Cognitive behavioral therapy

Treat the pain… or treat the depression? Carpal Tunnel Syndrome management
Carpal tunnel syndrome is a very common pain disorder associated with compression of the median nerve at the carpal tunnel. Approximately 139 women and 67 males per 100,000 people will report this problem over the course of one year, although this depends on the definition used. The problem with CTS is not only that it is common, but also that it affects function – it is really difficult to carry out normal daily life with a numb or tingly hand, poor grip strength (particularly in the fingertips), and disruption to sleep from the ongoing deep achy sensation in the hand. Additionally, some studies show that people with CTS also experience widespread pressure pain hypersensitivity, and an increased response to heat, suggesting that the problem either triggers, or is part of a central sensitisation process.

Diagnosing CTS is conducted using two main approaches – firstly the clinical signs of pain, paraesthesia in the median nerve distribution, symptoms worse at night, and positive Tinel and Phalen signs; secondly, electrodiagnostic testing must show deficits of both sensory and motor median nerve conduction.

In this study, the authors were interested in establishing the relationship between clinical signs and symptoms, physical signs and symptoms (notably CROM and pinch grip force), as well as neurophysiological measures – and they also measured depression. I wish they’d included measures of pain anxiety, or catastrophising, but this was not included in this study.

224 women were included in the study, which carefully screened out individuals with potential confounding contributory causes such as whiplash, pregnancy or diabetes.  The initial and expected findings were that women with higher reports of pain also demonstrated poorer CROM, pinch grip, lower heat pain hypersensitivity, and overall poorer functional hand use.

The first interesting finding was that women in this study reporting only moderate levels of pain also reported poor functioning. The authors suggest that, as a result of this finding “it may not be necessary to report higher levels of pain to find a repercussion in functional activities.” In other words, the impact of CTS on functional use of the hand appears ahead of the pain intensity, although the two are associated.

The study also found that heat pain hyperalgesia over the carpal tunnel as also associated with the intensity of hand pain – they suggest this may be due to peripheral sensitisation which is present from very early on in the presentation.

Looking at depression and the relationship with CTS, interestingly, the women did not demonstrate very high levels of depression, which surprised me a little given they had been selected for inclusion on the basis of having CTS symptoms for 12 months or more. The analysis found that depression was associated with poorer hand function and greater pain, even though the women did not report very high levels of depression. These authors suggest that “perhaps proper management of depressive symptoms in CTS may reduce, not only chronicity, but also induce an improvement in hand pain-related disability.”

Somewhat more controversially for some physiotherapists, these authors also argue that because depressive symptoms resolve during (as a result of perhaps?) physiotherapy treatment in 40% of people with work-related musculoskeletal pain injuries, perhaps those treatments should target mood management as well. So much for “but it’s not in my scope of practice”!

In fact, the authors are very clear that “proper management of individuals with CTS should include therapeutic interventions targeting physical impairments, that is, manual therapies; psychological disturbances (cognitive behaviour), and mechanical hypersensitivity (that is, neuromodulatory pain approaches).” If ever there was a time to get upskilled in a whole person approach to rehabilitation, this paper supports doing so now.

Fernández-Muñoz, J., Palacios-Ceña, M., Cigarán-Méndez, M., Ortega-Santiago, R., de-la-Llave-Rincón, A., Salom-Moreno, J., & Fernández-de-las-Peñas, C. (2016). Pain is Associated to Clinical, Psychological, Physical, and Neurophysiological Variables in Women With Carpal Tunnel Syndrome The Clinical Journal of Pain, 32 (2), 122-129 DOI: 10.1097/AJP.0000000000000241


Who can do Cognitive Behavioural Therapy for Rehabilitation?

I have heard many discussions about scopes of practice: the main concern as far as I can see is of people who are trained to work mainly with the body perhaps stepping out of scope to work with thoughts, beliefs, and emotions. There are risks from stepping too far away from what you’re trained to do, I acknowledge this, though I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge.  And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance.

When I read about a post-surgical rehabilitation approach for people who had spine surgery, I was immediately interested and not because of the surgery! This study compared “cognitive-behavioural based physical therapy” with an education programme six weeks after laminectomy for a lumbar degenerative condition. People were included in the study if they reported high fear of movement using the Tampa Scale for Kinesiophobia. Assessments were completed before treatment, after treatment and at a 3 month follow-up, and included the Brief Pain Inventory, Oswestry Disability Index, SF-12, and three performance tests (5-chair stand, timed up and go, and 10 metre walk).

There was no discussion about the physical rehabilitation, but the CBT and education sessions were conducted by phone and participants also received a workbook to take home and follow. Sessions took 30 minutes, except the first session which was for one hour. The main components of the programme are reported as education on the mind-body connection, activity levels, graded activity plan (graded hierarchy) and weekly activity and walking goals. A cognitive or behavioural strategy was introduced in each session, with the therapist helping patients identify enjoyable activities, replace negative thinking with positive thoughts, find a balance between rest and activity, and manage setbacks by recognising high-risk situations and negative thoughts.

