Research

Thought experiment: Would therapists be out of a job if we could “fix” persistent pain?


Every few years someone, somewhere, announces that “it won’t be long before we have a treatment to rid the world of persistent pain.” And there’s a hiss and roar to celebrate this momentous finding, and much ado about how wonderful it will be.

I’m still waiting. BUT I thought it might be an interesting thought experiment to wonder what might happen if a “cure” was available for fibromyalgia.

As readers will know, I have lived with what eventually was named “fibromyalgia” since my early 20’s, and probably longer. I’ve dabbled in various treatments over the years but sadly, nothing but good clean living has helped (by which I mean early to bed, good diet, maintain healthy movement, manage stress, have good friends to connect with, play, have fun). So I would dearly love a treatment that would remove the constant aching, reduce the prolonged DOMs, keep a lid on delayed recovery after injury, and generally offer me a life relatively “normal.”

I am definitely pro-pain reduction and pain treatment. I just haven’t found anything that changes mine.

We have had some spectacular developments in therapies over the past 25 years – particularly in the inflammatory rheumatological diseases like ankylosing spondylitis, rheumatoid arthritis and ulcerative colitis. Treatments with anti-TNF alpha biologicals means that my partner who lives with anky spond now has normal C reactive protein levels, no pain, the disease activity has stopped, and he’s tickety-boo.

So why am I just a tad reserved about the notion of a “fix” based on new discoveries about mechanisms associated with neuropathic and nociplastic pains? Why am I just a little skeptical of a new psychological study showing outstanding results (Ashar, Gordon & Schubiner, 2021)? Am I just worried I’ll be out of a job if there’s an effective treatment?

Nope.

You see, even though some people like my Manly Jack have had a wonderful response to treatment for inflammatory disease, there are many more who have not. Or, who have significant reductions in inflammation – but not to “normal” levels, and accompanied by complications/adverse effects, and, in many instances, continued pain. Why is that? Well – I think it’s because while treatments target mechanisms, people are enormously variable in both biology and more importantly, psychology and sociology.

And it’s these last two that have been identified as amongst the most important contributors to ongoing disability and limited participation.

Now the social deserves a little attention. Drug developments are not cheap. The medication my partner uses is extremely expensive – NZ$1200 every two weeks. Luckily for us, this drug is fully funded by the NZ Government. There’s an economic argument for having meds like these publicly funded – without this drug, it would have been very difficult for my man to carry on working. He was having trouble rolling over in bed at night, had trouble coughing, couldn’t inhale fully, and walked like a little old man. He’s now fit as a buck rat and pays his taxes because he’s working.

The problem is, as we can see from the Covid vaccination roll-outs world-wide, people and countries without resources have less access to effective treatments. Even in NZ where we don’t have the “vaccine hesitancy” of other countries, the people who are least likely to be vaccinated right now are those who have trouble traveling to a centre, who don’t feel “at home” in healthcare, who are hard to reach, perhaps not very literate, don’t speak English or te reo Māori. The NZ government is working incredibly hard to ensure the vaccine is given to these people, and I’m proud of the variety of ways they’re doing so.

But spare a thought for countries where there is no relative affluence. Where other countries don’t have the will to help. Where infrastructure is poor. Where women, children, and people from different cultural backgrounds or religions are discriminated against. In these countries, vaccinations are very slow to reach those in need.

So one risk from a fancy new treatment is that people who need it but can’t afford it, don’t trust healthcare (who would after the stigmatisation so many people receive?), and people who are from countries where the rest of the world doesn’t help out – they risk missing out.

Another risk is that while pain might be reduced or even eliminated, these address only the biology, and people are people, and pain is multidimensional. People remember what it was like to be in pain. People have their own narratives about what’s going on to create their pain. We all learn from our experiences, and beliefs, attitudes, emotions, the influence of others around us, the communities and families and workplaces we come from, all of these have an effect on “what it is like to be experiencing pain.”

We know that people who have completely successful joint replacements without pain, don’t resume the activities they were doing before their joints became painful (see my last blog post). People successfully treated with biologicals still hold fears about future harm that developed before they got their treatment. We know that many people take years before being diagnosed and treated successfully – and that’s a long time to develop beliefs, habits, routines and relationships that don’t support recovery. We also know the trauma of unhelpful and stigmatising healthcare interactions can live long, even after successful care.

Resuming daily life and valued activities is integral to pain rehabilitation. Helping people safely do what matters to them in their life contexts is still needed. In the enthusiasm for applauding treatment advances, we need to remember that people are more than the sum of their diagnoses, more than their biology, and our societies are not fair.

Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669
h ttps://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694?fbclid=IwAR23strMuoUXYs_Ae9EmTVz9eNAzYxgxAR1IBj64SePpbWeLQL_M_DOaXr8

Adam’s slow recovery


Not long ago I wrote about Adam Meakins back pain, and the astonishing response he’s had from fellow clinicians as he’s documented his recovery. Sadly, the polarised views of how therapists should approach a person with low back pain show me just how appallingly badly we adhere to low back pain guidelines… and worse, the kind of language and attitudes shown to a colleague who knows what he’s doing, demonstrates why change is so very slow.

What do I mean? Well, Adam has been following evidence-based low back pain guidelines that haven’t really changed a great deal since the advent of New Zealand’s “Yellow Flags” and guide to low back pain published waaaaay back in 1997. I’ve jumped to the NICE guidelines, as an example of one guideline, but you could look to many others.

NICE suggest these steps:

Assess for alternative diagnoses – in particular, “cancer, infection, trauma or inflammatory disease such as spondyloarthritis”

Risk assessment – basically, sorting people into those who are pretty OK with their pain, non-distressed and recommending those people receive “reassurance, advice to keep active and guidance on self-management.”

If Adam was distressed, or had a whole lot of risk factors for ongoing disability, then he might benefit from “more complex and intensive support for people with low back pain.” And yes, this mentions exercise programmes, manual therapy, psychological approaches.

Imaging – is not recommended, with imaging only used if the result is likely to change management.

Treatment – self-management, no orthotics or belts, no traction, and only offer manual therapy as part of an overall package that includes exercise.

No acupuncture, no electrotherapy.

Maybe use psychological therapies in conjunction with exercise.

Add in some NSAIDs

And don’t do much else…

In other words – exactly what Adam has been doing.

Why are there so many clinicians offering unsolicited opinions, without examining Adam, and without listening to his preferences, and without referring to the evidence?

What does this say about our clinical practice? What does it say about our confidence? What does it say about knowledge translation?

Most of all, what does this DO to the people we hope to help?

