in relationship work to begin “therapy”, there are some basic things we can and I think, should, do. We should because we’re already influencing anyway – so let’s do something helpful.

The second is, can we do anything to help? Well, yes – because as I’ve said above, we’re influencing anyway. Everything we say and do will likely influence the person we’re seeing and possibly their partner and family.

The first thing we can do is let the person we’re working with know that what they say and do influences the people around them. This might be a revelation to some! We can let them know that this communication is not deliberate, and neither is the interpretation by the partner. It’s part of being human and social.

The next thing we do is offer some information to the person and their partner. Preferably written or video – something that the person can share with their partner. This information should be about the nature of persistent pain (in particular), and that a person’s pain behaviour is unintentional. In other words, that what a person does is explicitly not intended to make the partner “feel bad for them” (ie garner sympathy – in fact, quite often it’s the opposite of what the person really wants!); that they’re not intentionally wanting to avoid doing something; and finally, that they’re not intending to “give in to the pain too easily”.

Another thing we can share with the person and their partner is that because pain is personal and internal, openly communicating about what’s going on is important. None of us are good at mind-reading! The responsibility for obtaining help has to be with the person living with pain, not the person who is observing. This might mean the person with pain needs to think about what they want their partner to do. Often it’s nothing – no fuss, no molly-coddling (been dying to use that word for a while!). But if the person does want something, it’s really good to be specific and clear: “I can’t lift this, can you give me a hand”. This doesn’t mean taking over, BTW!

Where possible, I think it would be great to ask partners and family to be involved in rehabilitation. I wonder at insurers who don’t allow partners or family/whanau to be involved in rehabilitation. I think it’s detrimental – because increasingly, we know that the social context of daily life is such an important influence on disability. Asking partners to be part of rehabilitation might be a bit easier under “lockdown” conditions in many countries at the moment, but even without these conditions, perhaps recording selected parts of sessions, even having a meeting (virtual or face-to-face) might allow partners to be part of their loved one’s rehabilitation journey.

Burns, J. W., Gerhart, J., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., . . . Keefe, F. J. (2018). Spouse Criticism/Hostility Toward Partners With Chronic Pain: The Role of Spouse Attributions for Patient Control Over Pain Behaviors. J Pain, 19(11), 1308-1317. doi: 10.1016/j.jpain.2018.05.007

Burns, J. W., Higdon, L. J., Mullen, J. T., Lansky, D., & Wei, J. M. (1999). Relationships among patient hostility, anger expression, depression, and the working alliance in a work hardening program. Annals of Behavioral Medicine, 21(1), 77-82.

What to do about acute low back pain


I should add another line to that heading: in one easy step! And I’d be inundated with hits and if I could cash in on them I’d be rich! And wrong.

If there was a simple recipe for success, I’d expect that by now we’d have it. The very fact that SO MANY options for managing a bout of low back pain exist is a good reason for skepticism should you ever get tempted to take a headline like mine as a cause for celebration. However I do want to talk about acute low back pain because I think clinicians are often probably doing it wrong.

First of all, low back pain doesn’t include pain that also goes down the leg. Let’s get the definitions clear before we talk! In 2008 a Delphi study by Dione, Dunn, Croft, Nachemson, Buchbinder, Walker and colleagues (2008) developed two definitions: a minimal definition, and an optimal definition. These definitions were developed for epidemiological studies and the minimal definition is very simple – “In the past 4 weeks, have you had pain in your low back?” and “If yes, was this pain bad enough to limit your usual activities of change your daily routine for more than one day?”

from Dionne, Dunn, Croft, Nachemson, Buchbinder, Walker et al, (2008)

Now when it comes to defining a first bout of acute low back pain, Ardakani, Leboeuf-Yde & Walker (2019) raise some very interesting points: researchers investigating acute low back pain don’t clearly distinguish between the factors associated with the disease of low back pain (as they put it, the onset of the very first episode) from its recurring episodes – as they put it, “the continued manifestations of the “disease”.” In fact, in their systematic review for identifying risk factors from “triggers” (their term for subsequent episodes), they could find only one study dealing with the true incidence of first time low back pain – and this was low back pain caused by sports injury. All the remaining studies either explored new episodes, or recurring episodes. The major problem with these studies? They didn’t define how long a person should have had no low back pain at baseline. And given many of us develop back pain in adolescence (see Franz, Wedderkopp, Jespersen, Texen and Leboeuf-Yde, 2014, or Jones & MacFarlane, 2005) for example) it’s probable that studies investigating those over 18 years old will include a lot of people who have had that first bout already.

The trajectories for those of us who do develop low back pain are also reasonably murky because of the challenges around definitions, and there are several studies with slightly different results as you’d expect. Essentially, though, most researchers find that there are three or four patterns that emerge from longitudinal studies: lucky ones who have one bout and no or low levels of pain thereafter; those who have persisting mild pain, those who have fluctuating bouts over time, and those who develop persistent and severe pain. Chen and colleagues (2018) found that “lower social class”, higher pain intensity at the beginning, the person’s perceptions of more challenging consequences and longer pain duration, and greater “passive” behavioural coping were most significantly associated with the more severe trajectory over five years.

So, what does this mean for clinicians – and how well are we doing?

Acute low back pain can really frightening for people, especially if the pain is severe. As clinicians generally choose this work because we care about people, we get hooked into wanting to reduce pain and help. There’s nothing wrong about this – unless it means we also get hooked into trying to offer something we cannot. We’re inclined to believe that people seek help for their back pain because of the pain – but as Mannion, Wieser & Elfering (2013) found from a study of over 1,000 people with back pain at the time of the survey, 72% hadn’t sought care over the previous four weeks; 28% had sought care – and most from more than one provider. Women were more likely to seek care, those who had experienced more previous bouts, those who had trouble with activities of daily living and more trouble with work activities. While pain intensity did feature, it wasn’t as much of a predictor as many clinicians would expect. Indeed, an earlier meta-analysis by Ferreira and colleagues (2010) found that disability was a stronger predictor for seeking treatment than pain intensity.

