Therapeutic approaches

Experiential avoidance – and persistent pain


Most of us will recognise that when we experience a pain, we firstly notice where it is, and the sensory qualities of it. We automatically make judgements about that pain – some of this judgement is about whether we recognise this pain (have we had it before?), some is about whether it’s important enough to interrupt what we’re doing (should I drop this hot cup of coffee, or can I hold onto it long enough to place the cup carefully on the bench), and some is about how we feel emotionally (yes, swearing is common when we smack our thumb with a hammer!).

In our response to acute pain, we often want to avoid or escape whatever we think gave us the pain – unless, of course, it’s something we choose to do even though it hurts. You know, things like lifting really heavy weights, running distances, taking rugby tackles, eating chilli! But in most cases where the pain is unexpected we’re inclined to want to make it stop, get away from the thing that probably caused it, and take a few minutes (or longer) to not do the things that make it worse. So we avoid walking on a newly sprained ankle and we don’t keep poking and prodding at a cut or a bruise.

Avoiding is quite common and even helpful when we experience the initial onset of a pain.

So why do we talk about “fear avoidance” as if it’s a bad thing?

Well, it’s because avoiding beyond a useful period of time often leads to ongoing problems. Some of these problems are possibly over-stated: things like “deconditioning” are probably not as much of a problem as we once thought (see Andrews, Strong & Meredith, 2021; Tagliaferri, Armbrecht, Miller, Owen et al, 2020). While other forms of avoidance may never even be considered.

What do I mean?

For a moment, think of a “weekend warrior”. The kind of person who heroically plays sport on a Saturday, trains once or twice during the week, and otherwise works hard and plays hard. Let’s think of this person as a male, perhaps in his late 30’s, thinks of himself as a hard worker and a family man. When he sprains his wrist after a particularly hard tackle in a weekend rugby game, he’s the kind who shrugs it off, and just keeps going. After a few weeks and his wrist doesn’t get much better, he heads off to see his local physio.

We wouldn’t usually think of him as an “avoider”. He’s not pain-avoidant, but sometimes because he doesn’t stop to take care of his wrist sprain, he ends up with a more troublesome injury. He might even develop a “boom and bust” pattern of activity: on a day he’s feeling good he’ll push through, but then his wrist starts playing up and he needs to take a day or two off.

I’m going to call it like I see it: this bloke is avoiding. What he’s avoiding is the experience of being vulnerable, of seeking help, of being advised to stop pushing himself for a day or so.

You see, experiential avoidance is what we do to avoid feelings (emotions) and actions that we don’t like or don’t want.

We see experiential avoidance most often described in pain research in the group of people who don’t resume their usual daily activities in part because they’re afraid of their pain. Or they’re afraid of what their pain might mean, or the effect of their pain on other things they need or want to do. For example, Angelina (see here) might be worried about the effect of pain on her sleep. And we’re reasonably OK with offering these people some information about what might be going on in their tissues, and that the relationship between pain and what’s going on in the tissues might not be as straightforward as it is when we hit our thumb with a hammer.

What we might be less aware of, and perhaps struggle to deal with is when a person appears to be doing the right things, like they’re remaining active and staying at work, but might be overdoing it. What might this person be avoiding? Perhaps, as I’ve suggested in the example above, it’s about avoiding feeling vulnerable, feeling like he’ll be told to slow down for a bit. Slowing down might be a sign, at least to our weekend warrior, that he’s not as young as he used to be. Perhaps he’s afraid of stopping because that means his busy mind can start to plague him with unhelpful thoughts about things he’s worrying about.

Experiential avoidance, like avoidance when a painful injury first happens, isn’t always a negative. When it’s used as the key strategy for life, indiscriminately and with an eye only to short-term benefits and not long-term consequences, then it’s not so good.

You see I hope we can help people to develop psychological flexibility: the ability to choose a response to any given situation that maintains moving towards what matters even if this means doing what feels odd or even a backwards step.

I also think we might benefit from developing psychological flexibility ourselves as clinicians. If we continue using the same old, same old strategy even if the results aren’t what we hoped for, we’re not helping anyone.

Andrews NE, Strong J, Meredith PJ. (2012). Activity pacing, avoidance, endurance, and associations with
patient functioning in chronic pain: a systematic review and meta-analysis. Archives of Physical Medicine & Rehabilitation. 93(11): 2109–21.e7, https://doi.org/10.1016/j.apmr.2012.05.029 PMID: 22728699

Tagliaferri, S., Armbrecht, G., Miller, C., Owen, P., Mundell, N., Felsenberg, D., Thomasius, F., & Belavy, D. (2020). Testing the deconditioning hypothesis of low back pain: A study in 1182 older women, European Journal of Sport Science, 20:1, 17-23, DOI: 10.1080/17461391.2019.1606942

Making first contact: What to do with all that information! Part 5


People come to see us because they have a problem. So the formulation approach I’m taking today begins from “the problem” and works back and forward. It’s called a “network” model, and is something many of us do without knowing that’s what we’re doing. The network model can also be called a functional analysis where we’re looking at what happens, and what a person does, and the ongoing consequences or loops that occur over time.

Angelina comes to see you because her neck is very sore. She’s not sure why it’s sore, or what happened to start it off, but she thinks it could be after working for a week at a new workstation where she had to look to the right to read documents, and straight ahead to work on the main monitor. It’s been there for over six months, and she’s come to see you now because she has a week of annual leave and some time to spend on herself. She’s played with changing her pillows because her neck is more uncomfortable in the morning, and it gets painful towards the end of the day just before she heads to sleep. She’s having trouble turning her head to reverse down her driveway, and looking up is almost her least favourite thing. Her sleep is OK once she’s got off to sleep, but initially it takes her a while to fall asleep because she can’t get comfortable. Her partner is getting frustrated with her because she doesn’t want to kiss him because that means she has to look up, and she doesn’t sit on the couch with him any more because he likes to rest his arm around her shoulders – and that increases her pain. She’s irritable and finds herself getting snappy at him. Angelina is in her mid-50’s, otherwise well, but has always lived with various aches and pains, most of which she ignores until they go away. She has had a painful shoulder and lateral elbow pain that lasted for over a year, but has gradually settled down – she didn’t do anything special to manage those after having only a small response to a steroid injection into her shoulder.