Seriously, folks. Watching the responses gives me nightmares.

I’ve been working in this field for 30 years now, and saying essentially the same thing about low back pain management for most of those years. I worry that an enormous business is built around scaring people, offering treatments with limited effect, for a condition that is common and responds well to doing normal movements.

In fact, one gripe I do have with the NICE guidelines is that they utterly and completely ignore daily life activities that a person needs to return to, and quickly. There’s nothing on managing sleep – and Adam’s described really rotten sleep until two days ago. There’s nothing on how to manage washing yourself, driving your car, sitting at a desk, doing the grocery shopping, preparing a meal, care for kids (or older parents) – absolutely nothing on the daily life activities that people need and want to do.

But, then again, I would say this – occupational therapists are the profession concerned about daily doing. The context of every day life. Knowledge translation from clinic/gym/exercise to what people actually do in their daily routines. It looks oh so simple – until you have to do it.

Back to Adam’s slow recovery. As I’ve watched Adam’s videos, I’m struck with the thought that many people just don’t know what to say – and so offer advice because that’s one way to deal with their own disquiet at helplessness. Clinicians, we need to develop better skills at managing our OWN emotional responses. We need to develop greater skills at sitting with our uncertainty. We need to stop leaping in with unsolicited advice that we offer just because we’re not comfortable doing nothing.

Could we just, for a moment, stop thinking about our reactions – and listen to what Adam (and I’m sure a whole bunch of our patients, too) says he wants? Listening means stopping that inner voice that’s got the “good” advice. It means really hearing what a person says. And only formulating a verbal response after we’ve digested the meaning the person is trying to convey.

Kia kaha Adam. You’re a brave man, a strong man, and I have much respect for you.

“Just a little scratch”


If you’ve had a blood test, flu jab or Covid-19 vax (please do, not just for you but for the vulnerable) you’ll probably have heard those words “Just a little scratch” then the needle goes in and ouch! I’ve wondered why phlebotomists and vaccinators use those words: is it to reduce the pain? give you some warning so you don’t pull away? why use the word “scratch” when it’s not a scratch?!

I suspect, though I haven’t read up on it, that the reason people say “just a little scratch” is to influence expectancies. Expectancies are defined as “cognitions regarding the probability of future experiences, events, and behaviour” (Peerdeman, van Laarhoven, Peters & Evers, 2016). In other words, what we expect to experience, happen or do influences what we actually experience, what happens, and what we do. Expectancies are really important when we consider placebo – and nocebo. Despite commentators who don’t consider placebo to be a thing (the response to being in a treatment ritual, over and above the effects of any active therapeutic agent), in pain, it is most definitely a thing, and one we need to be aware of as clinicians.

Back to expectancies.

Mostly, what we expect is what we experience. If we expect something to REALLY HURT then it’s likely to REALLY HURT! But what happens when we don’t expect something and it happens? Or when we expect something not to really hurt, but it actually does?

Peerdeman, Geers, Porta, Veldhuijzen and Kirsch (2021) investigated this mismatch between what we expect and what actually happens. It’s fascinating because the results weren’t quite in line with what the researchers thought…

What did they do?

The authors selected 82 healthy adults, aged between 18 and 30, with no health problems (physical or psychologist), no chronic pain, no current pain, no medications, no pacemakers, and no pregnancy. The participants weren’t allowed to use any medication, alcohol or other drugs in the 24 hours before the experiment.

Two experimenters undertook the experiments – one wasn’t aware of who was getting what, while the other was unaware of what was getting what until just before she gave the verbal suggestion. The experimenter who was blinded left the room before the second one gave the suggestion, in order to remain blinded throughout.

The participants were wired up to record heart rate, skin conductance, and then thermal and nociceptive perception thresholds were identified – at least in part to give participants a chance to get used to the heat stimulus. The experimenters went in to increase the heat to identify the temperature where participants indicated the pain was “moderately high” (who volunteers for these experiments? Oh – they recruited from around the university and on social media...). Then the experimenters got to work: participants were randomised to get either a suggestion of “no pain” (they’d already had three occasions where the thermal stimulus wasn’t painful, and three where it was), or a suggestion of moderately high pain. Then the stimulus was applied four times, with participants having to rate the expected pain intensity, how certain they were of this prediction, and how afraid they were. Afterwards, they were asked to rate pain intensity and unpleasantness.

For all the details of this experiment, head to the paper itself – it’s very detailed, and could be replicated.

Results

One person dropped out before the trial began – it was too painful – leaving 81 people remaining. The average age was 22 years, but the investigators don’t report gender.

When people were told “it’s not going to hurt” participants rated the pain lower than those who were told it was going to hurt, and while the ratings changed depending on what they experienced, when it was again suggested they’d feel no pain – again their pain ratings were lower than expected. Who knew pain intensity could vary so much? Reported pain intensity in the people who were told they wouldn’t experience pain was 4/10 points lower than the other group who were told it would hurt, and a bit over 2 points lower the second time (on a 0 – 10 numeric rating scale). That’s a thumping great amount of pain reduction! Add to this, these participants also were less afraid of their pain than the other group.

BUT, and this is important, participants in the “it’s not going to hurt” group reported less trust in the experimenter (who would have thought, huh?!). So beware: if you tell someone “oh this won’t hurt a bit” – they may experience less pain, but they’ll look at you sideways and be a bit wary of you because you violated their trust.

Discussion

I haven’t described the second experiment because of space, but go ahead and read it. Essentially they added some more participants, varied the procedure a little to reduce the memory burden on participants, and added a “medium” underprediction element into the process. The results showed similar outcomes – lower ratings of pain in both the “you won’t feel a thing” and the “it’ll hurt but not much” experiments, and yet again, less trust in the experimenter suggesting that it wouldn’t hurt.

Lessons to learn?

Think carefully about inflating how much pain relief someone will experience, especially if you’re going to see that person again. While people might experience less pain, losing someone’s trust in a therapeutic setting is a serious problem. The authors point out that healthy volunteers in a lab setting, getting short-term pain, is not like a therapeutic setting where it’s probable that trust is well-established. We don’t know what effect violating trust in a longer-term relationship might have.