So what do clinicians focus on? I suspect, though I aim to be proven incorrect, that almost every clinician will ask “what is your pain intensity on a scale from 0 – 10?” Frankly, this question is one that irritates me no end because how on earth do you rate pain? Seriously. Yes, there are a lot of clinicians who then ask about activities a person wants to be able to do (yay!) though when we look at the treatments offered, I wonder how many follow through with practical goal-setting for daily activities like getting shoes and socks on, carrying the groceries, sitting while driving the car or at work… And treatments? the arguments on social media between clinicians would be fun to watch if only they weren’t accompanied by such vehemence!

What I don’t see are conversations about how we help people recognise that they’re likely to follow one of those four trajectories, and what we do to help people self manage a life alongside low back pain.

I don’t see much attention paid to helping people sleep well.

Lots of conversations about pain neurobiology – in an attempt to use this explanation to bring someone on board to engage in treatments.

I don’t see a lot of discussion about how to ask about the person’s main concern – perhaps it’s nothing to do with pain, but more about “my niece is coming to visit and I’m not sure I can cope with entertaining her and managing my back pain”, or “we’re coming up to the busy time at work and I can’t not go in, but when I get home I’m trashed, how can I manage that?”, or “Monday’s are our busiest day, and I have to keep going because the team needs me, what do I do?”

I wonder whether clinicians could be persuaded to get out of the way and stop confusing people with recipes or algorithms or “special exercises” that “must be done this way” – I wonder if we could offer some very simple steps: specific answers to the person’s main concerns (best form of reassurance there is!); goal setting around the things the person needs and wants to do over the first six to eight weeks; sleep strategies including some mindfulness because that’s likely to help long-term; and lots of encouragement as the person returns to activity. Developing a relationship with the person doesn’t need lots of prescriptive steps or cookie cutter programmes, it does mean listening, showing trust in the person’s own capabilities, and willingness to let go of a few sticky thoughts we’ve acquired during our training. Maybe 2021 could be the year clinicians get back to basics and begin to support resilience in the people we see – firstly by showing them that we trust they have the capabilities.

Ardakani, E. M., Leboeuf-Yde, C., & Walker, B. F. (2019). Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature. Pain Res Manag, 2019, 6959631. doi: 10.1155/2019/6959631

Dionne, C. E., Dunn, K. M., Croft, P. R., Nachemson, A. L., Buchbinder, R., Walker, B. F., . . . Von Korff, M. (2008). A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine, 33(1), 95-103.

Franz, C., Wedderkopp, N., Jespersen, E., Rexen, C. T., & Leboeuf-Yde, C. (2014). Back pain in children surveyed with weekly text messages-a 2.5 year prospective school cohort study. Chiropractic & Manual Therapies, 22(1), 35.

Jones, G. T., & MacFarlane, G. J. (2005). Epidemiology of low back pain in children and adolescents. Archives of disease in childhood, 90(3), 312-316.

Mannion, A. F., Wieser, S., & Elfering, A. (2013). Association between beliefs and care-seeking behavior for low back pain. Spine, 38(12), 1016–1025

Why learning about pain can help – an old study worth revisiting


If you’ve read my blog over the years you’ll see that I love a bit of history. Learning from older studies, and older opinions, can help us position our current thoughts in a larger context. Older studies can also highlight concepts that haven’t grabbed the attention nearly as much as more recent studies but still have value.

Today’s post is about a studied published in 2004. It’s one I’ve often used to illustrate how influential our expectations or beliefs are when it comes to pain intensity and pain aversiveness/unpleasantness.

Take 31 healthy undergraduate students (50% were women in this case). Split them into two groups, and offer them a small incentive (a large bar of chocolate and a soft drink – OK I’m in!). Hold a set of objects to the back of their necks and ask them to rate the experience on a set of visual analogue scales ((1) very soft–very hard; (2) not prickling–very prickling; (3) not noticeable–very noticeable; (4) not painful–very painful; (5) not rough– very rough; (6) not damaging–very damaging; (7) not pleasant–very pleasant; (8) very cold–very hot; (9) very simple–very complex.). The objects were:

a feather, a small mirror, a rough brush, a paper handkerchief, a metal bar, a piece of hard plastic, a piece of sand paper, and a gel. The metal bar (aluminium, length 17.5 cm, diameter 3 cm) was cooled down to -25 degrees Celcius. This temperature was chosen because it’s not damaging when held briefly against the skin.

Each person was then individually exposed to the item, and asked to complete the ratings. The only difference between the groups was that participants were told just before the metal bar was applied, “this is very hot” or “this is very cold”.

The findings supported the hypothesis: when people thought the stimulus was hot they rated it as more painful AND more damaging than when they thought it was cold.

What do we make of this? The simple interpretation is that people interpret what happens to them in light of what they think is going on. That meaning influences the experience of pain. And that this interpretation occurs rapidly and without conscious awareness. The authors argued that attentional focus, anxiety and interpretation all influence the experience – however, in this instance, attention to the stimulus was greater in the case of the “cold” stimulus than the hot. Anxiety might influence attention to a stimulus, and “hot” might be more anxiety-provoking than “cold”, enhancing attentional awareness – or not. So the final consideration from this study is that if interpretation is essential in perceptual processing, tissue-damage related meaning might itself influence how pain is perceived.

The authors conclude by saying that their findings “support the hypothesis that higher order psychological processes influence the experience of pain” and go on to say they are “also of clinical importance, as they suggest that correction of dysfunctional interpretations of pain might help to reduce the burden the experience of pain poses on many people.”

Since this paper was published we have seen a proliferation of educational approaches to help people experiencing pain interpret this in a different way. I’m loathe to describe a person’s interpretation as “dysfunctional” because it is their experience – and at the same time I’m also aware that many unhelpful terms are used to describe what might be going on inside a person’s body. Some examples include “wear and tear” for osteoarthritis, “an unstable pelvis”, “your back has gone out”, “your spine is out of alignment” – the list goes on.

Here’s the thing: we can absolutely acknowledge a person’s distress at what they understand is going on, and what it feels like to them. We should, I think, always be compassionate and validate the distress we see in a person. That is real and their experience.