Angelina’s main concern is to establish whether her neck pain is anything to worry about, or whether it’s just more of the same, like her shoulder and elbow pain. Her other focus is on getting a comfortable position to go off to sleep because she thinks this is adding to her problem.

OK, so we have a lot of information about Angelina, and we can organise this information in many different ways. Given her main concern is her prognosis and then her sleep, we need to make sure the way we organise the information offers a possible explanation – a hypothesis.

Take a look at the network diagram below to see how I’ve sketched the information out – you’ll note that at this point I’m not trying to develop a diagnosis, I’m focusing on the problem as she sees it.

The matrix I’ve used here comes from Hofmann, Hayes & Lorscheid (2021) Learning Process-based Therapy, published by Context Press, New Harbinger.

What I’ve done is summarised the processes that I think might be relevant to Angelina’s presentation, and drawn the relationships between various aspects that she’s described. You might organise this information differently – and I’d usually do this in collaboration with the person.

If you look closely at the networks, you’ll see several loops that likely will continue if something doesn’t change. One to spot is this set below:

You can see that she’s worrying about her sleep, doesn’t get comfortable as she goes off to sleep, feels fed up, has changed her pillow (in line with her self-concept of someone who is a practical person), and the whole network will likely remain winding itself up unless “something” comes to disrupt this pattern.

This set of relationships raises some factors we need to consider when we’re thinking of interventions. As someone who sees herself as a practical person who doesn’t seek healthcare often, and has had previous bouts of pain that settled without specific treatment (though she sought it for her shoulder), we could interpret this as meaning she doesn’t panic about her situation too much – but we could also wonder if, because she’s seeking help now, she’s seeing her problem as different from previous pain problems and maybe this one is worrying her more than she’s ready to acknowledge. Just to the right of the loop I’ve shown above, you’ll see a box where she says “I’ll deal with it if it doesn’t get in the way of my family and relationship”. This is important – it’s an expression of how she sees herself, an important value, and her motivation for seeking help is also framed in terms of maintaining her loving relationship. For this reason, I’d be looking for interventions that either won’t intrude on her family life and routines, or I’ll be looking for ways to frame whatever treatment suggestions I make in terms of how this will support her relationship.

By drawing a network diagram showing potential processes that might be influencing Angelina’s presentation, I’m answering my question “why is she presenting in this way at this time, and what might be maintaining her predicament” – she really wants a prognosis so she can establish a strategy to maintain her relationship with her family, keeps her “practical person” view of herself alive, and in a way that she can still fulfill her desire (and others’ expectations) to be fully productive at work.

I could analyse (or organise) Angelina’s information in lots of different ways. This is just one – and in some ways, the particular model I use to assemble her information is less important than ensuring Angelina is an equal partner in sketching out these relationships. I could have drawn the Tim Sharpe CBT model or used an ACT-based model and looked for patterns of psychological flexibility. I could have used Vlaeyen’s fear-avoidance model – and I’m sure there are plenty of others that might have been useful.
Irrespective of the model, what needs to be evident is using the information the person offers us, modifying the way we approach therapy as a result, and collaborating with the person to decide treatment priorities. This means we as clinicians need to be nimble, responsive, adaptive, and stop using treatment protocols! Any approach that suggests offering the same approach irrespective of the unique things influencing a person’s presentation is doomed to do a half-arsed job. These protocols might work for some, but they won’t work for all, and they may fail to address the real reason the person came to see us in the first place.

Making first contact: What to do with all that information! Part 4


In the previous few posts on what to do with all that assessment information I’ve talked about generating a formulation to guide treatment, and a little about how teams might work together to generate one. This post is a little different because I want to situation the discussion around the ultimate aim of therapy.

I usually work with people who have long-standing pain that hasn’t changed much and doesn’t seem to be disappearing. I’m not a nihilist, but I do wonder if clinicians are trying too hard to “change pain” when the body doesn’t seem to respond all that much to whatever we offer when it comes to musculoskeletal pain! Perhaps all we do is offer support to the person as their body gets on with the job of settling down…?

Anyway, my focus is to help people respond flexibly to what life has thrown at them – because while pain poses one of the greatest problems for people, often it’s not the pain as such but what we do to avoid or control pain – or, for that matter, what we do to avoid or control the results of avoiding or controlling pain. Confused? Let me unpack it a little with an example.

About the time I started this blog wayyyyy back in 2007 I had a concussion and developed post-concussion syndrome. I found it incredibly difficult to concentrate, find words, remember things, switch my attention from one thing to the next, and to deal with sensory overload. I was advised to rest and let my brain recover in its own time – all good. BUT I never expected that recovery to take almost two years! so I returned to part-time work after two weeks. In my head I was balancing my fatigue/headache/difficulty concentrating against my need to return to work, keep my employer happy, and do things that mattered.

If I flip that motivation on its head, I wanted to control both my symptoms and my fear/guilt of failing and perhaps losing my job/fear of sitting still and doing nothing/fear of feeling useless. After all, I was the vocational rehabilitation therapist for the service I worked in!

By trying to control my fear of not doing, I created a whole bunch of trouble for myself – I failed at controlling my symptoms – they grew out of hand and I eventually had to take some time off work, got quite depressed, and achieved exactly what I’d hope to avoid – needing to stay at home doing nothing!