At the same time – it does strike me as intriguing that simply being told “it won’t hurt” can influence pain intensity rating. What’s going on? How can a communication stimulus influence an experience? How could a psychological input change the way we perceive a noxious stimulus? Perhaps the way forward might be to use neutral language or, more positively, suggest that the person can handle it? “Just a little sting and you’ll get through”

Peerdeman, K. J., Geers, A. L., Della Porta, D., Veldhuijzen, D. S., & Kirsch, I. (2021, Jul 1). Underpredicting pain: an experimental investigation into the benefits and risks. Pain, 162(7), 2024-2035. https://doi.org/10.1097/j.pain.0000000000002199

Peerdeman KJ, van Laarhoven AI, Peters ML, Evers AW. An Integrative Review of the Influence of Expectancies on Pain. Front Psychol. 2016;7:1270. Published 2016 Aug 23. doi:10.3389/fpsyg.2016.01270

When living with pain is too hard


**If you’re a person living with pain, and this headline caught your attention because you’re feeling it’s just too hard to carry on – PLEASE take a moment to seek help. If you’re feeling you can’t because they might judge you, or try to stop you feeling this way, at the very least give yourself an hour before you take any action. If that feels too long, give yourself a minute. Get through that, and give yourself another minute. And so on – until you’ve give yourself some time to let this awful feeling ease up a little. You can always revisit your decision to wait. Speak to someone – anonymously if you need to. There are helplines in every country. Phone one. Please.**

Living with persistent pain can be really hard, and clinicians, family and the person with pain can be worried about suicidal thoughts and possible actions. There’s good reason to be concerned, too, as a recent study from the 2012 Canadian Community Health Survey shows.

Grocott, Sommer and El-Gabalawy (2021) used the data obtained from this Canadian Health Survey to explore the relationships between pain intensity and suicidality in people with arthritis, migraines and low back pain.

The first question is how many people in the overall population involved in this study had any of the three diagnostic groups – and, as expected and in line with many epidemiological studies, between 10.3% (migraines) and 18.1% (low back pain) indicated they had been diagnosed. The “usual” pain levels across all three groups were between 25.9 – 27.7% indicating their pain was “mild”, 52.5 – 54.5% said it was “moderate”, and 19.7 – 20.9% described it as “severe”. This does not surprise me one bit – moderate levels of pain intensity are really common, and, albeit acknolwedging the difficulty of rating pain intensity on a numeric scale and the complex relationship between pain intensity and interference with daily life, demonstrate just how necessary persistent pain services are as a health services priority.

The team then identified the rates of “lifetime” suicidality – these were measured using the following questions.

“you seriously thought about committing suicide or taking your own life” (i.e., suicide ideation; yes, no), “you made a plan for committing suicide” (i.e., suicide plans; yes, no), or “you attempted suicide or tried to take your own life” (i.e., suicide attempts; yes, no).

It’s important to note that this question asked about whether the person had ever, during their life, had these thoughts – not that they were currently present. Remember this as you interpret this study, because suicidal thoughts are relatively common but acting on those thoughts is less common.

The authors found that people who were usually in pain were more likely to have suicidal thoughts, plans or had made an attempt than those who had periods of time without pain (ie intermittent pain). The different rates were reasonably large, too – just in terms of ideation, between 18.7 – 34.0% of people who were usually in pain had suicidal thoughts as opposed to those with intermittent pain (10.5-16.6%), and this association was particularly strong for people with migraine. For people with low back pain, having pain all the time was associated with much greater odds of suicidal thoughts (1.79, 95% CI [1.19-2.68], p<.05).

Pain intensity was also a factor – lifetime suicidality prevalence increased as pain intensity increased, and this was relevant to all pain conditions measured, and especially amongst people with severe pain and migraines.

A good question to ask is whether the odds were the same for people with current mental illness as for those without – and using the magic of statistics, the authors found that this only held for some forms of pain. People with arthritis (note they didn’t identify the kind of arthritis people had) reported lower levels of suicidality even in the presence of mental ill health.

The authors point out that this is an interesting study in that yes, suicidality was higher in people with migraines, and similar to other studies, but their intriguing finding was that differences in the intensity of usual pain increased the odds, along with elevated odds if people reported higher levels of pain intensity.

Why did I choose to summarise this paper?

A few reasons: one is that as health professionals, we may not be aware of just how many people in our communities live with pain. It’s a lot – and this study only included specific diagnoses. Yet, at least in New Zealand, pain management services for people with pain are scarce.

Most people in New Zealand will maybe get referred to a physiotherapist, but it’s often difficult for people with persistent pain to raise their issues with pain with their health provider and for those providers to respond with empathy (Thompson, Dowell, Hilder, Macdonald, Stubbe & Alchin, 2021). This means that many people may not be seen by clinicians with confidence to help people with psychosocial aspects of their pain (eg Holopainen, Simpson, Piirainen, Karppinen, Schutze, O’Sullivan & Ken, 2020, Zangoni & Thompson, 2017) if they even indicate that this is a concern for them during the consultation.

Another reason is that many clinicians who work mainly in “physical” health may not know what to do if someone does disclose suicidal thoughts. It is confronting to hear someone say they don’t want to live any more – and knowing what to do next can feel highly risky. How does this fit within my scope of practice? What if I say something wrong and the person goes ahead and attempts suicide?

Note though, that this study didn’t look at current levels of suicidal thought – it’s lifetime prevalence. Perhaps people who have had occasion to think about killing themselves have a greater degree of vulnerability for persistent pain, particularly when pain is intense. We don’t know – but the authors speculate. Worth reading the paper in full to find out their thoughts.

My thoughts (briefly!) are:

  • Prepare ahead of time. We’ll all likely encounter a person who is really distressed, at the end of their tether, and indicates they’re thinking of harming themselves. Being prepared makes responding to this situation much easier.
  • Preparation should include writing a policy for your practice or your setting. It should include a list of people to contact in a psychiatric emergency (when a person indicates they’re ready to take action to harm themselves), as well as specific actions to take when talking to the person.
  • We’re not all psychologists and it’s not our job to be psychologists – all we’re asked to do in this kind of situation is be a human. What I mean by this is – listen, affirm that the person is feeling really bad and support them to access the help they need. This might mean calling the psychologist if you have one you work with regularly, or calling the person’s family doctor, or calling psychiatric emergency services.
  • Ensure you hand the person to someone who will take care of them. This means not letting them go off in their car without letting their family doctor know, even if they say they’re fine. For your own reassurance this is important.
  • Take care of yourself. Don’t just go on to see the next person waiting for you. Take some time to process what’s happened, what you did, and debrief with someone you trust. It doesn’t need to be a trauma counsellor – it’s just as useful to talk to your colleagues who know you and the kind of work you do. Go have a cup of coffee, go for a walk, give yourself space to recognise that you just helped someone who was really distressed. That’s an important job.
  • Don’t ignore the person and pretend they didn’t just say that. Affirm that they’re feeling rotten. Don’t trivialise it and suggest they should just harden up, or it’s not really that bad, or that they’re at fault for feeling this way. Just be gentle and human, and recognise the privilege you have – this person trusts you enough to say how they’re really feeling. It’s an honour. So if you can’t think of anything to say, just sit with them and bear witness to their distress. Hand them a tissue. Be there for them.