Here’s another thing: when the distress is based on inaccurate or unhelpful information, then I think it’s unethical to leave a person thinking this – even if we’ve offered validation and compassion. Would we leave a person to believe they had cancer when they didn’t? And yet some people would argue that to offer an alternative explanation somehow invalidates the person’s experience. We can both validate the distress a person is feeling AND offer a more workable or useful alternative.

At this point in my blog I want to be absolutely crystal clear – I do not know all the mechanisms involved in pain. Nobody does. And none of our explanations are terribly “True” with a capital T, because we actually don’t know. We do have some workable explanations to dispute or replace some unhelpful or unworkable explanations – eg that what we can see on imaging doesn’t equate with pain; that “issues in the tissues” are poorly correlated to pain; that “wear and tear” is often interpreted by people as “I’m wearing out” when it might be more useful to describe osteoarthritic changes as “age-related changes”. We definitely know that the brain is involved in our pain experience, and we know that various so-called psychological processes influence how much of a nociceptive stimulus is processed. What we don’t know is how – and that’s OK. To a great extent the “how is pain ‘produced'” question remains unanswered. But to leave people with an impression that “if I bend without using my core, I’ll do serious damage”, or “this could leave me in a wheelchair if I’m not very careful” in the name of validating a person’s experience is, I think, the very worst example of paternalism.

Do I espouse any particular way of helping someone make sense of their experience? Yes, glad you asked. My preference is to take the person through their own experiences, to help them “join the dots” of the various factors that might be influencing their pain. If, and when, it’s appropriate I might add in some things we know about pain such as increased anxiety likely increases pain and attention to pain – and this is why, in the middle of the night when there’s not much going on, and a person isn’t sleeping, they might notice their pain really going nuts. I accept that pain is present, and how or why isn’t nearly as important as exploring what this person notices about their own pain. And sometimes that might include some gate control theory, some neuromatrix, some descending inhibition information, and so on. In the service of my clinical reasoning about why this person is presenting in this way at this time, and what might be maintaining this person’s predicament.

TL:DR – what a person thinks is going on has a powerful influence on both pain intensity and unpleasantness (oh and beliefs about harm). This matters because some explanations given to people (and some of the rubbish found on the internet) are not helpful at all.

Arntz, A., & Claassens, L. (2004). The meaning of pain influences its experienced intensity. Pain, 109(1-2), 20-25. doi:10.1016/j.pain.2003.12.030

On values, culture and health


This week is Te Wiki o te Maori – and the theme is Kia Kaha te Reo Maori. For those readers not familiar with te reo, kia kaha translates to “be strong.” It’s a word people from Otautahi (Christchurch) have used a lot since 2010 and the first of the many events that have shaken (literally) our world since then. Te Wiki o te Maori is a week dedicated to celebrating and strengthening the use of Maori language in New Zealand.

While the week celebrates the language of Aotearoa, it also helps us tangata tiriti, or people of the Treaty of Waitangi, remember that we have a place in this whenua (land). It helps me remember the values that those of us living in Aotearoa hold dear.

The thing about culture is that many of us don’t even recognise that we have a culture. Cultures are the assumptions, practices, values, beliefs, habits, ways of being that we have absorbed without knowing we have (see here for a nice description of culture). We all live within more than one culture, irrespective of the colour of our skin – culture is not synonymous with ethnicity or “race.”

This year “Black lives matter” has erupted onto the consciousness of thousands of people around the world. It’s as if, for many people, the whole notion of equality vs equity has never before been a thing. And it’s this blindness to social differences that I want to discuss today.

Recently I’ve been talking about the way exercise is discussed amongst health professionals. I pointed out that not everyone enjoys the gym, and that 3 x 10 sets of exercises is possibly the best way to kill anyone’s enthusiasm for movement. I also argued the aim of rehabilitation is to give the person their own life back – not some “living by numbers” recipe made up of lists, targets and goals.

Both those posts met with a certain amount of enthusiasm, and an equal degree of push-back. Push-back comes from a sense of certainty that of course exercise is a thing we all should do for our health. Because, of course, our health is the thing we should most value.

Or is it? Health professionals enter their professions for many reasons, but one often unacknowledged one is that we value health. We might not state it in those words, we might couch it in terms of “I want to help people”, “I like to give to my community” or even “I have a calling” (Witter, Wurie, Namakula, Mashange, Chirwa & Alonso-Garbayo, 2018), but during our training, we are encultured into valuing health more highly than, perhaps, we would have.

We are also privileged as health professionals. Witter and colleagues also point out that people become health professionals for financial reasons – job stability, respect, status in a family or community. Some health professionals can train for free, while most will recoup the cost of education during their working life. We are privileged because we have education. We have work. We have respect, mana, so what we say carries weight.

When I consider this construct we call health, I bring to mind the WHO definition which is “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June – 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948). Health is more than the absence of disease or infirmity. That bears repeating. Health, in tangata whenua terms, is viewed as wellbeing in four areas: taha tinana (physical wellbeing), taha hinengaro (mental wellbeing), taha wairua (spiritual wellbeing) and taha whanau (family wellbeing).

I bring to mind a person I know. Let’s call her Allie. She is five years older than me. She is overweight, smokes tobacco and has COPD. She left school at 14 years old, and has worked in minimum wage jobs her whole working life. She became pregnant at 16 years old, and raised her only child as a single parent. He has had a mixed and disrupted life, spending many years in prison with a methamphetamine addiction and multiple convictions for burglary. He has a 14 year old daughter who now lives with her grandmother, Allie.

Now Allie has seen a lot of health professionals. Almost all of them have talked to her about her smoking. They’ve also talked to her about diet and exercise. None of this talk has helped her kick the smoking habit, and exercise? What of it? As she said to me once, “tell me when I can go exercise after I leave home at 6.00am, go to one job, then get back from the second job at 7.30pm?”

What matters to Allie? He tangata, he tangata, he tangata. The most important thing in the world to her is keeping her grand-daughter safe. Allie has spent countless hours trying to give her grand-daughter the security of a settled home, a place where there are rules and boundaries, and a place where there is warmth, food, a bed to sleep in, and people who care. And she’s done this with minimal support from her son, her grand-daughter’s mother, and the NZ social welfare system.