The education sessions included the usual contents delivered by a physiotherapist, and featured biomechanics, daily exercise, and ways to promote healing. Information on stress reduction, sleep hygiene, energy management, communicating with health providers and preventing future injury were also provided.

What did they find?

Firstly, only 68% of those eligible for the study agreed to take part, which in itself is interesting. A number of other factors influenced the total number of people entered into the programme – not being treated for a degenerative lumbar condition, not having high enough scores on the TSK were the main reasons. Dropout rates for both programmes were quite low – 7 – 5%, and both programmes had good follow-up outcomes (not too many people missed the follow-up).

Now here’s a thing: 91% of participants also received clinic-based physiotherapy during the treatment phase (roughly 8 visits), and right up until the three-month follow-up (about 6 – 7 visits). No real difference between the groups here.

What did differ was the long-term improvement in the cognitive behavioural group – in terms of back and leg pain, pain interference and disability. The education group still improved in their leg pain and disability, but back pain and pain interference stayed the same. Similarly, the CBT group continued to improve on measures of physical and mental health over time, while the education group’s physical scores improved but mental health scores stayed pretty much the same. The CBT group’s scores improved more than the education group on almost all the measures including the physical performance tests.

What does this mean?

Well, interestingly, the authors of this study suggest that they obtained large and clinically relevant changes because of the specific focus they had on decreasing barriers to functional activity and walking rather than focusing solely on resolving pain symptoms. I think this is very interesting indeed. Although this study used physiotherapists, the clinician was naive to using CBT and was trained specifically for this study. Participants received concurrent physiotherapy in a clinic – the CBT (and education sessions) were additional to what was delivered in the clinic setting. To me the results suggest that the occupational therapy focus on creating opportunities for people to do more within their own environment might be a potent tool in post-operative rehabilitation.

Once again, it also suggests that the professional discipline of the clinician delivering a CBT approach is far less important than the fact that the CBT approach is tailored to the concerns of the patient, and that the treatment targets factors within the real-world context.

Important points to note: these patients were selected on the basis of high levels of pain-related fear and avoidance. I don’t think the outcomes would be nearly as fabulous in a general or undifferentiated group. This approach, while relatively inexpensive to implement, is an added cost – though if we look at the effect on patient outcomes, I would argue that the financial cost is far outweighed by the positive human results.

Finally, I think this study also shows that addressing thoughts, beliefs and emotions is a part of what every health professional should be doing: it’s unethical not to learn to do this well.

Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips S, George SZ, McGirt ML, Spengler DM, Aaronson OS, Cheng JS, Wegener ST, Cognitive-behavioral based physical therapy
for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.09.013.

What does using a biopsychosocial framework mean in practice?

A good friend of mine told me that during her training (as a physiotherapist), psychosocial factors were “what you blame when your treatment doesn’t work”. It’s something I’ve heard more than once. I’ve also been asked many times “…but are you sure you’re not doing something outside your scope of practice?” when I talk about using cognitive behavioural principles and ACT (Acceptance and Commitment Therapy) and other psychological strategies. And some of you might have seen earlier posts of mine where I ask “How social is your biopsychosocial model?”

Today’s medical students are trained in using a biopsychosocial framework in their undergraduate years. They leave medical school, begin their hospital and advanced training, and I guess I wouldn’t be alone in asking “what happened to the psychosocial?” when we see them working.

So today’s post is a bit of a reflection and a musing on what I think using a BPS approach might mean in pain practice.

BPS is, I think, less of a “model” than a way of thinking. Thinking that is based on a systems approach – every factor affects and is affected by every other factor. In fact, Engel, the originator of this way of viewing human health, was strongly influenced by general systems theory which was developed by Ludwig von Bertalanffy, a biologist who lived between 1901 – 1972. General systems theory was a model describing processes thought to be common in many different fields of knowledge. General systems theory is based on these five beliefs:

(1)  There is a general tendency towards integration in the various sciences, natural and social.

(2)  Such integration seems to be centred in a general theory of systems.

(3)  Such theory may be an important means of aiming at exact theory in the nonphysical fields of science.

(4)  Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.

(5)  This can lead to a much-needed integration in scientific education.