Oh, and in that paper, while 18.7 – 34.0% had suicidal thoughts over their lifetime, 7.2–14.5% had made actual plans, while 6.6–14.7% had made attempts. Don’t trivialise suicidal thoughts, but at the same time, don’t freak out that the person is going to kill themselves – just take action to support them, and in most cases, the thoughts will fade as the person gains hope.

Grocott, B., Sommer, J. L., & El-Gabalawy, R. (2021, Jun 28). Usual presence and intensity of pain are differentially associated with suicidality across chronic pain conditions: A population-based study. Journal of Psychosomatic Research, 148, 110557. https://doi.org/10.1016/j.jpsychores.2021.110557

Holopainen, M. R., Simpson, M. P., Piirainen, D. A., Karppinen, P. J., Schutze, D. R., Smith, P. A., O’Sullivan, P. P., & Kent, A. P. (2020, Jan 16). Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain. https://doi.org/10.1097/j.pain.0000000000001809

Thompson, L., Dowell, A., Hilder, J., Macdonald, L., Stubbe, M., & Alchin, J. (2021, Jan 4). How do patients and General Practitioners talk about pain and negotiate empathy in consultations? A direct observational study. Health & Social Care in the Community. https://doi.org/10.1111/hsc.13259

Zangoni, G., & Thomson, O. P. (2017, 2//). ‘I need to do another course’ – Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskeletal Science and Practice, 27, 71-77. https://doi.org/https://doi.org/10.1016/j.msksp.2016.12.015

Why I don’t trust my clinical reasoning: and why this matters


“See someone experienced” I hear people with pain say. “They’ll know what’s wrong with you.”

Well, based on the research I’ve read, I wouldn’t be so sure. In fact, I’m certain my own clinical reasoning is biased, prone to errors that I don’t notice, and influenced by factors that most clinicians would be horrified to think they, too, were influenced by.

Let me give you a few to ponder:

I’m interested in women and pain – and there’s a lot of evidence showing that women’s pain doesn’t get the same kind of diagnostic and management attention as men. Now part of this is due to the inherent bias in research where experimental studies often rely on male rats, mice and undergraduates because they don’t have those pesky hormonal fluctuations each month. Even volunteering to take part in a pain study has been found to be biased – people who volunteer have been shown to be more risk-taking and more extraverted (Skinner, 1982) – though to be fair this is an old study!

But contextual factors such as gender, distress and even the supposed diagnosis do influence judgements about pain intensity (Bernardes & Lima, 2011) including potentially life-threatening chest pain (Keogh, Hamid, Hamid & Ellery, 2004). Gender bias has been identified in a large literature review of gender bias in healthcare and gendered norms towards people with chronic pain (Samulowitz, Gremyr, Eriksson & Hensing, 2018).

And if you have the misfortune to be judged to have low trustworthiness and you’re a woman, you’re more likely to be thought to have less pain and to be exaggerating your pain (Schafer, Prkachin, Kaseweter & Williams, 2016). Beware if you’re overweight and a woman because you’ll be likely judged as having less intense pain, the pain will be judged as less interfering, more exaggerated and less related to “medical” factors – women’s pain in particular is likely to be judged as “psychological” and given psychological therapy rather than other treatments (Miller, Allison, Trost, De Ruddere, Wheelis, Goubert & Hirsch, 2018).

The weird thing is that the clinicians involved in these studies were oblivious to their bias. And let’s not even go there with people of colour or so-called “minority” groups such as LGBTQI.

So as clinicians our initial impressions of a person can lead us astray – and I haven’t even started with the contribution experience has on clinical reasoning. Let me go there then!

Something that cognitive psychologists have explored for some years now, is the type of thinking that we draw on for clinical reasoning. System one is “fast reasoning” – where we rapidly, instinctively and emotionally make decisions on the fly. Kahneman (1982) first described these two processes and noted that fast thinking gets better with rehearsal and are helpful especially for skilled clinicians needing to make decisions in pressured contexts, and draw on “pattern recognition” – or to be precise, draw on deviation from a recognised pattern (Preisz, 2019). System two is “slow reasoning” where decisions are made in a considered way, are not influenced by emotional state, and can be thought of as “rational.” Slow thinking is most useful where the situation is complex, where decisions need to weigh multiple pieces of information, where the situation might be novel, or where, for persistent pain in particular, there are multiple disease processes occurring.

OK, so we should choose system two, right? Not so fast! System one is hard to switch from – it’s what underpins “intuition” or “hunches” – and it gets more entrenched the more experienced we are. According to Preisz (2019), system one “seeks to form a coherent, plausible story by relying on association, memories, pattern matching and assumption.”

Why is system one thinking not so great? Well, we’re human. We’re human in the way we respond to any reasoning situation – we anchor on the first and most “plausible” ideas, and these might be unrelated to the actual presentation we see. For example, if we’ve been reading a journal article on a new treatment and its indications, it’s amazing how many people will present with those exact same indications in the next week! This is availability bias or anchoring bias. We’re also inclined to believe our own patients and judgements are different from “those people” – especially “those people” who might respond best to clinical guidelines. This means that even in the face of clear-cut research showing the lack of effects of knee arthroscopy (Brignardello-Petersen, Guyatt, Buchbinder, Poolman et al, 2017) an orthopaedic surgeon I know argued that “we choose our patients very carefully” – essentially arguing that his patients are different, and this approach is the best one.

If experienced clinicians find it hard to “unstick” from old practice, or move quickly to “intuitive” reasoning (even if it’s called “pattern recognition”), and if we all find it hard to recognise when we’re biased, or even that we are biased, what on earth should we do? All us old hands should retire maybe? All follow algorithms and not use “clinical judgement”? Take the “human” out of clinical management and use AI?

Some of these things might work. There is evidence that algorithms and AI can offer effective and (perhaps) less biased diagnosis and management than our unaided human brain (Kadhim, 2018) but there are also studies showing that direct comparisons between decision aids and clinical judgement are rarely made, and those that have been carried out don’t show superior results (Schriger, Elder, & Cooper, 2017). But watch this space: AI is a rapidly developing area and I predict greater use of this over time.

The risk with decision aids is – garbage in, garbage out. If we look at existing research we can see that male, pale and potentially stale dominates: this doesn’t bode well for people of colour, for women, for the unique and idiosyncratic combination of diseases a person can have, or for untangling the impact of disease on the person – in other words, disability and illness.