So as health professionals, when we begin to judge or critique people for not being “compliant”, for not being “motivated”, for failing to go to the gym, for not stopping smoking – we need to stop for a minute. Allie has tried countless times, believe me – but has anyone asked her what she gains from smoking? It’s her stress relief. In the absence of alternatives, it’s her reliable stand-by. The only way we’re likely to influence Allie is if we view her life through her eyes, and work with what she values.

And when we prescribe what we think is Most Important because we think the person in front of us values what we value – we’re speaking from a place of privilege, and through a lens that reflects our own priorities. And we could be completely oblivious to this. Such is the nature of privilege. Let’s take a moment to appreciate that the people we serve want to return to their own lives, valuing what they value, with their own priorities, and their own perspectives. Kia kaha, arohanui.

Witter, S., Wurie, H., Namakula, J., Mashange, W., Chirwa, Y., & Alonso‐Garbayo, A. (2018). Why do people become health workers? A nalysis from life histories in 4 post‐conflict and post‐crisis countries. The International journal of health planning and management, 33(2), 449-459.

What to do when one size does not fit all


Alert: rant ahead.

Early in my career working in persistent pain management, it was thought that “chronic pain is chronic pain is chronic pain” and pretty much anything that helped one person would help the next. Over time we’ve learned a lot more about persistent pain: the mechanisms differ a lot between neuropathic mechanisms and nociplastic mechanisms. Even within these groups, the mechanisms are very different. We’ve also learned a lot more about the psychosocial variables that are associated with prolonged disability and distress when pain persists. Some of the earliest work by Turk and colleagues found that by using the Westhaven-Yale Multidimensional Pain Inventory, people could be classified into four subgroups (Kerns, Turk & Rudy, 1985). While the names of these subgroups could do with some updating (to avoid negative labelling), there’s a large body of research supporting the four groups they found.

When I first worked at Burwood Pain Management Centre, the WHYMPI was the workhorse pre-assessment questionnaire used to help clinicians understand more about the person they were seeing. Interestingly, at the time there were two group programmes on offer: one was the three week full time residential pain management programme, and people who were admitted to this programme were those with high levels of distress and disability, often with very unhelpful beliefs about their pain, and needing the intensity of the full-time programming to help them make changes that would be sustained when they went home. The other was an outpatient programme, two sessions a week for six weeks, and this was intended for people who had more disturbance in their relationships with others, who felt unsupported and as a result were distressed. Also in this group were people who were generally managing well but needed to learn some new skills so they could get on with their lives.

Times change. Neither of those programmes are running in the same way as they were and there’s been an increase in individual sessions with single discipline input right around the world. Some commentators point out that changing funding models has led to the rise of single discipline intervention (Loeser, 2006), others discuss the ethical dilemmas raised by funding that is allocated on outputs (numbers of people seen) rather than outcomes (how well those people who have been seen are doing, and especially how well they do over time) (Loeser & Cahanda, 2013). This discourse has spilled over into how clinical guidelines have been developed (Chou, Atlas, Loeser, Rosenquist & Stanos, 2011), and this in turn has led to policy and funding decisions made at local level.

The rise of interventional pain treatment (Manchikanti, Pampati, Sigh & Falco, 2013) has been observed right around the world, including in New Zealand. Interventional pain treatments aim to reduce pain intensity via non-surgical means, often through anaesthetic injections (blocks), and in some cases by localising the supposed source of nociception through diagnostic blocks, then ablating or coagulating the proteins around the nerve, to stop transmission (Cohen, Stojanovic, Crooks, Kim, Schmidt, Shields et al, 2008). These latter procedures apply to a very small proportion of people with back pain, nevertheless they are popular – albeit not always applied to the cohort of people originally intended (Bogduk & McGuirk, 2002).

Alongside the rise of interventional procedures, in New Zealand there has been a shift from passive physiotherapy modalities (acupuncture, heat packs, interferential, ultrasound) to active management – which pretty much looks like exercise in New Zealand. New Zealand’s ACC funds community-based pain management programmes that are intended to be tailored to the person’s needs, have a multidisciplinary team approach, and use a multifactorial model of pain. While these programmes superficially look progressive and innovative, results from a recent study colleagues and I have carried out, sadly it looks much like exercise plus psychology, and the teamwork aspect is minimal. More concerning is the rise of “cookie cutter” programmes, limited understanding and use of the carefully collected psychometric information completed by patients, and inappropriate referrals to the services.

The landscape of publicly funded pain management in New Zealand is fraught with problems. Each district has a health board consisting of elected plus appointed members. District health boards have the task of allocating the money central government gives them, according to the needs and wishes of the community. Note that in NZ, accident-related rehabilitation is funded by our national accident insurer (we only have one, it’s no-fault and 24/7). Given we have patchy community service provision for people with pain following accidental injury, you’d think our district health boards would have some consistent approach to helping the one in five Kiwi’s living with pain lasting more than three months. Now while not everyone who has persistent pain will need help to manage it (think of those with osteoarthritic knees and hips who are not quite ready to head to surgery), amongst those who have the most trouble with pain are also those with a history of trauma. Christchurch and the Canterbury area have had, over the past 10 years, over 10,000 earthquakes (the last noticeable one was only last week – take a look at geonet), the Kaikoura earthquakes, and the mosque shooting. During the five or so years after the earthquakes, the city’s children were disrupted by changes to schools (thanks, Hekia Parata and the National Party – you are not forgiven). What all these events have in common is the impact on people with pain. And you guessed it, there is no coherent national approach to pain management, no pain plan or policy.

We know there is a relationship between traumatic events, particularly those in early childhood, and persistent pain (eg Ne4lson, Simons & Logan, 2018). We also know that victims of crush injuries, traumatic amputations, and bullet wounds are likely to experience greater neuropathic pain which is particularly hard to treat. People with persistent pain, especially when it’s been around for some years, are also likely to have poor sleep, mood problems, anxiety problems, and in many cases, will have had repeated surgeries and be given a multitude of pharmaceuticals to help reduce pain and distress.