Engel then applied this to a model of the influences on human health. At the time he wrote his seminal article (Engel, 1977), psychiatrists were being challenged by reductionism on the one hand, particularly around approaches to mental health – the distinction between “diseases” where biological causal factors are influential, such as neurological disorders, and “problems of living” such as alcoholism, where the relevance of biology was, at the time, hotly debated; and concern that psychiatrists might lose ground to nonmedical practitioners such as psychologists. It’s an argument that continues today: should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management? (For a very interesting discussion of socio-political debates about this, read Wilson, N., Pope, C., Roberts, L., & Crouch, R. (2014). Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain. Social Science & Medicine, 102(0), 138-145. doi:

Back to the story. The broad BPS “model” can’t be tested, and to some, was never intended to be a “scientific” model but rather a discussion tool. A way of shaping a dialogue between the person seeking help, and the clinician wanting to understand what was influencing how and why this person was presenting in this way at this time. I like to think of it as a way to remember that the person seeing you is a person-in-context.

We can argue the toss about exactly which factors belong in which “bit” of a biopsychosocial approach, but broadly speaking, we want to understand biological influences on health. Some of these are genetic (a bit hard to investigate for most of us), some of these are environmental (rickets? Vit D deficiency?), some are other organisms (M. leprae and M. lepromatosis? – Leprosy to you and me). Some are associated with what people do – tripping, jumping off things; while some are associated with what people don’t do – manage diabetes, exercise. The bio part is far more readily assessed and addressed than the other messy bits and pieces, so I won’t deal with that any further.

The psychosocial, on the other hand, is messy. It’s muddled and hard to measure and changes over time and geography and culture.

To me, it means remembering that when two people get together, it’s not just about the words we use, it’s about what we both bring to the setting in terms of experience, habits, expectations, vulnerabilities. It’s about where we meet. It’s about the purpose of meeting. It’s about recognising that everything we say and do is imbued with meaning – but it’s also about not necessarily knowing what we know, or what we don’t know.

So if I’m practicing in a biopsychosocial framework, I’m going to have to know a great deal about myself and my assumptions, my attitudes, habits, how others see me, and even what I don’t know. And the same applies to my knowledge about the person I’m seeing – only because I’m usually the “treatment provider”, I need to shape my conversation so that it’s OK for that person to tell me about this stuff, and this means knowing a bit about how people tick. I especially need to know how to hear what the person coming to me is saying – and not saying.

I see much that is called “psychological” as being about how we communicate and what we know about helping people change behaviour. I’m not “doing psychology” when I teach my child how to tie shoelaces, yet I’m using psychological techniques – modeling, reinforcement, verbal instructions and so on. Likewise when I’m helping someone feel OK about driving their car when they have back pain, I’m using psychological techniques such as verbal instruction, grading the difficulty, encouraging, supporting and so on. To suggest we can’t use psychological techniques to enable normal function is unthinkable.

Using CBT or ACT or motivation interviewing simply means refining my interpersonal skills so that I can optimise the chances that the person feels heard, can understand what I’m on about, and begins to feel OK about taking steps towards the life they want and being themselves. It’s about learning ways of explaining things, learning how to show that I’m listening, learning about the right level of support and challenge that will enhance the chances of success. Most people who live with chronic pain probably don’t need to see a psychologist – they need someone to help them make sense of pain, to show they’re there as they find their way through, and celebrate when they’re doing what’s important in their lives. I think all health professionals should be doing this.

Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. doi:

Developing a shared plan

Last week I introduced you to one way I use to develop a shared understanding of the many factors influencing how and why a person seeks help for their pain.  The person and I work together to understand his or her perspective. I use a range of open-ended questions and reflective listening to guide our discovery of how his/her pain affects life and emotions.

Some points to note:

  • I don’t try to give explanations at this point – explanations will influence what the person says to me, and may inadvertently shape or change what he or she says without necessarily changing his or her beliefs.
  • I’m not trying to make any diagnoses either. A diagnosis is just a short-hand way of lumping a bunch of symptoms together. Great for research, and great for when we have a clear treatment, but a diagnosis tells us nothing about how the problem is affecting this person at this time. And in pain we’re always looking at the person and his or her experience, because even if we successfully get rid of the pain, the person will have learned something through the experience and this will influence the person in the future.
  • I’m informed by what we know about pain from research, so I’m constantly probing and looking for the relationships between factors we know will affect the person. Note that I’m not looking for tissue-level influences, but rather I’m investigating at a “person” level. This means I’m looking at psychological and sociological processes. I’m not ignoring those tissue-level factors, but I’m placing those off to one side for the moment. There are a couple of reasons for this: the first is that I’m probably not going to directly influence tissue-level factors. I don’t lay hands on people. I don’t give drugs. The second is that the person isn’t likely to be aware of those factors. They know much of their own experience (not all – but we’ll come to that), and experience and perception are the most potent drivers of what a person believes and therefore does.
  • I try wherever possible to flesh out my interview with additional information. This might be from questionnaires, or observing, or clinical notes from other people. And yes, I incorporate this information with the full knowledge of the person – in fact, they’re part of the process of integrating this information.

What do I end up with?

A spaghetti junction! A diagram that looks a lot like this:

formulationThis diagram is a pretty simple one, when you think of all the factors that could be involved – and in this case, I’ve made it much clearer than my usual scribble!