So, to summarise. We are all biased, and it’s best to acknowledge this to ourselves upfront and personal. We can then turn to strategies that may reduce the biases. For me, the one I turn to most often is a case formulation, using information gathered from a semi-structured interview and a standard set of questionnaires. These have been developed a priori so my biases in information gathering are limited. By taking time to follow a case formulation, my thinking is slowed to that more deliberative system two. At least some of the biases I know I’m prone to are mitigated.

And yet, I know I am biased. That’s why I use a supervision relationship to help me identify those biases, to be challenged and to reflect.

Bernardes, S. F., & Lima, M. L. (2011, Dec). A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain. Psychology & Health, 26(12), 1642-1658.

Brignardello-Petersen, R., Guyatt, G. H., Buchbinder, R., Poolman, R. W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N., & Vandvik, P. O. (2017, May 11). Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open, 7(5), e016114. https://doi.org/10.1136/bmjopen-2017-016114

Kadhim, M. A. (2018). FNDSB: A fuzzy-neuro decision support system for back pain diagnosis. Cognitive Systems Research, 52, 691-700. https://doi.org/10.1016/j.cogsys.2018.08.021

Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.

Keogh, E., Hamid, R., Hamid, S., & Ellery, D. (2004). Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain, 111(1-2), 209-217.

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018, Jan). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. J Pain, 19(1), 57-66. https://doi.org/10.1016/j.jpain.2017.09.001

Preisz, A. (2019, Jun). Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. Journal of Paediatric Child Health, 55(6), 621-624. https://doi.org/10.1111/jpc.14447

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018.

Schafer, G., Prkachin, K. M., Kaseweter, K. A., & Williams, A. C. (2016, Aug). Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 157(8), 1618-1625. https://doi.org/10.1097/j.pain.0000000000000536

Schriger, D. L., Elder, J. W., & Cooper, R. J. (2017, Sep). Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior. Ann Emerg Med, 70(3), 338-344 e333. https://doi.org/10.1016/j.annemergmed.2016.12.004

Skinner, N. F. (1982, 1982/12/01). Personality characteristics of volunteers for painful experiments. Bulletin of the Psychonomic Society, 20(6), 299-300. https://doi.org/10.3758/BF03330107

Knowledge gaps for working together


Whenever we work with someone living with pain, we form a team. A team, by definition, is “a distinguishable set of two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal/objective/mission” (Salas et al., 1992). So while many clinicians work outside an interprofessional team, they are always working in a team consisting of at least the person with pain, and themselves.

There’s a good deal of research on teamwork, and a heap of references in pain management literature on the benefits and, indeed, the need, to work in a team for best outcomes (both in terms of effects for the person and in terms of cost-effectiveness). Gilliam and colleagues (2018) demonstrate that long-term outcomes are retained by participants attending an interdisciplinary pain rehabilitation programme, while Guildford and colleaguees (2018) also showed reductions in analgesic use during an interdisciplinary pain management programme. It’s not new news folks!

Teamwork is well-investigated in health, particularly interprofessional/interdisciplinary teamwork. Much of this research, however, is focused on nursing and medicine interactions, with rather less attention paid to allied health and nursing/medicine teamwork. This matters because while nursing and medicine are moving away from the old medical model, the professions probably represent the two most similar in terms of clinical models. And this matters because one thing that’s found to be important for good teamwork in health is having a shared mental model (for example – from operation room – Wilson, 2019).

All good so far – nothing new here, move along, right?

Hold it right there, folks.

You see, when we work together in a team, particularly for people with persistent pain, we often generate a heap of new information about the person we hope to help. In New Zealand, the person will have completed the ePPOC set of questionnaires, then there will probably have been some physical performance testing, maybe some basic ROM, and muscle testing, perhaps some daily life functioning tasks, certainly some more psychological questionnaires, if the person sees a medical practitioner, there will be the obligatory bloods, urine, perhaps imaging – you know what I mean! A heap of information that each clinician deems necessary and I haven’t yet gone into each clinician’s desire to “hear the story from the beginning again!”

What’s lacking in our research on teamwork in persistent pain is discussion about how we assemble this information so that we move from a multidisciplinary team – Multidisciplinary teams involve people from different health disciplines working alongside one another while using clinical models drawn from their own professional discipline (Körner, 2010) – to an interprofessional/interdisciplinary team – Interdisciplinary teams also involve people from different health disciplines working alongside one another but meet regularly to collaborate on treatment goals and priorities (Ruan & Kaye, 2016). There is limited hierarchy and considerable communication, cooperation and often overlap between team members (Körner, 2010).

Not only a lack of a shared mental model (because we all think our model is The Best), we also lack an understanding of team processes. How do we develop an effective way to communicate, to cooperate, to deal with conflict in an open and creative way, to coordinate our work so things happen at the right time, to be coached so that the team-as-a-whole moves in the same direction and new people coming to the team feel part of the culture? Not forgetting that teams work in an ever-changing context, and team membership changes over time, while the overall team culture is something that emerges from a team collective (Salas, et al., 2015).

Are pain rehabilitation teams different from teams working in older person’s health, or palliative care, or as part of a primary health team?

I suspect so, but I can’t find good research detailing how our pain teams are different. It’s like a black box of mystery (a bit like interprofessional pain management programmes – one murky black box out of which a person pops!)

I’m left with this feeling that because teams in pain management and rehabilitation have become scarce in most part of the US, and that this is where all the research funding lives, there’s not very much that we actually know. We don’t know who holds the positions of power – is it the medical practitioner? the psychologist? the physiotherapist? the occupational therapist? Who makes the call as to when it’s time to work with the person to move from pain reduction to living well alongside pain? Are the team members actually using a common model or are they really working in parallel? And how can a team be maintained over time – I’ve had the privilege of working in a very close-knit and effective team for some years, but I’ve seen that team become smaller, fragmented, more multidisciplinary than interprofessional, with limited attention to processes of induction, developing effective conflict management, and really becoming weakened.

There is one conclusion I can draw from the mountains of material I’ve been learning and it’s this: it’s impossible to put a bunch of clinicians together and call them a team without putting effort in to develop those processes I’ve listed above. And when was the last time you attended a CPD session on “how to work in a team?”