When we think of ACT (Acceptance and Commitment Therapy) for living with pain, we often think of the person working hard to control or avoid pain and our focus is on helping them to be willing to make room for pain and begin doing things – and yet I’ve met a great many people who have got caught up in a vicious cycle of over-doing and under-doing, or who “get on with it” with gritted teeth and sheer determination! So one thing we can be looking for in our “first contact” is to identify how workable are the ways the person is approaching this time in their life, a time when they’re dealing with pain and life restrictions, stress, balancing priorities, working, family and so on.

ACT provides a series of six processes that together offer a way to be flexible about how we handle what life throws at us, and help us do what matters in our life. In an ACT formulation, we’re looking for unhelpful patterns that constrain how flexibly we can do what matters. Some of the patterns we might see could be:

  1. Unwillingness to stop and create space for pain so the person gets stuck acting as if there is no pain, trying to do everything the same way as normal but either getting fatigued and stressed and just hanging on in there, or doing short bursts of “normal” and crashing periodically.
  2. Getting stuck with rigid beliefs about what’s going on like thinking the pain must be able to be fixed and quickly, or that the pain is the most horrible disaster ever and everything about life must be shelved until it’s fixed.
  3. Comparing what he or she can currently do against a previous level of performance and being frustrated and angry because this doesn’t fit with how they see themselves, and especially thinking that this is the way it’s going to be forever…
  4. Losing sight of important things like being with family, or seeing friends because of feeling irritable, sad, thinking they don’t want to see them like this, not being able to do the things they used to do, waiting for the pain to reduce, or looking for the fix.
  5. Anticipating calamity or remembering disasters either about “the last time I tried doing this” or “because I saw this happen to [name]” and then feeling utterly stuck.
  6. Casting about being erratic or just not sticking to a plan, getting off track maybe because results don’t happen, or maybe because it’s something new and feels unfamiliar, or perhaps because someone else suggested another option…

There are always other ways people respond to pain, not just the patterns I’ve listed here, but these are some common ones I’ve seen. In ACT we’re looking for unworkable patterns that don’t lead the person towards being the kind of person they want to be, doing the things that bring meaning in their life.

When I’m jotting these things down, I’m looking to identify the core things the person isn’t willing to experience: thoughts, emotions, memories, situations. I want to understand what the person does to avoid them – like things the person has stopped doing or deliberately avoids, the ways the person avoids or controls emotions associated with that thing (like drinking more alcohol, zoning out, lashing out), and what I observe during our initial assessment like skipping over topics that feel uncomfortable.

I want to understand the cost or “unworkability” from the person’s perspective: what’s the impact of responding in these ways. I need to understand what’s going on in the person’s context – their family life, employment situation, influence of case manager or insurance/compensation, friendships. And I want to look at the factors that might be adding to the person’s inflexible responses, and these are myriad and often include what we do as clinicians – like being told to stop doing a favourite hobby “because it might be damaging” (how many people with low back pain have been told to stop running, stop fishing, stop dancing, stop lifting, to sit in a certain way, walk in a certain way, lift in a certain way, stop slouching, walk faster, slower…?). And of course I want to understand a person’s strengths: have they had an experience like this before? Do they have strong values? Have they succeeded in some area in life? What brings them joy and takes them into the zone? How have they modified the way they do things so they can do what matters?

I like to do this in collaboration with the person (how else could I do it?!) and to look at the good and not so good of everything they’ve done along with the context. Because one thing that always resonates with me is that people do what they do because it’s worked in the past. Always. At least once.

For more on ACT, you can’t go past the Association for Contextual Behavioural Science – https://contextualscience.org/

And Chapter 2 from Lance McCracken’s book Mindfulness and Acceptance in Behavioral Medicine, 2011, Context Press, New Harbinger:

Vowles, K.E, & Thompson, M. (2011). Acceptance and Commitment Therapy for Chronic Pain, pp31 – 60.

Making first contact: what to do with all that information! part 1


Last post I wrote I said I’d continue with a process for structuring and synthesising the information we gather from the initial contact we make with the person. This process is integral to clinical reasoning, and somewhat surprisingly, there’s not a great deal of research to give us guidance on the best way to do this – and it’s even more challenging for those of us working in an interprofessional team setting, where different professions, personalities and assumptions are part of it.

If we work backwards from the end point, we might get some clues about what to do. Our end point is to help this person do what matters in their life. All our efforts are pitched towards this end. Because people are unique, what matters to them in their context is likely to be unique, and because pain and disability are multifactorial, there will be many paths to help that person get to where they want to be. Algorithms are designed to make the task of clinical reasoning a lot simpler, but there are some enormous assumptions associated with using an algorithmic approach: that we know the important factors associated with change; that we can address those factors successfully; that each person has the same set of factors evident in their presentation… and frankly, I don’t think I’ve seen strong evidence of any of these when it comes to pain.

Clinical reasoning is about a series of cause and effect assumptions. We have limited certainty about much of pain and the relationships between factors we think influence pain and disability. We’ve also been holding on to some outdated and inaccurate assumptions about the way grouped data applies to the one person in front of us. Prof Steven Hayes points out that as early as the 1940’s (perhaps earlier) we knew that there was no such thing as “the average man” (or woman!). This emerged in human factors/ergonomic design, where using the average/median of all the anthropomorphic measures we have does not help us design a workstation or control panel that will work for all people. Instead, we have to design to suit the minimum and maximum clearances and reach, and add adjustability so that everyone can make their workstation work for them. The assumptions used in early application of anthropometrics were that everyone is essentially similar: it’s ergodic theory (https://en.wikipedia.org/wiki/Ergodic_theory). Ergodic theory holds two assumptions that don’t work well for people: all the events in ergodic theory must be stationary, and all elements in the mathematical model must obey they same rules.