At this point I have a series of hypotheses to explain why Gerald is in this state. Together with Gerald, we’ve established that there could be some fear of pain, and in particular, fear that Gerald won’t be able to cope if his pain goes up and doesn’t settle. Gerald has also identified that he can feel helpless at these times, because he doesn’t know what else to do to manage his pain. He believes he’s getting unfit, and that’s adding to his feelings of frustration. He doesn’t want to go out with his mates because he’s irritable. He tries not to let his wife know how he’s feeling to protect her, but this adds to him feeling isolated. He doesn’t want to go back to work, not because he’s not motivated, but because he’s afraid he’ll let them down and this will add to his guilt. He doesn’t think his case manager understands this.

I could ask Gerald to list his main concerns and use these as a guide for my treatment outcomes, but I’ve recently started using a different approach. I’ll ask Gerald what he would be doing differently if his pain wasn’t such a problem to him.

Bronnie: Let’s imagine for a minute, what would you be doing differently if your pain wasn’t such a problem?

Gerald: Well, I’d be back at work, for one thing.

Bronnie: OK, and would you think you’d be back at work full time, or ease your way back in?

Gerald: Well, I think it would be sensible to ease myself back in because it’s been a while and I’m out of shape. Better to know I can do it than have a go and fail.

Bronnie: Great idea. What else would you be doing differently if your pain wasn’t such a problem?

Gerald: I’d take my wife out for dinner, it’s been hard on her while I’m so laid up and grumpy.

Bronnie: What’s your main concern about going out to dinner with your wife right now?

Gerald: I can’t sit long enough to enjoy a meal out. It all seems so hard, to get into a car, and drive to a restaurant, and sit there for three courses. I’m just too sore to do it.

Bronnie: So going to a restaurant and sitting to get there and while you’re there is going to increase your pain?

Gerald: Yeah. Is it worth it? What if it doesn’t settle? I can’t sleep and then the next day I’m shattered. I don’t think it’s worth it.

Bronnie: OK. Is there anything else you’d be doing if your pain wasn’t such a problem for you?

Gerald: I’d be going out and seeing my mates, going fishing and 4 wheel driving. I miss that. There’s no way I could do that right now.

Bronnie: What’s your main concern about going fishing, and seeing your mates at the moment?

Gerald: I’d be ready to go home before they’d even started. They’d get fed up with me slowing them down. And casting is really hard on my neck.

Bronnie: So to sum up then, it seems like there are some things you’d love to be doing, but reasons you think it would be better not to be doing them right now. If we go through them, you’d love to go back to work, but you’d like to do it gradually so you can get in shape again, and so you know you’ll succeed. You’d love to take your wife out for dinner, but the whole dinner thing feels too hard, and you’re worried that your pain will get out of hand and you won’t be able to sleep. And you’d really love to get back out with your mates again, and go fishing, but right now you think your mates would get fed up with you because you’d want to leave too early, and you wouldn’t be able to cast without setting your pain off. Does that sound about right?

Gerald: Yeah.

Bronnie: I think there are some things we could begin to work on so you feel more confident you can handle it when your pain levels go up and down. And I think we could work on some physical things that could help you feel a bit fitter, more able to do things for longer. And finally, I think it would be great if we could help you and your wife connect a bit more, perhaps not yet at a sit-down restaurant, but perhaps there are other ways this could happen. What are your thoughts? Is there anything you’d especially like to look at?

What I’ve tried to do here is identify the underlying reasons Gerald isn’t doing things. While pain appears to be the problem, it’s not the pain it self but the fear of possible effects of pain that haven’t even happened yet that are really stopping him from doing things. And this is adding to the misery of having neck pain.

By giving Gerald the chance to tell me his dreams, we’re going beyond “I need to get rid of my pain” and into the reasons for living in the first place. People don’t just live to get rid of pain, they live to have lives full of meaning, let’s not ever forget that.

Routines, habits, boredom & variety: Life skills for living with chronic pain?

I’ve just had a wonderful week on holiday. I escaped the internet, social media, telephones, power, flushing toilets, running water… and it was awesome! There’s something good about taking a break from my usual world to do things completely differently. Now that I’m back I’m reflecting on routines and habits, and how they form an important part of my life.

Routines are sets of behaviours (occupations if you know occupational science) that regularly occur in a certain sequence. Habits are behaviours or occupations we do without needing to directly think about them – maybe because we’ve done them so often they’ve become semi-automatic. Both routines and habits are useful because they reduce the demand on our attention and therefore draw less on our cognitive resources.

This can be a good thing – who would want to have to think about every single thing we have to do to get up and off to work each day?