Gilliam, W. P., Craner, J. R., Cunningham, J. L., Evans, M. M., Luedtke, C. A., Morrison, E. J., Sperry, J. A., & Loukianova, L. L. (2018). Longitudinal Treatment Outcomes for an Interdisciplinary Pain Rehabilitation Program: Comparisons of Subjective and Objective Outcomes on the Basis of Opioid Use Status. J Pain, 19(6), 678-689. https://doi.org/10.1016/j.jpain.2018.02.010

Guildford, B. J., Daly-Eichenhardt, A., Hill, B., Sanderson, K., & McCracken, L. M. (2018). Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change. Br J Pain, 12(2), 72-86. https://doi.org/10.1177/2049463717734016

Körner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), 745-755. https://doi.org/10.1177/0269215510367538

Ruan, X., & Kaye, A. D. (2016). A Call for Saving Interdisciplinary Pain Management. J Orthop Sports Phys Ther, 46(12), 1021-1023. https://doi.org/10.2519/jospt.2016.0611

Salas, E., Dickinson, T. L., Converse, S. A., & Tannenbaum, S. I. (1992). Toward an understanding of team performance and training. In Teams: Their training and performance. (pp. 3-29). Ablex Publishing.

Salas, E., Shuffler, M. L., Thayer, A. L., Bedwell, W. L., & Lazzara, E. H. (2015). Understanding and Improving Teamwork in Organizations: A Scientifically Based Practical Guide. Human Resource Management, 54(4), 599-622. https://doi.org/10.1002/hrm.21628

Wilson, A. (2019). Creating and applying shared mental models in the operating room. Journal of Perioperative Nursing, 32(3), 33.

The stigma of being a woman in pain


Women, it is often thought, must be much tougher than men when it comes to dealing with pain – after all, don’t women have babies without anaesthetic? Don’t men faint at the sight of a needle?

Ummmm, not quite so fast. Now before I begin, in this post I’m referring to cis-gender females, and in the experiments, participants were selected on the basis that they believed that negative gender discrimination was a thing. And as I write this post, I want to be clear that sometimes we have to begin with a very simplified model before research can be conducted on a much more messy cohort – and that this doesn’t negate the incredibly harmful and known effects of gender discrimination, and trans/inter/queer experiences. I can only hope that by starting this kind of research, as a community we’ll begin to understand the terrible impact that stigma has on people.

This paper investigated whether stigma related to one’s identity influenced the perception of nociceptive stimulation. It’s written off the back of earlier research showing that when people are excluded socially, their experience of nociceptive stimulation was greater (ie people didn’t need as much stimulation for it to be perceived as painful) (Eisenberger, Jarcho, Lieberman & Naliboff, 2006). Other studies have shown that people with low back pain who perceive themselves as stigmatised reported greater pain intensity, and that stigmatisation is the main source of social consequences for this group of people (Zhang, Barreto & Doyle, 2020).

These researchers (Zhang, Zhang, Li, Hu, Kong & Su, 2021) conducted two experiments to test the hypothesis that stigmatised women would experience greater pain intensity with nociceptive stimulation.
The first experiment used tonic cold pain (cold pressor test) in participants who had already been selected because they believed they had been stigmatised as a woman, asked them to immerse their hand in icy cold water (1 degree C) for as long as they could (to a maximum of 3 minutes), then take part in a mock online job interview. Some of the participants were told that was the end of the study; another group were told they were successful in the interview; and a third group were told that “woman are generally not suitable candidates for these kinds of jobs”; and the final group were simply told “you didn’t get the job” with no reason given. The latter three groups then underwent another cold pressor test as before. And finally they were all debriefed.

The researchers found that those who were told “women are generally not suitable for this kind of work” did feel more stigmatised than the others, and not only reported more sensitivity to cold (threshold) but also showed lower tolerance to the pain experienced in the cold pressor test.

The second experiment involved women who were selected as above. This group of women were shown images downloaded from Google – one set was of content showing devaluing of women, while another set were control or neutral images. The authors used a heat stimulation this time, and randomly showed either neutral or stigmatising images just before the heat was applied. Participants rated the pain after each stimulation.

The results of this experiment showed that when participants were shown the stigmatising content, they reported higher pain intensity from the same nociceptive stimulation. In other words – stigma-inducing images led to these women reporting more pain when given the same amount of heat stimulus.

Not content with this, the researchers conducted a third experiment, this time examining nociceptive-evoked brain responses. They used the same experimental design as for the second experiment, but instead of self-reporting, participants had EEG signals recorded during each heat stimulation.

The results of this experiment once again showed that when participants were shown stigmatising images, they rated their pain experience more highly, and that this was reflected in the EEG results they obtained. N1 amplitude and P2 latency in time and LEP magnitude in the time-frequency domain were influenced by the stigmatising cues.

What does this all mean?

Well, for one thing it’s nice to see research being conducted in women (there’s a bit of a bias against women being involved in basic science pain research because of that pesky old hormone thing – see Samuloitz, Gremyr, Eriksson & Hensing (2018) for more). And for a study to have positive findings.

I’m particularly interested in the brain responses – simply by manipulating the sense of stigma, the same nociceptive stimulation was processed differently. Now this isn’t the same as saying “psychological factors cause pain” because this study is not looking at that – nociceptive stimulation was included – but the same nociceptive stimulation was prioritised in parts of the brain usually active in emotional responses, while P2 is an area involved in the “advanced stage of perceptual processing” was activated sooner in the stigmatised manipulation than in the control condition. The authors argue that because stigma is a threat to sense of self, and because this sense of threat can lead to vigilance about potentially stigmatising cues, greater attentional processing is allocated to threat information, and this in turn, enhances the experience of pain. The greater N1 amplitude demonstrate that attention was drawn to stigmatising material and then influenced the subsequent nociceptive information.

Let’s take a moment to consider the implications of this. Many women have reported their feelings of being devalued both because of their gender as well as their reports of pain. Women may be told “there’s no cure for being a woman” and given inadequate pain relief for period pain (true story). Women do report more pain, are more likely to develop persistent pain, and seek help for pain more readily than men. The latter can be seen as a bad thing – shouldn’t we just “cope”?

Implicit attitudes towards women remain throughout our society, despite the efforts of Kate Sheppard who was one of the women who worked so hard to enable women to vote (in New Zealand, in 19 September 1893). People with pain are also often stigmatised. My post last week is intriguing in that I pointed out that we cannot determine who is, or isn’t, “faking”. It’s the only post I’ve had with nearly 40 votes, but a total score of 2/5. It’s unplatable to some to think that a subjective experience is just that – subjective, not able to be measured, and for clinicians, that we need to accept what a person says without judgement. Stigma is judgement – let’s not do it.

N. I. Eisenberger, J. M. Jarcho, M. D. Lieberman, and B. D. Naliboff, (2006)“An experimental study of shared sensitivity to physical pain and social rejection,” Pain, 126(1), pp. 132– 138.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research and Management, 2018.