When we work with people, we know their presentation is a series of responses that continue to move over time. Their presentation is dynamic, changing all the time but exhibiting similarities in terms of processes. And we also know that different factors influencing a person’s presentation don’t always follow the same patterns. There are things like legislation, unexpected events like trauma or earthquakes, biases and stigma – and these don’t affect everyone equally.

One solution is to acknowledge this and instead look to the particular, applying to this person at this time – idiographic, or as Hayes calls it “idionomic.” A network diagram, showing the dynamic hypothesised relationships between contributing factors can help us generate ways to influence change. And the diagram should “make sense”, or explain, what’s going on to all the team members including the person with pain.

I’ve used a cognitive behavioural formulation model for many years now (see here and here – and use the search bar for “case formulation” for a list of the posts I’ve made over the years). The assumptions in this approach are that directly influencing the thoughts a person has about their pain will have flow-on effects on pain, emotions, actions and physiological arousal. And to a certain extent this is true – plus, there are some things we cannot readily change, such as family responses or previous trauma. But the flexibility of a formulation approach is that we can include anything that’s relevant including strategies the person has used in response to those things that can’t be changed.

The biggest assumption that I make is that pain on its own isn’t the main problem. It’s how we respond to pain, what we think is going on, how we react to the things we do in response to pain (or things we don’t do but think we should), and how the people around us influence us, that help determine how much pain bothers us. There is plenty of research showing that people willingly do painful things if they do so for important reasons. Some everyday examples include ritual tattoos, endurance sports, boxing and martial arts, eating very spicy chilli. Of course, these aren’t examples of persistent pain – and yet, people with persistent pain started with acute pain. There are some highly influential factors that are present from the outset and these do have an impact on how we respond to pain, especially as time goes on.

The second assumption I make is that everyone is able to learn how to do things differently, and in doing these, we can develop a different relationship with pain and become less distressed and disabled by our experience. This doesn’t mean (a) that we should just give up and be resigned to a life of pain and not seek treatment to reduce pain; or (b) that we should just ignore pain and grit teeth and bear it. It also doesn’t mean that we will feel happy about pain, or that life goes on as normal. But it does mean that we can make some room for pain to be present, and move towards doing what matters rather than having pain become some invisible barrier to a life worth living.

Exactly what we include, and how the relationships between each factor play out is the topic for next weeks’ blog – stay in touch!

Making the first contact


How do we begin working with someone who is asking for help with their persistent pain? In this post I’ll describe some of the considerations I have when I begin, because as Benedetti points out, the “meet the therapist moment” is one of the most potent times in the therapeutic ritual (Benedetti, 2011). It’s the time when the person’s expectations and the clinician’s empathy and competence meet, and the “meaning response” blooms.

My two clinical questions are:

  1. Why is this person presenting in this way at this time, and what’s maintaining their predicament?
  2. And what is this person’s main concern?

But before I ask these questions, I want to take a moment to think about the person and what might be going on in his or her mind.

Benedetti points out that expectancies are an important part of a response to treatment – whether that treatment has any active action, or not. Expectancies are about what a person brings to a therapeutic encounter: there are two, one is stimulus expectancies (anticipations of external events – eg that the next painful experience will be less), and the other is response expectancies (predictions of your own nonvolitional response – eg that after doing this thing, I expect to experience less pain) (Kirsch, 1985).

People who come to see a clinician, especially a clinician from a little-known profession (occupational therapy!) will hold expectancies about what that person will do, but these will likely be weaker than the expectancies a person might hold about seeing a well-known profession. The strength of an expectancy is different from the direction of an expectancy – for example, a negative experience with a physiotherapist might lead to a strongly negative expectancy about future treatments, while not having had an experience with an occupational therapist might lead to a weakly positive expectancy about what’s about to happen.

Along with expectancies, the person will likely be anxious about what’s to come. The possibility of something that might help (or not), meeting a new clinician, and living with pain are all stressors – and anxiety erodes a person’s ability to absorb lots of information, while biasing them towards remembering threatening words (Reidy & Richards, 1997).

So there’s a lot going on in the person’s mind when they attend that first session.

There’s also often a large power imbalance (Joseph-Williams, Edwards & Elwyn, 2014). This emerges from the fact that often clinicians hold a lot more information about the person we’re seeing than they do about us. Especially after we’ve asked a bunch of questions, often quite intimate in nature. For a person seeking help, this imbalance can make it hard to ask questions, to direct the conversation, to hold a sense of independence throughout the encounter.

So having set the scene for you, I’m sure you can agree that how we go about collecting information from a person is incredibly important – especially so that relationship can begin to build.

Introductions

In the introduction, I seek to give the person some information about who I am – not just as a clinician, and the kind of treatments I use, but also about who I am. I’ve drawn inspiration from tikanga Māori here, where the cultural tradition entails letting the person know where I come from and who I’m connected to. I like to let people know my childhood roots are in Turanganui a kiwa, or Gisborne. That the mountain my heart connects with is Mount Hikurangi – the first mountain in NZ to see the sun. The river I connect with is the Taruheru, flowing into the sea in Gisborne. I also let people know my whanau connections – the Lennox’s, and the Thompson’s, are my whanau (extended family), and I’m a 5th generation New Zealander. I now live in Otautahi/Christchurch. This introduction only takes a few minutes, and your culture might not value this form of introduction. For me in Aotearoa/New Zealand, it’s one way I can show respect and follow a tradition that means the person I work with knows something more about me than just my name.

I also include my profession – what I do. I’m an occupational therapist, my job is to help people do what matters in their life contexts.