The problem is that when these are applied without the support of a team, they may well be applied without finesse. They may reduce pain, a little (though this is arguable given how poorly analgesics perform – and the misapplication of the WHO analgesic ladder, Ballantyne, Kalso & Stannard, 2016). But we know that pain intensity and disability are not well-correlated. So while the focus on reducing pain via injections, ablations, surgery, pharmaceuticals and so on is helpful on it’s own it doesn’t necessarily change a person’s sleep pattern, their low mood, their lost job, their fear of moving, the relationship that’s fallen apart, the loss of sense of self…

Worse: when pain management is poorly coordinated and doesn’t target the real needs of people who live with pain and who don’t respond to these efforts (the majority of people with neuropathic pain, for example), people don’t stop seeking help. They pop up in all sorts of places: primary care practices (to the GP who is over-worked, poorly supported and often poorly educated about pain); via Emergency Department (where, although the pain may have been present for a long time, it must be treated as an acute pain problem because that’s what EDs do); admitted for investigations, to provide “respite” for family, to be reviewed yet again by a clinician who is not well-informed about pain because our training in pain is pretty poor (Shipton, Bate, Garrick, Steketee, Shipton and Visser, 2018). They are invisible to NZs health system because they’re not coded as having pain as their primary problem. And people with persistent pain don’t die, and the public’s attention (and media) is focused on deaths. Like the long-lasting Covid-19 patients who continue to have trouble from Covid-19 months after their initial infection, people with persistent pain just hang around. And medical-only approaches simply do not work to treat rehabilitation needs. Rehabilitation is where it’s at. But rehabilitation is no longer a focus of in-patient care in hospitals (neither should it be) – but there are few places outside of hospitals that are funded and staffed to help.

This lengthy post is written out of frustration because too often I’ve seen conversations about pain management saying “oh it doesn’t work” – true! Nothing works well. But most things work a bit. Our problem is twofold: we can’t predict who will and won’t respond very well (though the old WHYMPI and similar psychometric measures/profiles do offer some guidance); and we have little national cohesion around sharing resources. We need to better monitor the impact of our treatments so we can quickly add, or remove, treatments to target particular problems. And all of the providers must have skills for working with people who have persistent pain.

Let’s do better. Let’s clamour for more nationwide planning. Let’s raise the profile of the allied health workforce who do the majority of rehabilitation with people living with pain. Let’s make our teams TEAMS not sets of individuals working in parallels. Let’s have some leadership around the value of pain management, and why it’s important. Let’s bring this whole issue to light. Let’s do it.

Ballantyne, J. C., Kalso, E., & Stannard, C. (2016). WHO analgesic ladder: a good concept gone astray. BMJ, 352, i20. doi:10.1136/bmj.i20

Bogduk, N & McGuirk, B. (2002). Medical Management of Acute and Chro5nic Low Back Pain. An Evidence-based Approach. Pain Research and Clinical Management, Vol3. Elsevier.

Chou, R., Atlas, S. J., Loeser, J. D., Rosenquist, R. W., & Stanos, S. P. (2011). Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? J Pain, 12(8), 833-839. doi:10.1016/j.jpain.2011.04.012

Cohen, S. P., Stojanovic, M. P., Crooks, M., Kim, P., Schmidt, R. K., Shields, C. H., . . . Hurley, R. W. (2008). Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine Journal: Official Journal of the North American Spine Society, 8(3), 498-504.

Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The west haven-yale multidimensional pain inventory (WHYMPI). Pain, 23(4), 345-356.

Loeser, J. D. (2006). Comprehensive Pain Programs Versus Other Treatments for Chronic Pain. The Journal of Pain 7(11), 800-801.

Loeser, J. D., & Cahana, A. (2013). Pain medicine versus pain management: ethical dilemmas created by contemporary medicine and business. Clin J Pain, 29(4), 311-316. doi:10.1097/AJP.0b013e3182516e64

Manchikanti, L., Pampati, V., Singh, V., & Falco, F. J. (2013). Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to 2011. Pain Physician, 16(4), E365-378.

Nelson, S., Simons, L. E., & Logan, D. (2018). The incidence of adverse childhood experiences (ACEs) and their association with pain-related and psychosocial impairment in youth with chronic pain. The Clinical Journal of Pain, 34(5), 402-408.

Shipton, E. E., Bate, F., Garrick, R., Steketee, C., Shipton, E. A., & Visser, E. J. (2018). Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain and therapy, 1-23.

The hardly hidden costs


Chronic/persistent pain management is not sexy. No-one gets a magic cure. Lives are not saved – at least not in a way that mortality statistics show. Chronic pain management is under-funded.

And now: buried in a list of other proposed service cuts in the local health board’s plan to save millions of dollars, is a proposal to “save” $650,000 from the pain clinic. You’ll note also reductions in community services, GP support for vulnerable, and healthy lifestyles programmes.

https://www.stuff.co.nz/national/health/122558278/hundreds-of-staff-nurses-and-services-may-be-axed-at-canterbury-dhb

I know that nursing staff, senior medical staff and 200 admin staff are also in the firing line. I also know that this health board has been side-swiped by earthquake earthquake re-building, the terror attacks with so many victims needing urgent and ongoing surgery and rehabilitation, along with the mental health impacts of all of these events and now Covid-19… Delays and poor workmanship on new buildings on the main hospital site have meant these new facilities are well over-budget, and two years late – and there is still no car-parking for patients and staff. Historic under-funding by past governments has meant Canterbury DHB has developed innovative and nimble responses to these challenges – and been lauded internationally for their work. I won’t say anything about the growth in middle management, suffice to say that where there was once one general manager at one site, and a direct report line from the clinical director of a service – now there are three or four layers of management…

Let me turn to why cutting expenditure on pain services is likely to cost rather than save.

In 1987 or so, a new pain management service was developed in Christchurch. One of the primary reasons for opening this centre was to address the burgeoning rise in numbers of people presenting for orthopaedic surgery but for whom surgery was not an option. Either because there was nothing to find on imaging – pain can’t be imaged, and surgeons can’t operate on a normal x-ray or MRI – or because the person’s problem would likely not respond to surgery.