Waugh, O. C., Byrne, D. G., & Nicholas, M. K. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 550-e1.

M. Zhang, M. Barreto, and D. Doyle, (2020) “Stigma-based rejection experiences affect trust in others,” Social Psychological and Personality Science, 11(3), pp. 308–316, 2020.

Zhang, M., Zhang, Y., Li, Z., Hu, L., Kong, Y., & Su, J. (2021). Sexism-Related Stigma Affects Pain Perception. Neural Plasticity, 2021, 1-11. https://doi.org/10.1155/2021/6612456

Not all pain is the same


When I started working in the field of persistent pain, many of the approaches used were based on the idea that every pain was the same. Oh yes, of course we had neuropathic pain and inflammatory pain, but our treatments tended to approach each person as if they were pretty similar. We later refined that approach and started to look at people in groups. In the service I worked in, we used the Westhaven-Yale Multidimensional Pain Inventory which generates three main psychologically-based profiles – and for a long time this was a very useful way of establishing who needed the three-week residential programme, and who would do well with a briefer outpatient programme.

Well things change over time, and we’ve become more aware of what Clifford Woolf describes as a “mechanism-based” classification approach (Woolf, 2004). In this approach, clinicians try to establish the dominant mechanistic group in which a person’s pain might be classified, then suit the treatment to that mechanism. This means clinicians diagnose inflammatory pain, neuropathic pain, and nociplastic pain – and use what looks like the best combination of medications to suit the mechanisms. For example, for neuropathic pain it’s more likely people will be given gabapentin/pregabalin and a tricyclic antidepressant in combination than an opioid.

There’s a problem, though – in fact, TWO problems I can see.

Methods for identifying pain mechanistic groups

The first problem is that we don’t have wonderful methods for establishing the main mechanistic groups.

In fact, in a recent very large and thorough review of methods used to discriminate between each category, the authors found that “few methods have been validated for discrimination between pain mechanism categories”, and although there was “general convergence” between methods, there was also “some disagreement” (not that this is unfamiliar to anyone who reads research!) Shraim, Masse-Alarie, & Hodges, 2021).

What was interesting, albeit not too unexpected, was the overlap of findings between categories because people present with mixed types of pain; and that many of the studies attempted to only discriminate between two of the groups, rather than more. Having said this, the authors identified five groups of method used to help clinicians and researchers distinguish between pain mechanisms: clinical examination; quantitative sensory testing; imaging; diagnostic and laboratory tests; and questionnaires asking participants to describe their experiences.

Now I know that research studies aim to be a little more rigorous than clinical practice, but that should sound an alarm when we begin looking at what we need to do in clinical practice. “Subjective” pain examination included aggravating and easing factors, pain location and pain characteristics (can anyone tell me when pain is NOT subjective?). It also included psychological factors (although my radar went off at this – more of this later!). Physical examination (is this supposed to be ‘objective’ pain examination?) included general clinical assessment, general neurological testing, nerve provocation testing and neurodynamics, clinical bedside somatosensory function testing, movement and functional testing. Quantitative sensory testing had no greater degree of sensitive, specificity and reliability than physical examination and “subjective” history, and laboratory testing was pretty poor despite superficially looking more “accurate.” A similar state exists for questionnaires – oh lordy!

So these authors found 200 methods that could be used to determine which pain fits into a specific box, but overall the results are pretty underwhelming for clinicians wanting a direction for their approach. It’s not helped that the current “gold standard” used is – wait for it – clinician-based diagnosis.

Where are we left? Well, I think we’re not that far away from where we were in the 1990’s and early 2000s. We really don’t have a clear way to distinguish between the various mechanisms, and many people likely present with pain that includes more than mechanism. However – these authors provide a table summarising the commonly used, and possibly most likely approaches to diagnose pain mechanisms, and this is useful for those of us who want the “best guess” for now.

Problem two

At the beginning of this piece, I said there were two problems with using mechanistic descriptors. You can see the problems with reliability, specificity and so on – and the lack of agreement in the research and likely “mixed” presentations we will see in clinic – from my comments above (do read the whole article, though, it’s well worth it).

The second problem is that these descriptors, even when accurate and reliable, don’t tell us anything about the person experiencing pain. Unless, and until we have effective treatments for each of these mechanisms, we are inevitably running experiments to see what might work for this person in front of us. And this means we find less utility in diagnosis than we would if we drew on a case formulation approach.

What’s the difference? Diagnosis allows us to group “like with like” – on the basis of similar underlying mechanisms. We can then treat those mechanisms, and voila! the person recovers! It works well with fractures, with infectious diseases, and even with diabetes. It doesn’t work as well when we don’t have treatments we can use on the mechanisms. For example, although we can diagnose many neurological disorders, for so many of them we have very poor treatments. This means people live with their disease – and this is where a diagnosis falls down. It does not tell us HOW this person will experience their disease. Diagnosis doesn’t explain illness, disability, functional status, or participation.

And, because all of us are unique, this means that a one-size-fits-all approach to persistent pain (or even an algorithm, subtype, or subgroup) isn’t likely to offer clinicians or the person with pain a useful path towards well-being.

You’ll remember I said my radar went off with the psychological assessments included in the methods used to identify a pain mechanism. My reason is this: pain is a stressor. Even a paper-cut captures my attention (albeit just a little until I use a hand sanitiser!), my heart rate goes up a bit, I’m alerted to the experience and want to get away from it. Now imagine if that pain continued. Maybe variably, maybe constantly, maybe intermittently. And imagine if I couldn’t get a good understanding of what’s going on. And perhaps I was being questioned by my clinicians – and maybe even stigmatised. “What do you mean, you have pain we can’t diagnose, we can’t image, we can’t treat?” I’m guessing by now, perhaps some months after my pain started, I’d be feeling a bit irritated, perhaps a bit low in mood, my sleep might not be great, I might find it hard to do what matters to me because I’m not sure if I’m doing myself some harm.

What we don’t know in many studies of pain “predictors” is whether they are cause or effect. There is undoubtedly an association between various measures of pain-related anxiety, avoidance, low mood, thinking the worst. What we do not know is whether this was present before the pain came on – or whether it came afterwards.

So, to my mind, using psychological factors as part of diagnosis risks labelling people and what are probably normal responses to abnormal experiences. Let’s not do that.

Where am I left after reading this paper? I’m glad someone set about doing this review. I think it offers a good summary of the state of play, and identifies some of the current problems with a mechanistic approach. We need to get consensus on definitions, we need far better methods, we need to stop using the word “subjective pain examination” (because ALL pain is subjective), and we need to leave psychological factors out of diagnosis until we can clearly identify which came first.