I like to then let the person know that they’re brave and courageous for seeking help – it’s not easy to say you can’t do this on your own. It takes courage to tell someone that.

Questions

Then I open with a broad question about what has led this person to come to see me. I might add in something about “tell me about your pain and what you’ve done so far for it.” I’ll often ask what their theory is about their pain, what they think is going on.

Then I ask “What is your main concern today?”

Throughout this process I’m reflecting what I’ve heard, to ensure I’ve understood what the person has experienced. I’m NOT giving reinterpretations, I’m NOT giving out new information, I’m just listening.

I often spend time asking about four areas of life: relationships, fun, work, and health. Or I might ask the person to take me through a typical day, from the time they wake up.

I like to find out not just what the person has done to help themselves, but also what they’ve learned from these experiences. The messages they’ve received over time, and the things they’ve tried but perhaps didn’t like or that didn’t help.

Questionnaires

I was a big fan of questionnaires filled out ahead of time, and I am still a fan but don’t use them as much. This is mainly because so many people have filled out endless questionnaires and nobody has sat down with them to talk about what they mean! So I’m a little more selective and focus much more on listening first then choosing something that will offer me and the person some insight into what might be going on. For example, I might choose the PASS20 (McCracken & Dhingra, 2002) because it helps me figure out where to begin with reducing pain-related anxiety. It’s a good measure to use each week to track changes over time, and I’m beginning to delve into repeated measures of progress rather than a pre-post-follow-up approach that’s typical.

Observation

Covid has meant it’s not as easy to carry out observational assessments, but I’m always watching how the person sits, moves, walks, and body language. What I’m not doing is interpreting these observations without talking to the person about them! Too many clinicians make judgements about the person based on maybe one or two observations, out of context of the person’s life and environment, and without checking in with the person to work out what might be contributing to what they see. Let’s not do that – the person might be completely oblivious that they’re guarding their sore hand, or they keep shifting in the chair, or that a habitual movement like taking a jacket off might be easier to do than being asked to perform some weird movement at the command of the clinician!

Pulling it all together

Just as we wouldn’t expect to be marched in for surgery straight after our first consultation with an orthopaedic surgeon, I don’t believe it’s OK to offer something to a person on their first visit just because we feel internal pressure to do so. Having said this, I will often suggest to the person that they spend a bit of time doing some brief “noticing without judging” exercises. We’ll give it a go at this first appointment, so they’re not being expected to go do it without knowing how. The reason I start with brief noticing experiments is that it’s something we could all do more often, it gives the person a new skill (usually) to develop, and it’s often an introduction to being fully present without judging. Being fully present without judging is hard to do when you’re sore because the mind likes to anticipate how bad it’s going to be (“you’ll need to take it very quietly or you’ll pay for it”) or remember previous pains (“last time you just sat around your pain went nuts, you don’t want to risk that now do you?”).

Notes/Documentation

I write conversational notes directly to the person, going through what we’ve talked about and pulling together all the information I’ve gathered in this first meeting. I find it helps me to make sense of what’s going on, it allows me some time to reflect on what I’ve observed and heard, and I can assemble it in a case formulation that the person and I can explore if/when we meet again.

Assessment is never over. Every time I meet with a person I’ll be learning more about what’s going on. I don’t feel pressured to “find it all out” at that first session just because there are goals that must be developed. In fact, one goal I leave in for everyone is “develop goals” (well, I don’t use goal language – it’s more about directions and actions that take you there). Because seriously, how can anyone meet someone and immediately develop goals – that’s disrespectful to the person who may not have had time to think about what matters the most, and it’s disrespectful to the complexity of goal setting as a process anyway.

Theme and variations

I’ve written one approach I use for learning about the person I’m trying to help. There are others – a time line, drawing a life map, mind-mapping, walking and talking, making a coffee – all of these and more can be used to explore the same information.

Let’s not call it “the subjective” – let’s call it what it is, our first “getting to know you” meeting.

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189–1202.

Joseph-Williams, N., Edwards, A., & Elwyn, G. (2014). Power imbalance prevents shared decision making. Bmj, 348.

McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research & Management, 7(1), 45-50.

Reidy, J., & Richards, A. (1997). Anxiety and memory: A recall bias for threatening words in high anxiety. Behaviour Research and Therapy, 35(6), 531-542.

Pain model – helping to target change


In my recent post on behavioural approaches to pain management, I had a number of commentators ask why do it, why not focus on pain intensity, and aren’t I invalidating a person’s experience if I target a person’s response to their experience. Today’s post will explore some of these points.

I suppose my first point needs to distinguish between pain as an experience, and pain behaviour – or what we do when we experience pain. I like to use a pretty old “model” or diagram to help untangle these concepts. It’s drawn from Loeser’s “Onion ring” model, and he wrote about this way back in the early 1980’s. This is my interpretation of that way of thinking about the person experiencing pain. It’s not intended to represent Truth – but to help us to get our heads around an individual’s truth, or their experience. It’s one way to consider the factors we’ve learned are associated with human pain. It should be evaluated in terms of its utility and practical usefulness for a person experiencing pain, and for clinicians hoping to help them.

The “BIO”

Firstly, we have all the neurobiological processes involved in transmitting nociceptive information throughout the body. Much of this information never reaches conscious awareness – activity in nociceptors occurs all the time, and we have rapid reflexive responses to this such as blinking, shifting in a chair, swaying while standing and so on. A whole lot of neurobiological activity occurs as this information reaches conscious awareness – much of this activity occurs above the brainstem. In fact, if we look carefully at neurobiological activity, much of the reason we never notice reflex responses to nociception is because we have a pretty effective inhibitory system that’s operating constantly to limit how much nociceptive activity hits consciousness. That’s all part of cortical and brainstem (yeah – BRAIN) processes. If anyone learns neurobiology of pain and doesn’t include attention, motivation, emotion, expectations then they’re missing an enormous chunk of what nociception and pain are about.