One of the things people working in chronic pain management often discuss with those they see is how to manage activity levels so that important things can get done without leaving the person feeling exhausted, flaring up their pain, or omitting to do things they value. Activity pacing is one of the main strategies discussed, and although the evidence base for this strategy is skinny, it’s a very common approach. BUT, and it’s a big BUT, it requires people to plan and organise both what they want to do, and how and when they do them.

Many people would think this is pretty self-explanatory. Who doesn’t sort out a To Do list and prioritise what needs doing in a day or week?

Ermmm – actually, there are plenty of people who don’t do this regularly. That’s why one of the most common tools in business is time management! Remember the Day Runner Diary? The Four Quadrants (Steven Covey) Approach? The ABC of prioritising? All tools used to organise what does and doesn’t need to be done.

While these tools are readily used in business, it’s rather less often that we think about helping people organise their lives outside of the workplace. I guess this is because most of us think this just happens naturally – intuitively, if you will. Intuition, though, can be defined as “over-learned habits” that we have learned so well we’ve forgotten we ever needed to learn them in the beginning.

The field of habits and routines is part of self-regulation. Self-regulation includes these components, but also incorporates the ways we raise our energy, calm ourselves down, maintain time awareness, set our sleep/wake cycle, and manage emotions.  Self-regulation theory has been proposed as a model for helping people with some forms of chronic pain cope more effectively with their pain and fatigue (Sauer, Burris,  & Carlson, 2010). There’s some neurobiological evidence to show that some forms of chronic pain, notably fibromyalgia, have greater connectivity and baseline activity between regions of the brain involved in self-regulation including the really important parts involved in executive functioning. This means things like switching attention from one thing to another, or responding to threat appropriately (then settling down afterwards) are more difficult.

And some people are born with, or perhaps develop, less effective self-regulatory neural processes – these are perhaps the people who seem to forget deadlines, arrive late, don’t take medications at the right time, perhaps don’t have regular meals, maybe run out of ingredients (or clean clothes!), and generally find it more difficult to get their life together.

Self-regulation treatments are often concerned with ways to down-regulate breathing, heart rate, and to manage attention. Habits and routines, on the other hand, are larger chunks of behaviour that might not be addressed. Maybe this is why some people forget to do their CBT thought records and don’t do the exercises they’re meant to do. As clinicians, we can think these “forgettories” are a sign of noncompliance, lack of motivation, or not really understanding the importance of the things we ask them to do. I suggest that maybe, for some people, it’s more about failing to have some of the foundational skills needed to get organised into a routine so that there’s enough brain space for people to add new tasks into their day.

What to do about this?

I think we can draw from three main sources of literature here. The first is self-regulation theory where people like Nes, Roach, & Segerstrom (2009), Sauer, Burris & Carlson (2010) are looking at some really useful models. By helping people develop mindfulness, relaxation skills, and awareness of internal physiological states, greater ability to self-regulate is developed. But this only addresses the internal states – what about the bigger chunks?

The next source of literature is probably that from mTBI, or post-concussion rehabilitation. One of the features of post-concussion syndrome is difficulty switching attention, becoming fatigued, recognising when and how to stop or slow down. There are plenty of fun games (yes, even Lumosity!) that can be used to help people develop greater cognitive flexibility, memory, and to improve concentration, attention and so on.

But this still doesn’t address the bigger chunks of activity we need to do. So here’s where I think occupational science and occupational therapy might be really useful: all the tools of time management, cognitive props like using a cellphone alarm to remind you to take medications, daily planners, post-it notes, identifying values and using these to prioritise tasks, having a diary, writing lists – all of these can help, provided they’re tailored to the individual’s needs and lifestyle.

So, before you think that habits and routine are boring, and that planning removes variety – or that the person you’re working with who just doesn’t do those exercises is really Just. Not. That. Motivated. Maybe it’s to do with not being all that great at habits and routines or self-regulation, and maybe you can help them get better at these foundation skills.


Clark, F. (2000). The concepts of habit and routine: a preliminary theoretical synthesis. Occupational Therapy Journal of Research, 20(Sup 1), 123S-137S.

Nes, Lise Solberg, Roach, Abbey R., & Segerstrom, Suzanne C. (2009). Executive functions, self-regulation, and chronic pain: A review. Annals of Behavioral Medicine, 37(2), 173-183. doi:

Sauer, Shannon E., Burris, Jessica L., & Carlson, Charles R. (2010). New directions in the management of chronic pain: Self-regulation theory as a model for integrative clinical psychology practice. Clinical Psychology Review, 30(6), 805-814. doi:

Whiteford, G. (2007). Artistry of the everyday: connection, continuity and the context. Journal of Occupational Science, 14(2), 77-81.

Wiese, Dunn W. (2000). Habit: What’s the brain got to do with it? Occupational Therapy Journal of Research, 20(Sup 1), 6S-20S.