As a result of the new pain management service, people who weren’t suitable for orthopaedic surgery were referred for multidisciplinary pain management: medical assessment, functional assessment, psychosocial assessment, and appropriate pain management from there. Fewer people with low back pain were being admitted to the orthopaedic wards as a result. Win!

It’s only possible in the first few years of a service to clearly demonstrate the impact of it on the rest of the health system. Why? Because it’s not possible to show what isn’t happening. Now that pain management services have been in place for many years, the effect of people attending these services rather than other parts of the healthcare system is invisible.

For example, people who attend pain management services don’t need as many ambulance trips, visits to the Emergency Department, admissions via Emergency to hospital wards. They don’t stay in hospital beds while they undergo investigations – all the while using bed space, “hotel services” (food, linen, soap, towels, hot water, cleaning services), along with the skilled healthcare staff – doctors, nurses, physiotherapists, occupational therapists, laboratory workers, phlebotomists, radiographers, pharmacists and on and on…

People who are served well through pain services don’t take up as much space in the rest of the system – and the very people who need pain services are the people who otherwise do end up in many places throughout the healthcare system (Blyth, March, Brnabic, Cousins, 2004; Duenas, Ojeda, Salazar, Mico & Failde, 2016). It’s evident from so many epidemiological studies that people with chronic pain will have an impact across “physical” health services, “mental” health services, primary care (General practice), secondary care and tertiary care. And an acute hospital setting is not the right place for people with chronic pain to be treated.

Until recently, though, admissions for chronic pain haven’t been counted as “chronic pain” because the coding used (ICD10) doesn’t have chronic pain as a stand-alone category. This means a person with chronic abdominal pain, for example, will have their condition listed within an acute pain admission category. Similarly with chronic non-cardiac chest pain – these admissions are coded as “cardiac”. The new ICD11 will help make these currently hidden admissions visible – but currently, it’s not possible to identify just how many people are being seen in these departments but who could be better managed in a persistent pain clinic.

Now I’m the first to admit that our treatments for chronic pain don’t show massive effects. Pain intensity, disability, distress all continue to have an impact on people even after attending a pain service. BUT that is the nature of a persistent pain problem – people don’t die from it, but like those with “long-Covid19”, they continue to need help. And yet, by comparison with the costs of not providing these services, pain clinics save a health system money – and this has been known since the 2000’s (Gatchel, McGeary, McGeary & Lippe, 2014; Loisel, Lemaire, Poitras, Durand, Champagne, Stock .et al, 2002).

The saddest thing about the proposal to cut funding is that by losing skilled and experienced – and passionate – clinicians, we all lose. Community pain services in New Zealand are largely staffed by clinicians who have little/no additional training in persistent pain. It’s well-documented that physiotherapists find it hard to identify and work with psychosocial factors – the main predictors for long-term distress and disability. Psychology programmes in New Zealand have little/no pain content. There are too few pain specialists. And most of the community pain services pay lip service to interprofessional teamwork because they’re not co-located, haven’t developed effective team structures because these are considered a “cost” to service delivery by private owners, and use contractors who are not paid to attend meetings.

New Zealand’s population is aging. Along with aging is an increase in painful conditions such as osteoarthritis and diabetic neuropathy (we have such high rates of diabetes). We have no national pain strategy. Our clinical workforce is under-skilled and many clinicians find pain management work is hard and demoralising. I can see why clinicians feel demoralised when what should be seen as essential services are in the sights of cost-cutting administrators.

Blyth, F. M., March, L. M., Brnabic, A. J., & Cousins, M. J. (2004). Chronic pain and frequent use of health care. Pain, 111(1-2), 51-58.

Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of pain research, 9, 457.

Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: past, present, and future. American Psychologist, 69(2), 119.

Loisel, P., Lemaire, J., Poitras, S., Durand, M. J., Champagne, F., Stock, S., … & Tremblay, C. (2002). Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine, 59(12), 807-815.

Whose life is it anyway?


A couple of weeks back I posted about my concerns that exercise is often over-hyped, has limited effects on pain and disability, and therefore people going through a rehabilitation programme will likely dump doing the exercises as soon as the programme ends. Well, that was an interesting conversation starter! TBH I expected the response. On the one hand we have avid strength and conditioning people (including a whole bunch of physiotherapists) saying it’s crucial to get strong and fit because it’s good for health and longevity, while on the other hand we have a large group of “others” who think life is too short to spend it in a claustrophobic gym, sweating and grunting and going red in the face. I may exaggerate a teeny tiny bit. Not about the sweating, grunting and going red though.

Part of my intention for that post was to stir the pot about the form of movement options being offered to people who live with pain. I’m not sure that message got across as strongly as I’d like – you see, I am not against getting fit, or improving strength and flexibility. I AM against cookie cutter approaches to rehabilitation where everyone gets the same thing irrespective of their personal values and interests – and competing demands on time.

So I thought I’d ask a bunch of people what they think a person’s life might look like 6 – 12 months after completing a rehabilitation programme. Fascinating. I won’t report the findings because this was an informal opinion survey, it’s in a private group, and people were not asked to give consent to the findings being reported.

What I will say is that opinions were diverse. Mostly people indicated that the person’s own life, goals, and preferences should be the determinants. Pain intensity wasn’t mentioned as often, and many responses showed that doing what matters to a person is key.

Well and good.

What’s my perspective? Having an injury or a problem that becomes persistent disrupts normal life. For many people this disruption is reasonably brief and life does “return to normal”. A hiccough on life’s journey. For others, it’s a complete change in life trajectory – long periods in limbo land while decisions are made on the person’s behalf, and not always with their cooperation (insurers, surgeons, rehabilitation professionals, I’m talking about you here) (Richardson, Ong & Sim, 2006). Life is never the same. And still others find it an opportunity to regroup, to review and perhaps to grow and flourish. Some commentators consider this latter group to have greater psychological resources than those who don’t (Wettstein, 2018).

We have paid a lot of attention to those who find it really difficult to integrate this persistent pain into a sense of self. There’s good reason to: people who find it hard to resume life with pain use more health resources, have poorer health more generally, and can be viewed very negatively by health professionals (Buchman, Ho & Illes, 2016; Mutubuki, et al, 2019).