Added to this neurobiological information are another whole bunch of physiological and hormonal responses – and these are incredibly complex and often omitted from our discussions. For example, men and women differ in their hormone production, and this means more women experience persistent pain, women have lower pain tolerance, and respond to nociceptive information more quickly and at lower thresholds than men.

Suffice to say, there are a whole bunch of biological processes that are integral to our experience of pain and to nociceptive transmission, transduction and perception. So if anyone should suggest that a “biopsychosocial” model of pain does not include BIO – go wash your mouth out please.

Pain-the-experience

The next aspect of pain that Loeser included was “pain-the-experience” – the subjective, personal, unshareable “what it is like to experience pain” part. This encompasses the qualia – the sensory qualities of pain, and includes intensity and location. Pain is always experienced as having a negative or aversive quality, so we know that the urge to avoid or take action to reduce, and indeed our tendency to attend to this experience is part of a human experience of pain. Note that Loeser (and I) don’t include appraisal at this point! In other words, this is the “ouch” that a baby feels when we perform a Guthrie heel prick test. It’s that moment when scalding coffee hits your lap, before you’ve realised you’ve spilled your coffee.

But just to complicate things here – unless we’re newborns, we’re always aware of context and pretty much once we learn language, we’re interpreting when/where/how/why events are happening. This means that factors such as expectations, past learning, predictions we make about “what next” always inform “pain-the-experience”. Even before we’re consciously aware of these influences! So technically, as soon as we recognise “ouch” we’re already invoking a whole bunch of higher cortical processes into our experience. This matters because pain is a conscious experience, and requires perception before it can be experienced.

Judgement or appraisal

The next “ring” of Loeser’s model was called “suffering” – I’ve translated this into a cognitive process of “appraisal” because while pain is inherently tainted with negative emotional valence and a motivational urge to avoid, it’s also possible to view our experience of pain in different ways. Some commonplace examples are the jab from a vaccination – many of us will welcome that nociceptive input, and judge the pain to be negligible. Others who may be less comfortable with a vaccination might view it more negatively and be more aware of that pain. People who run or train in a gym might appraise the pain from working hard “feel the burn” as a sign that they’ve done enough to make performance gains. And some of us who live with persistent pain such as fibromyalgia might notice pain and consider it to be “just a nuisance”.

Suffering is an interesting concept, and I prefer to take Erik Cassel’s definition of it: suffering refers to the loss of a sense of self. A paper cut typically doesn’t lead to a loss of sense of self, while low back pain that remains for many months might be far more likely to erode that sense of “who I am and what I can do”.

Judgements and appraisals are influenced by a whole lot of factors – socio-cultural norms (I’m in a rugby-mad country, if a rugby player experiences pain on the field, he or she may well grit teeth and keep going, believing that it’s not OK to “give in” to pain – the appraisal might be “this isn’t so bad, I can still keep going”. Socio-cultural norms are often implicit – we absorb them effortlessly within our own cultural context, and we’re quite capable of holding different implicit norms depending on our current proximity to our social group. Consider the rugby player who will brush off an on-the-field injury but when getting a splinter might feel a little sick. The meanings we attribute to our pain influence how willing we are to go with them – tattoos and body piercings and body suspensions are really good examples of times when we’re OK to experience pain in the pursuit of something else, similarly post-surgical pain after joint arthroplasty.

When appraisals are unhelpful is when we get tripped up. When a person holds an inaccurate understanding of what’s happening – thinking, perhaps, that this back pain is a sign of cancer metastasising, or the end of a career as a sportsman, or an indication of some dire outcome, then a couple of things happen. Firstly, negative emotions are likely to rise, along with sympathetic arousal (the two systems are linked in the experience of pain), and then what we do about pain also begin to turn to short-term over long-term outcomes.

Pain behaviours

Pain behaviours are what we do when we experience pain, and they’re shaped both by evolution and by socio-cultural norms, as well as what we think is going on. I wrote about pain behaviour recently – click

Pain behaviours are the only part of “what it is like to experience pain” that we can observe.

Let me say that again – what we do about pain is the only part of the pain experience that a person who is NOT The Person In Pain that we can share.

Pain behaviour includes everything a person does and says in relation to their pain, both reflexive and automatic actions that we’re not aware of, as well as those we are aware of. Some of the behaviours we do are reflex responses (blinking and tearing up), some of them are not. Some of them are well-learned – we’ve been doing them since we were tiny kids. Others are things we’ve learned to do, perhaps on the advice of someone else, or because we’ve observed someone else, or because we think it might help or it’s worked once before.

The thing is – pain behaviours are malleable. They can and do change. Again, read my earlier post on how pain behaviours can be changed, and know that just because a behaviour has changed, the person’s experience of pain may not. In other words, while I move pretty normally, and to many onlookers I don’t appear to have pain – I still do.

Social context

I’ve already alluded to the influence of contextual factors. Things we’re aware of – prevailing attitudes in our immediate social group, our community, our spouse, our treatment providers. Things we’re often less aware – of implicit attitudes about gender, ethnicity, socio-economic status, supposed pain mechanisms, visibility of tissue damage and so on. And we are ALL influenced by these implicit socially constructed attitudes and beliefs, people with pain and their clinicians and their families and their communities….