How does chronic pain management work? A hypothesis to ponder

There have been increasing calls for clinicians and researchers to move away from using grouped results from randomised controlled studies because these fail to distinguish between those people who do really well and those who do not. Eminent researchers like Amanda Williams, Chris Eccleston and Steven Morley have said it’s time to move away from “black box” RCTs in chronic pain, and begin to use more sophisticated methodologies to examine not only outcomes but processes during therapy (Williams, Eccleston & Morley, 2012).  While early studies comparing CBT-approaches to chronic pain vs waiting list controls demonstrated moderate to large effects, over time the results have shown smaller effects as these approaches are compared with other active treatments.

The magic ingredients in an effective CBT-approach to self managing chronic pain are not all that clear. There are some people suggesting that it’s all about providing good neurophysiology information about pain mechanisms to people with chronic pain (Moseley, Nicholas & Hodges, 2004; Louw, Diener, Butler & Puentedura, 2013) and this does seem to be part of the picture – but is it enough? Education doesn’t have the greatest of effects on behaviour in any other area of health (think of diets, smoking, exercise, immunisation), and while there’s no doubt we need to reduce the threat value of pain by helping people understand the old message “hurt does not equal harm” (a message I know has been around since the early days of Fordyce and Sternbach), this doesn’t always produce results.

There are other people who argue that it’s all about exercise and that exercise is not only good for people with chronic pain, but also as a “preventative” for those with acute pain who are at risk of develop chronic pain (for example in early whiplash) but this has recently been challenged by the findings from PROMISE, a study by Michaleff, Maher, Lin, Rebbeck, Jull, Latimer et al, (2014).  Nevertheless, exercise does seem to be a common ingredient in most self management programmes.

Pacing, as I indicated a couple of posts ago, has been included in many pain management programmes, but has not been examined in-depth – and even defining pacing has been pretty difficult.

Similarly for most of the approaches included in chronic pain self management: lots of “logical” reasons to include components, but when we take a closer look at them, there’s either very little information on the coping strategy itself, or the effect sizes are equivocal.

Nevertheless, for people with chronic pain who haven’t responded to any other form of treatment, these programmes are a life-line. Remember, that for many people it has taken 4 years to get referred to a pain management programme, and the chances of finding good medication options (or interventional procedures) that abolish pain are pretty slim.

“ Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients … do not always occur with concurrent improvement in function … These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain & to have a major effect on physical & emotional function in most patients with chronic pain.”Turk DC, Wilson HD, Cahana A: “Treatment of Chronic Non-Cancer Pain”, The Lancet 2011; 377: 2226–35 (25.6.11)

So, we have programmes that are offered to people who have reached the end of their treatment line, but we don’t really know much about what works and for whom. Yet there is an effect on people, small though it may be, and there’s some evidence that people who do what the programmes suggest do better than those who don’t (Nicholas, Asghari, Corbett, Smeets, Wood, Overton et al, 2012).

Two things occur to me:

  1. We need to use more sophisticated ways to study process and subgroup analysis of people in chronic pain self management programmes. I think this might include using single subject experimental design. This design was used in some of the early work by Vlaeyen and colleagues looking at response to graded exposure for pain-related fear and avoidance (Vlaeyen, de Jong, Geilen, Heuts and van Breukelen, (2001), and Asenlof, Denison & Lindberg (2005). It allows clinicians and patients to really monitor the effect of various parts of treatment, and can be a very sophisticated way for “real life” clinical work to be evaluated.  Another option is the kind of analysis conducted by Burns, Nielson, Jensen, Heapy et al (2014) where subgroups were evaluated over the course of a pain management programme to identify the programme elements that might be most effective. Their findings suggest that there are two mechanisms: one directly relevant to the components of the programme such as relaxation or exercise, and another that they call “general mechanisms”. It’s this latter one that interests me.
  2. The way in which a programme might work may not be associated with the components. Like Burns and colleagues, I’ve thought that perhaps there is something within group process, or therapeutic process that is the “active ingredient” for change. Let me quickly unpack this.

Some people do quickly adopt what a programme suggests is useful – or at least they complete recording sheets to suggest they have. Others might still use the strategies, but perhaps in a different way from that originally intended (think of pacing as a good example: lots of patients I’ve seen who have been through a chronic pain management programme think that it’s all about “stopping before your pain gets out of control”, and rather than maintaining a consistent level of activity over time, their function gradually reduces as they do less and less. Their interpretation of pacing is that it’s about using your pain as a guide.

And still others pick and choose elements of what is covered in a programme – and use the strategies flexibly within the context of their daily lives. So on one day they may boom and bust, while on other days they chunk their activities into smaller bits. One day they’ll arrange their environment to suit them, another day they’ll ask other people to give them a hand. Their coping skill use depends on their goals and priorities at the time.

What DOES change is their self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.


Asenlof, P., Denison, E., & Lindberg, P. (2005 ). Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single-case studies of patients with recurrent and persistent musculoskeletal pain in primary health care. Physical Therapy, 85(10), 1061-1077.