Shraim, M. A., Masse-Alarie, H., & Hodges, P. W. (2021, Apr 1). Methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a systematic review. Pain, 162(4), 1007-1037. https://doi.org/10.1097/j.pain.0000000000002113

Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med 2004;140:441–51.

What happens to pain over 21 years?


No! I was not born then… I’m much older than that. No, in this longitudinal cohort study, participants recruited from the general public in Sweden were surveyed five times: at inception in 1995, again in 1998, 2003, 2007 and 2016. The article I’m reporting on included all respondents who had completed information on at least 3 of the 5 time points, a total of 1858 people! That’s a decent-sized study.

Longitudinal studies are really hard to do but offer us so much information about what happens over time to a group of people and it’s something we need to do more often. The problems with longitudinal studies are that people drop out, get lost to the researchers, they cost a lot to run, and research changes over time so the research questions may change, the measurement instruments may change, and it’s difficult to predict the variables that might be relevant at the beginning of the study. So, hats off to Aili, Campbell, Michaleff, Strauss, Jordan, Bremander et al (2021) who carried out this study!

Like many of these longitudinal studies, the authors developed an analysis in which groups of people who share similar characteristics in their persistent pain were identified. By following these groups over time, researchers are able to identify who changes, who doesn’t, and to identify some of the predictive factors that might put a person in the “at risk” group for developing increasingly poor outcomes. The “so what” factor for this type of study is that by identifying “at risk” people early on in their trajectory with pain, it may be possible to develop interventions that could help reduce this risk and that has to be both a human and economic gain for a community. In this instance, in order to interpret the findings, it’s important to remember that Sweden and other countries in the world don’t all look alike, have different healthcare systems, different genetic factors, and different social structures that can influence the process. So bear that in mind as I proceed.

The question asked about pain was this: “have you experienced pain lasting more than 3 months during the last 12 months?” Participants were then asked to indicate the location of the pain using a manikin with 18 predefined bodily regions in the musculoskeletal system; head and abdomen were not included (that latter one is a bit of a problem for me, tbh – given abdominal pain is a common experience for many women…). Participants were then identified as either having no chronic pain, or chronic widespread pain or chronic regional pain.

Sleep, health status, socio-economic status, treatment-seeking (for pain), lifestyle factors (alcohol, tobacco use), immigrant status and social support were also analysed.

Now for the statistics! Latent class growth analysis was used to identify common patterns or trajectories of pain over the time of the study. This analysis clusters participants according to their pain status over time, with each cluster representing a certain pattern of pain over time – participants were placed in a group where they had the highest probability of belonging based on their individual pattern of pain over time.

Results

At the beginning of the study, nearly 13% of participants reported chronic widespread pain, with just over a quarter (25.3%) reporting chronic regional pain. Using the analysis and various confirmatory statistical processes, the authors identified a 4-cluster model, and a 5-cluster model. Both models included a group that had NO ongoing pain at all, as well as a group with ongoing widespread pain. The preferred model was the 4-cluster model, as this had four different but clinically meaningful patterns – persistent no pain; persistent chronic widespread pain; those moving from chronic regional pain to chronic widespread pain, and a change trajectory: eg no chronic pain to chronic regional pain or chronic widespread pain. The cluster identified as including those who typically migrated from NCP to CRP or CWP was the smallest (5% of the sample), and the least reliably detected.

The trajectories are really interesting: (1) 47% of people never reported persistent pain at all over the 21 years. 5% pf people reporting no pain initially, but then moved to chronic regional pain or chronic widespread pain over time. (2) 22% of people reported chronic pain initially, or moved from chronic pain to no pain over time – the authors argue that the cluster of people may have chronic regional pain initially and migrate between chronic regional pain and no pain over time. (3) 10% of the group moved from chronic regional pain to chronic widespread pain and this grew more likely over time. (4) The final group were a small group (6%) of people who continued to report chronic widespread pain over the whole 21 years

The predictors for those in group (3) were being female, seeking care for pain over the preceding 12 months, lack of social support, poor physical function, poor vitality, and poor mental health. Being a manual worker nearly made the cut, and in an age-adjusted analysis, did for the group moving to widespread pain. Age (middle-age!), poor sleep, smoking and being an immigrant also tended towards having a poorer prognosis.

What on earth does this mean?

Well, one exciting thing is that a large group of people never experience persistent pain. This might imply that these people are generally more healthy, and it can also help explain why some people living with pain feel so alienated from the rest of their community. If most people around you don’t develop pain, then they most likely don’t understand what it might be like to live with pain 24/7.

When we look at the factors that predicted moving from no pain to chronic pain, there were several factors that can be modified to reduce the risk: sleep problems, poor physical and mental health, poor vitality, seeking treatment, and limited social support. Perhaps by addressing these factors, some people might find their move towards greater pain could be reversed, or at least halted. My question is, however, whether treatment seeking might reflect the fact the person wasn’t feel great either physically or mentally, and for some people, being unwell might mean withdrawing from social interaction, so it’s not entirely simple to interpret.

The authors point out that “The highest risk of belonging to the group developing CRP or CWP is seen in age groups below 50 years. Previously published figures from baseline data in this study show a prevalence of over 20% of chronic pain already among 20 to 29 year olds. The overall image is that long-term patterns of pain are already becoming established by the time adulthood is reached, and rising age in adulthood increases the likelihood of stable patterns over time.” [italics mine] They also point out that women who develop pain have a greater risk for developing long-term and increasingly widespread pain. Other important factors for this group were those who were older, had poor sleep, worked in a manual job, drank less alcohol, were immigrants, had less education, generally poor health, more care seeking and low social support.

To me, this study shows the impact of living on the fringes of our society – the women (in particular) who work manual jobs like cleaning, who left school early, perhaps moved to a new country and have few friends, and were probably quite stressed – leading to poor sleep, and poorer health, with consequent treatment seeking. What are we doing to help these women? Here in New Zealand, we can probably add Māori, Pasifika, refugees, and people who don’t speak English terribly well. How well are our current pain management services working for these people?

Aili, K., Campbell, P., Michaleff, Z. A., Strauss, V. Y., Jordan, K. P., Bremander, A., Croft, P., & Bergman, S. (2021, May 1). Long-term trajectories of chronic musculoskeletal pain: a 21-year prospective cohort latent class analysis. Pain, 162(5), 1511-1520. https://doi.org/10.1097/j.pain.0000000000002137

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.