I often use this way of exploring factors involved in why a person is presenting in this way at this time, and what might be done to reduce distress and disability. I might package the conversation in various ways – perhaps more complex if I expand on some aspects, perhaps less so if the person doesn’t want or need to explore something (often this is the neurobiological part). While it’s imperfect remember that the purpose of a model like this is contextual. I am not hoping to represent Truth as a universal law about “how pain works”. I AM hoping to explore useful elements for a particular purpose. One purpose might be to demonstrate that emotions and appraisals influence pain behaviour. Another might be to introduce medical students to the complex factors that might be involved in their interpretation of a patient’s distress. And another to help someone understand why he avoids a movement in one context but not in another. And even another might be to help someone know why she has such a panicky feeling when she’s in the middle of a flare-up.

As a pragmatist, and basing my practice on approaches that might help this person achieve a specific something in this moment, I use models like these to build therapeutic alliance, to enable the person to be willing to play with new ways of being, and to help them recognise that the target for change might not be what they initially think is relevant.

Loeser, JD. (1980). Perspectives on pain. In P. Turner (Ed.), Clinical Pharmay & Therapeutics (pp. 313-316). London: Macmillan.

Loeser, JD. (1982). Concepts of pain. In M. Stanton-Hicks & R. Boas (Eds.), Chronic low back pain (pp. 145-148). New York: Raven Press.

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.

Radical? Radical!


Welcome to 2021! An interesting start to the year for my US friends, more of the same for my UK and European friends, and life in NZ and Australia goes on with an added dash of uncertainty because of the new! improved! more contagious Covid19!

I’ve had a few weeks away from my usual Monday morning writing routine, but I return to the blog today with a lovely book I’ve reviewed. There’s no secret about my personal preference for ACT both for living and flourishing in daily life, and for those of us living with persistent pain. Today’s book review is about Radical Relief: A guide to overcome chronic pain, written by Joe Tatta, physiotherapist. From the outset, I’ll acknowledge that I was sent a free promotional copy of this book – but I would have bought it anyway, I promise!

There are a few books I recommend for clinicians working with people living with pain. The first is a textbook called Pain: A textbook for health professionals which is one of the most accessible and clinically useful books for clinicians wanting to enhance their understanding beyond what they learned in undergrad training.

Another is an old CBT-based book written by Turk and Winter called The Pain Survival Guide which runs through the main conventional approaches to managing pain. It’s written for people with pain, and while there are certain parts I’m not certain are really well-supported by research, it offers the standard strategies that have been included in multi- and inter-professional pain management for years.

And now, Radical Relief arrives on the scene, and I think it will be another of those references I will use over and again. Radical Relief is written for people living with pain. It offers a “radical” way to returning to life, drawing on well-established, well-researched strategies for pain management from an Acceptance and Commitment Therapy perspective. For those who are not familiar with ACT, one of the major premises is that often our problem-solving mind gets in the way of us living a values-aligned life, particularly when we’re confronted with a situation or experience we can’t change.

Now I’m going to take a moment to comment on pain changing. Pain changes all the time. The intensity can go up and down. The quality might be intrusive – or fade into the background. It might be there all the time, or intermittently, or unexpectedly. There are so many factors that influence our experience of pain that it wouldn’t be at all surprising to find that most clinicians find that their patients experience at least some relief during or after treatment. And sometimes we clinicians like to take credit for that – and often we want to focus on getting a report from the patient that yes, pain has reduced. Sometimes we’ll almost do anything we can to find a way to “reduce the pain.” Part of the definition of pain (see here for the full definition and notes) includes the word “unpleasant” – “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”, so I think it’s safe to assume most of us don’t want to experience pain. And yet we know that for many people, reducing pain intensity is not possible. That’s a fact that some clinicians don’t want to recognise. How we as clinicians handle our inability to alter pain intensity is a test of our willingness to read and acknowledge scientific literature.

OK, back to the book. ACT is based on the idea that underpinning successfully navigating life is a concept called psychological flexibility. This concept consists of six processes that appear to underpin how we can be psychologically flexible in the face of an unpredictable and challenging world. Joe Tatta, in this book, articulates these processes as they can be employed by people living with pain. How to be open, willing, aware and do what matters to you in the presence of pain, and all that this experience brings with it.

I won’t review how ACT might help – there’s plenty of information available on the web, including my blog, for those who aren’t familiar with it. I will, though, say that the way Joe writes is clear, succinct and empty of jargon. He writes as if he’s speaking directly to the reader. The sentences are short and full of questions to ask yourself. The chapters are also short and offer activities to try. Joe identifies that some of the activities might feel odd – they’re not “typical” of many self-help suggestions, because Joe invites readers to experiment, to try, to see what happens, to be open to what happens. This is refreshing!

Some features of this book that I particularly like are the room to write your own thoughts and responses down. The certificate at the end of the book is delightful. And the illustrations – gorgeous!

I think if I was a person who came across this book I’d be intrigued by it. I think I’d find it easy to read, and I’d be willing to try at least some of the ways Joe suggests. If I worked through this with a clinician, I think I’d find it even more useful. It’s not easy to step outside of yourself and recognise your mind’s sticky thoughts and attitudes. It’s hard to make changes on your own. So it’s not the way the book is written that means I’d suggest using it with the support of a coach or clinician, it’s simply the nature of motivation to change in the face of pain.

Now ACT has been found to be no more (and no less) effective than CBT (or indeed any other treatment approach we have: surgery, medications, exercise) for persistent pain. This doesn’t mean ACT “doesn’t work” – it just means that, like any of our approaches to persistent pain management, it’s not a case of one size fits all, or one therapy will be the magic bullet. I’ve advocated for a while that precisely because we have no over-arching “successful” treatment, this offers clinicians and people with pain an opportunity to find out the unique combination of strategies that are helpful for this person at this time and in this context. ACT, although it includes the term “acceptance” does not mean “resignation” – I prefer the term “willingness” to experience pain (rather than doing everything possible to suppress or avoid pain) in the pursuit of what matters. ACT’s functional contextualist philosophy means we need to ask “how well is this working?” about everything we do – because the ultimate measure of success is about whether the approach is helping us do what matters in a particular context. I think that’s pretty radical myself. And, like this book, while we won’t always have a “perfect” outcome, we can MOVE.