Burns, J., Nielson, W., Jensen, M., Heapy, A., Czlapinski, R., & Kerns, R. (2014). Does Change Occur for the Reasons We Think It Does? A Test of Specific Therapeutic Operations During Cognitive-Behavioral Treatment of Chronic Pain The Clinical Journal of Pain DOI: 10.1097/ajp.0000000000000141

Louw, Adriaan, Diener, Ina, Butler, David S, & Puentedura, Emilio J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy theory and practice, 29(3), 175-194.

Moseley, G., Nicholas, Michael K., & Hodges, Paul W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi:

Michaleff, Zoe A., Maher, Chris G., Lin, Chung-Wei Christine, Rebbeck, Trudy, Jull, Gwendolen, Latimer, Jane, . . . Sterling, Michele. (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet, 384(9938), 133-141.

Nicholas, M., Asghari, A., Corbett, M., Smeets, R., Wood, B., Overton, S., . . . Beeston, L. (2012). Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16(1), 93-104.

Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research & Therapy., 39(2), 151-166.

Williams, Amanda C. de C., Eccleston, Christopher, & Morley, Stephen. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD007407.pub3

Coalface conversations

Knowing about something doesn’t hit the heart or mind nearly as well as doing it. As regular readers of my blog will know, I teach various aspects of pain management to postgraduate health professionals who come from a wide range of disciplines. Hopefully I can guide people towards thinking about the range of factors that can influence what goes on between delivering a treatment and the eventual outcome. It’s difficult, though, because much of what I need to do is based on giving access to information rather than opportunities to practice and then integrate this material.

I thought about this the other day when I met with a new patient. He comes to me with a history of seeing lots of health professionals, and learning lots of skills, but still essentially having the same struggle as he’s had throughout his lifetime. What can I possibly add to his ability to cope when he’s already had such a lot?

One of the conversations I often have with new patients is the relevance of psychosocial factors in their situation. It’s a conversation many health professionals fear – and then avoid. I’ve heard people say that they’re worried that their patient will think they’re saying “it’s all in your head”, or that their problem isn’t taken seriously. That comment is certainly something I’ve heard from patients as well.

So, when I met with this patient I decided to use what he had already learned to find out what he thought was going on, and to help us both discover more about what I could offer. This is essentially Socratic Questioning. Socratic questioning is styled after the teaching approach of Socrates and written about mainly by Plato.  It’s an approach where questions are asked after each answer, and through doing this, people discover the underlying beliefs or “truths” for themselves, rather than being told what to think. It’s a process of discovery – and when I use it with a patient or client, I use it so we can BOTH discover something.

It’s not easy to describe how to use Socratic questioning without coming up with a pat series of responses, but I’ll have a go. In reality, Socratic questioning is a subtle series of responses that can summarise, clarify and then probe behind the superficial to access deeper insights for both parties. If the clinician “knows” what the answers are, and uses this line of questioning to simply show the client something, it can end up being a process to show off how brilliant he or she is, subsequently missing the point of this approach.

Here’s an excerpt (as far as I can remember it):

B:       Tell me what’s been going on since we last caught up.

P:       Well, I’ve had a few flare-ups and I’m struggling a lot with the effort it takes to keep going even on a bad day.

B:       You look defeated when you say that. Do you feel defeated?

P:       Yes. I’m no good. I haven’t got what it takes.

B:      What do you mean “I haven’t got what it takes?”

P:       I haven’t got the strength, or the commitment to keep going. I’m just not good enough.

B:       Has something happened to lead you to this conclusion, or have you felt this way for a long time?

P:        It’s just got clear to me this last week.

B:        So this is a change in your thinking?

P:         Yes. I spent the weekend with my family and saw how happy they all are, and here am I doing nothing and sitting on the sidelines. If my kids were with my brother, they’d be so much better off.

B:        So…because you care about your kids, you decided you’ve let them down, you haven’t got what it takes.

P:        That’s it. If I didn’t have this pain, if I could fight it more, I wouldn’t let them down and they’d be happier.

B:        You said this was a change in your thinking. You’ve had your back pain for quite a while now, and you’ve been around your family lots of times. What did you think about yourself in the past?

P:        I think I was feeling better about myself because at least I was trying and my pain wasn’t in the way as much. Trying hard isn’t enough.

B:        I don’t think I quite follow. Why is trying not enough?

P:       Because no matter how hard I try, I can’t get around my back pain and my kids aren’t getting what they should from me.

B:       Is that what they say to you?

P:       No, but I can see my brother’s kids are so happy.

B:       And you’d like your kids to be happier.

P:       Yes.

B:        What things would you do differently if your pain wasn’t such a problem?

P:       I’d talk with them more, I’d encourage them, I’d play ball with them, I’d be there more for them.