We’ve paid less attention to those who flourish. To those who have found new meaning in life, new plans, a new sense of self. And I think part of this lies with our attention to “problems” rather than successes (because people who don’t seek healthcare are invisible to most of us, especially policy developers).

I was encouraged by some of the responses to my informal poll. Many clinicians talked about joy, meaning, values, curiosity, self-reliance, and being able to live despite pain’s presence. Several people with pain talked about the need to have a life, even if it meant pain increased (not all, but some). In other words – living! Not having a set of prescribed goals to tick off each day, although some of the activities that made up “life” were based on goal-derived activities drawn from their rehabilitation.

This is what I hope we will help people do: live a life that responds flexibly to what is thrown at us (Covid19, lockdown, age, accidents, disease processes, other people, life span events, earthquakes, climate change…), and that we move towards the things that matter to us. That our lives are imbued with the qualities we most value. That we feel connected, competent, to be able to feel deeply, for life to make sense, to know the directions we’re headed in, and to be able to make choices for ourselves (Thanks Steven Hayes! These are the basic yearnings from A Liberated Mind written by Dr Hayes and published this year).

Which leads me to goals and goal-setting. OMG we need to do some work, people. An auto-ethnography by Jenny Alexanders and Caroline Douglas points out that practices of clinician-centred goal-setting continue (Alexanders & Douglas, 2018), while a study by Gardner and colleagues (2018) found that while goal-setting was often collaborative, those therapists with a higher biomedical orientation in their treatment approach involved patients less. Levack, Weatherall, Hay-Smith, Dean, McPherson & Siegert (2016) found there is an increasing amount of research into goal-setting in rehabilitation, but that study design and heterogeneity of studies mean the quality of evidence for the effect sizes is pretty poor.

I take from this, that while clinicians often undertake goal-setting with people, currently our practice is patchy. We may mean well, but a focus on what WE prioritise, along with unhelpful processes (setting goals at the first appointment is really difficult for people with persistent pain, especially when we might not have established the contributing factors to disability and distress), time-frames, and for people who may be at the “making sense” stage of their rehabilitation (Lennox Thompson, Gage & Kirk, 2019), a focus on future achievements may be premature.

We might also need to develop a deeper understanding of goal-setting theory, and learn processes rather than techniques to help someone move towards the life THEY want to live, rather than a simulation consisting of multiple “goals” that have to be done each day.

Alexanders, J. and C. Douglas, Goal setting for patients experiencing musculoskeletal pain: An evocative autoethnography. Pain and Rehabilitation-the Journal of Physiotherapy Pain Association, 2018. 2018(45): p. 20-24.

Buchman, D.Z., A. Ho, and J. Illes, You Present like a Drug Addict: Patient and Clinician Perspectives on Trust and Trustworthiness in Chronic Pain Management. Pain medicine (Malden, Mass.), 2016.

Levack WMM, Weatherall M, Hay-Smith EJC, Dean SG, McPherson K, Siegert RJ. Goal setting and strategies to enhance goal pursuit in adult rehabilitation: summary of a cochrane systematic review and meta-analysis. Eur J phys rehabil Med, 2016

Gardner, T., et al., Goal setting practice in chronic low back pain. What is current practice and is it affected by beliefs and attitudes? Physiother Theory Pract, 2018. 34(10): p. 795-805.

Lennox Thompson, B., J. Gage, and R. Kirk, Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 2019: p. 1-12.

Mutubuki, E.N., et al., The longitudinal relationships between pain severity and disability versus health-related quality of life and costs among chronic low back pain patients. Quality of Life Research, 2019.

Richardson, J.C., B.N. Ong, and J. Sim, Is chronic widespread pain biographically disruptive? Social Science & Medicine, 2006. 63(6): p. 1573-1585.

Wettstein, M., et al., Profiles of Subjective Well-being in Patients with Chronic Back Pain: Contrasting Subjective and Objective Correlates. Pain Medicine, 2018: p. pny162-pny162.

Secondary gain: really?


One of my most popular posts ever is one I wrote many years ago on malingering. Secondary gain, like malingering or symptom magnification is one of those terms used by people who don’t live with persistent pain, and commonly used when a person with pain doesn’t seem to be progressing “as expected”. The term is an old one, originating in the psychoanalytic literature, brought into compensation and insurance environments but never really examined (Fishbain, Rosomoff, Cutler & Rosomoff, 1995) until well after it had become a popular label.

Freud first identified the potential for gains from being unwell – primary gains referred to the direct gains obtained from developing a psychiatric illness in the face of unresolved psychic conflict while secondary gains were considered to be “an interpersonal or social advantage attained by the patient as a consequence of his/her illness”.

The sick role, or illness behaviour, is a sociological phenomenon (Bradby, 2009). As a society we permit people who are unwell to take time off responsibilities of paid employment, caring for others, socialising and doing the everyday life activities that people do. We also, in some cases, pay people to stay away from work, both to undertake recovery and to protect others from the illness in the form of sick leave entitlements and compensation. To ensure “fairness” or a sort of moral agreement between the ill person and society, humans have used healers, shaman or religious authorities to ensure the person has an authentic problem: ie, that they are morally fit to receive our help.

To most of us, particularly people in Australia and New Zealand, UK, Canada with largely socialised healthcare systems, the idea of sharing the burden of ill health through socially sanctioned support seems natural. We allow people a period of time to get well and then, when recovered, the person can return to normal activities. If the person sustains some nasty event, like spinal cord injury or brain injury, leaving him or her with ongoing ill health, we support ongoing payments (some more than others, depending on the funding bucket used). It’s easy to justify this when the person’s problems are visible – but for people with less visible, or truly invisible disabilities, our moral compass starts going awry.

For example, we have Mobility Parking: but woe betide the person with an invisible disability such as irritable bowel disorder, or panic disorder, using the park even when displaying the appropriate sticker! Tut! tut! tut! It is even more difficult with an invisible problem such as persistent pain, and even more so when the person’s problem hangs around. Secondary gain is the word whispered in the wind as people judge whether this person really has a problem – or is it “secondary gain”?