M= Make room for unpleasant sensations (and thoughts!)

O= Open up and observe non-judgementally

V= Values guide life, not pain

E= Engage in activities in line with your values

Thanks for the opportunity to review your book Joe, I appreciated it very much.

Springboard: Beginning to live life again


Springboard is a six week, 120 min once a week programme for people with pain. I developed this programme in the context of New Zealand’s Accident Compensation Corporation (ACC) community-based pain management services.

So, why use a group approach and what’s inside Springboard?

Pain can be such an isolating experience, and for many people, not only do friends and family not “get it” but neither do some of their health professionals! Living with pain, even for “just” a few months can lead to loneliness because most people don’t know what it is like to experience pain that doesn’t go away. Simply coming to a group where everyone else is in the same boat offers people a chance to be authentic about what it’s like. Connection with other people is so important – remember humans are a social species.

The second reason I love groups for this kind of work is that we get to share much more information and learning from one another than can be achieved in a one-to-one setting. As each person talks about their experience, others can relate “I’m the same”, or compare “I’m not like that”. Participants can share their wins and losses. They can contribute to help solve one and other’s problems. They can challenge one another in a way that health professionals who haven’t lived with pain can’t emulate.

If we look at Bandura’s social learning theory we can see that direct experience is the most powerful influence on self efficacy, and the second most powerful influence is vicarious learning. Being able to see how others approach the challenges of every day with pain gives participants a powerful learning tool.

What’s inside Springboard?

Springboard is based on ACT (Acceptance and Commitment Therapy) and also draws on motivational interviewing as a therapeutic stance. Rather than focusing on changing pain, the focus in Springboard is on learning ways to live life again, even in the presence of pain. In other words, Springboard is about beginning to be yourself again.

One of the most profound losses when a person experiences pain that doesn’t follow the “typical” trajectory is a loss of previously implicit assumptions. The body becomes more significant with pain – movements are attended to, daily activities are bounded by far more awareness than normal, assumptions about what a person can expect from him or herself are challenged. In turn, this awareness brings a loss of sense of “self”. Self concept is an idea about “what I can expect to do, be competent at, and what others believe I can do” – and when pain is present, these expectations are violated.

Springboard aims to help people take stock of their lives, decide what matters, and begin to move towards valued actions in the presence of pain. Opening up more of life than just attempting to get rid of pain and “go back to normal”.

The thing is, “normal” has gone – whether pain ultimately resolves or not. Because each person who has gone through this weird experience of pain that doesn’t obey the rules will remember what it was like when they had their pain, and the old certainty and belief that the body will do whatever it’s asked to do will have likely eroded.

So Springboard asks the questions: if pain was less of a problem for you, what would you be doing? What matters to you? How can we work together to get more of that – and in doing so, enrich your life, and the lives of those you care about.

Each session begins with a review of the “missions” all participants undertake in their own contexts. These are values-based actions that participants choose for themselves, and that will build towards being and doing what matters in life. In other words, making life bigger.

As participants review their progress, and share their successes – and challenges – all the other participants contribute ideas to solve the problems, celebrate the successes, encourage setting new actions and learn from one another.

Each of the six sessions has a focus.

  1. What do we know about pain? Sharing information each person has been given, and what sense they make of it. Generally working towards a common understanding of some of the mechanisms, some of the treatments people have tried, and getting perspective on how variable individual responses are to treatment. There is no single magic wand cure.
  2. How can we organise activity levels? AKA the “pacing” or activity management session. We share the various trajectories people have been on – the deactivation process, the boom and bust process, the push through until you gasp approach, the gradual increase approach, and the consistency or quota approach. Rather than telling people which is “the best” we look at the good and the not-so-good about each, using participant’s own examples. That way we can help people weigh up their options for the various contexts in which they live.
  3. Dealing with sticky thoughts and feelings. This is the “ACT” session – discussing cognitive defusion strategies, noticing, willingness, perspective taking, and finding wiggle room. Each session begins with a mindfulness “arrival” moment, so participants are familiar by this time with noticing that the mind likes to dictate. Participants begin to use “Choice point” as a creative way to notice what their mind is telling them, and choose an action to align with what matters to them in that context.
  4. Sleep is always a hot topic! In this session we discuss all manner of sleep strategies, and how/why sleep is such a problem and so important for people with pain. Our solutions are diverse – everyone has something to contribute – and again, we look at the good and not-so-good of each option.
  5. Who’s on your team? In this session, participants explore the many people they’ve interacted with because of their pain, all the people they’ve told their story to. We examine the various contributions these people make, and begin to look at how better to communicate in an authentic, respectful and “straight-up” way. Some participants bring family to this session as we build a list of who is on the team, and help the person with pain be the captain.
  6. Flare-ups, set-backs and pre-planning. The final session is about when things go wrong. Identifying things that disrupt newly-developed skills and habits, whether these are pain flare-ups, pain settling (yet, it’s a thing that can trip people up!), holiday routines, returning to work, new assessments – all the things that life holds! Participants work on drawing up their own pain management plan (written down so it can be pinned on the fridge!), and on a set-back plan or “can cope” card.

The real grunt work of this programme lies in the home-based missions each participant does. It’s in doing new things, taking small steps in a different direction, stopping to notice before acting, defusing and giving a moment of space before choosing what to do – these actions are reviewed at the beginning of every session and really form the core of what Springboard offers.

Over the next six weeks I’m putting the facilitator training for Springboard online. This will make the training available for more people, both in New Zealand and elsewhere. Keep watching out because I’ll make an early bird announcement very soon!

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.