Let’s unpack the notion of secondary gain. From a behavioural perspective, behaviour is repeated if (1) something introduced afterwards increases the likelihood of the behaviour being repeated, eg a tearful child is cuddled after tripping, meaning the next time the child trips, he will look for someone to cuddle him; (2) something unpleasant is removed as a result of the initial behaviour, eg the pain of a grazed knee reduces with some topical analgesia. In these situations, the child is not usually aware that the contingency offered changes what they do – they just do what makes sense.

It’s when we start looking at people who don’t fit the typical response curve after an injury, that commentators begin flinging the term “secondary gain” around as if the person deliberately chooses to remain ill. Of course, insurers who fund compensation received by the person have a vested interest in reducing their payments and, given persistent pain can’t be objectively measured either directly or indirectly (Tuck, Johnson & Bean, 2019), will question the motives of a person who doesn’t recover. And therein lies our problem.

In our societies, medical practitioners are pseudo priests in many ways. The word of a doctor holds a great deal of weight: medical certificates, death certificates, oh and judgements about diagnosis and recovery. When it comes to insurers, the opinion of a doctor is used to verify that a person really has the problem they say they have, and can then continue receiving payment. The problem with pain is, yet again, having no direct objective measure of pain. The doctor is assumed to have special powers to detect whether a person really has pain – and yet there is considerable evidence that many medical practitioners have very little training in pain and even less in persistent pain in their training (Shipton, Bate, Garrick, Steketee, Shipton & Visser, 2018).

How is the term “secondary gain” experienced by the person living with persistent pain? Lang, Igler, Defenderfer, Uihlein, Brimeye & Davies (2018) undertook an intriguing study of how the various ways pain in adolescents can be “dismissed” by clinicians. They report that 40% of adolescents indicate their pain was dismissed by others, with almost 30% of those individuals stating this was done by a physician (p. 664). It’s probably not surprising that this kind of dismissal happens more often to female adolescents! Their study established that no, the sense of being dismissed wasn’t an indication of adolescents being “too sensitive”, but rather, that being dismissed by either misbelief (you don’t really have this pain); minimising (you have pain but it’s not as bad as you think it is); secondary gain (you’re using this as a way to avoid something like school); and psychogenic (it’s your emotional state that’s the real problem and cause) – are all likely to lead adolescents to look for another opinion, and to feel stigmatised.

So – is secondary gain a real thing? I like to look at it through a different lens. Taking the moral judgement tone out of the equation (that belief that only people who truly ‘deserve’ help should get it), I like to look at the problem of delayed recovery through a lens of problem solving.

Yes, there can be some gains from being unwell – who doesn’t like a bit of fussing or to be excused from doing something you don’t enjoy. The question is whether these gains come at the expense of other things – and there’s pretty compelling evidence that the losses outweigh any possible gains (Worzer, Kishino & Gatchel, 2009). At the same time, telling someone “you’re just doing this because you don’t want to get better” or words to that effect is not likely to help them have any desire to change what they’re doing – it seems to shift the person towards resisting any change in how they’re coping. It’s counter-productive.

Let’s look at a few losses:

  • employment (and people DO value working for reasons other than money! – think self concept, identity, social interaction, daily routine…)
  • relationship loss (partners, family roles, friendships – some of the most profound stories I hear come from men saying they no longer have mates they spend time with)
  • emotional impact (depression, anxiety, anger, demoralisation, shame, guilt)
  • financial loss (with loss of employment and increased healthcare costs) (Worzer, Kishino & Gatchel, 2009)

What traps someone into these losses? What might maintain someone’s helplessness and demoralisation? Pain, of course, but so too does shame; stigma from time away from work (employers want to know if you have a “bad back” – then run a mile); lack of confidence about capabilities (am I reliable? can I be counted on?); disability (there are some things I cannot do); limited communication (how do I ask for help?) and a myriad of other things. For the avoidance of doubt, people do not magically “get better” once they obtain their insurance payout (Fishbain, Rosomoff, Goldberg, Cutler, Abdel-Moty, Khalil, et al, 1993).

What can we do?

  1. First do no harm, that means avoiding moral judgements about motives for ongoing disability. It doesn’t help and does harm.
  2. Second, begin working on the actual problems the person is experiencing – things like building consistency in activity levels; improving communication skills; increasing confidence.
  3. Third, start addressing the social stigma associated with persistent pain. This means taking a long, hard look at ourselves as clinicians, and at our workplaces and social scenes, and insurers or funders.

Why do we run from the conversation that yes, pain does persist for a good number of people? Why don’t we acknowledge that even the best treatment in the world may not reduce pain – and that this is not the person’s fault for not trying?

This doesn’t mean researchers and clinicians should stop searching for pain reduction approaches – it does mean giving those who are not helped the chance to view living well with pain as a viable option.

Bradby, H. (2009). Defining health, defining disease. In Medical sociology: An introduction (pp. 51-64). London: SAGE Publications Ltd doi: 10.4135/9781446211724.n4

Fishbain, D. A., Rosomoff, H. L., Cutler, R. B., & Rosomoff, R. S. (1995). Secondary gain concept: a review of the scientific evidence. The Clinical journal of pain.

Fishbain, D. A., Rosomoff, H. L., Goldberg, M., Cutler, R., Abdel-
Moty, E., Khalil, T. M., et al. (1993). The prediction of return to
the workplace after multidisciplinary pain center treatment.
Clinical Journal of Pain, 9, 3–15.

Shipton, Elspeth E, Bate, Frank, Garrick, Raymond, Steketee, Carole, Shipton, Edward A, & Visser, Eric J. (2018). Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain and therapy, 1-23.

Tuck, Natalie L., Johnson, Malcolm H., & Bean, Debbie J. (2019). You’d Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain. Journal of Pain, 20(2), 133-145. doi: http://dx.doi.org/10.1016/j.jpain.2018.07.002

Worzer, W. E., Kishino, N. D., & Gatchel, R. J. (2009). Primary, secondary, and tertiary losses in chronic pain patients. Psychological Injury and Law, 2(3-4), 215-224.