B:       Are these things you could do even though your back pain is more than normal?

P:        Well… I couldn’t play ball with them.

B:       What about talking, encouraging them?

P:       Well, I suppose I could, but I’m scared I’ll just get angry with them.

B:       How would it feel just to try some new things anyway, even if you get irritable by the end?

P:       I suppose it would be a start, and they would at least see I tried. But I am still worried I’ll let them down.

B:      If you did let them down, would it negate having tried encouraging them at first?

P:      No, I guess it would give them a bit of the old me for a while.

There are roughly three steps in this exchange: (1) collecting information together; (2) examining this information together; (3)  inviting the patient to develop his own plans for doing something with that information. You’ll see that I didn’t attend to his pain, but instead focused on what he was afraid of – that his pain would make him grumpy, and that this would make his kids sad.  The conversation is all about discovering together, being curious and trying to learn about his experience from his perspective. By doing this together, we make long term changes because our clients learn how to discover what they’re thinking and doing, explore their thoughts and actions from a variety of perspectives, and generate their own answers.

Simply giving my patient/client the task to “do things differently” with his kids might have given him some homework, but it doesn’t help him learn about himself, nor about his main concern which is the effect of his back pain on his relationship with his children. This is definitely a psychosocial issue, but my patient didn’t reject what I had to say because we discovered it together and he gave me the information himself. It’s a very rewarding way to collaborate with someone.

Here’s a handout swiped from

A more in-depth web page of info on Socractic questioning and cognitive therapy is here

CBT and other therapy resources

Just a quick update here – this page is the most popular page on my site, so it must serve an important purpose!

If you’re looking for worksheets and ideas for CBT/ACT/DBT etc “homework” (how I loathe that word!) this page of my blog has heaps. I’ve checked the links, and they all work, so don’t be shy, go look at it.

For more information on ACT you might like to go to Russ Harris’ blog – lots of cool FREE information on it (ACT therapists are incredibly generous).

Another excellent source, contributed by a reader: CCI Health

Worrying about health

You may wonder why I’m writing about health anxiety: how does this fit with pain management? Read on – the connection is pretty clear.

Health anxiety (or hypochondriasis) is thought to be fairly common in the community, maybe 5% lifetime prevalence. It involves being extraordinarily worried about the meaning of body symptoms, over-interpreting the significance of ambiguous body sensations.  As you can probably imagine, people who experience health anxiety turn up in many different guises in the health system. It’s distressing to the person, not just because they’re afraid they have some dire disease, but also because the interactions between people with the problem, and healthcare providers, can be strained.  Health providers can think people with health anxiety are “just wanting attention”, that they need a firm hand and should be turned away so that people with “real” problems can then be seen.

Health providers generally like to give explanations to people seeking help, and try to demonstrate that “there’s nothing wrong”.  This means in the early stages at least, people with health anxiety get a lot of investigations and imaging to try to either establish there’s nothing wrong, or to find out what IS wrong. The problem is, in this group of people, giving reassurance by way of a clear MRI or blood test just doesn’t work. In fact, a bit like the spider phobic who covers the spider up with an upturned glass, clear imaging reduces anxiety for a very brief time and then the anxiety goes up. Spider phobics might cover the spider up with a glass, but they keep on coming back just to check it’s still there. And woe betide if it disappears – where oh where has it gone?!

If giving reassurance via imaging doesn’t work, what does? Well, explanations don’t always cut it either – logic doesn’t really play a part in anxiety of any kind. I mean, if you’re afraid of speaking in public, you KNOW the crowd is not going to kill you, but does your mind know that? In New Zealand spiders are not, by and large, poisonous, but my goodness, a big spider will make my heart go pit-a-pat!This response to reassurance or explanation means I’m just a little skeptical about thinking that “pain education” on its own is enough to get people doing things again.

The study that triggered this post is a really large CBT trial in the UK in which patients attending general hospital clinics were screened for health anxiety using a 14-item questionnaire (Health Anxiety Inventory).  28 991 patients were screened and 444 were identified as having  excessive health anxiety. This group were randomised into two groups – one to receive standard care, and the other to receive up to 10 CBT sessions.The outcomes were reduced scores on the HAI as well as some important health use indicators two years later.

The outcome this group obtained were significant reductions in health anxiety for the CBT group, little change in the standard care group. A slight reduction in healthcare use was found between the two groups.

A couple of important points:

  1. People with chronic pain are not mentioned in this article, but other research shows elevated health anxiety in those with chronic pain . Health anxiety increases treatment seeking, so that if a person has pain somewhere – maybe chronic noncardiac chest pain, chronic abdominal pain, and even chronic pelvic pain – a health anxious person is likely to look for help for it, while someone who is less anxious may just let it go and get on with life.
  2. The clinicians delivering CBT for health anxiety were not specialist clinical psychologists. Instead, they included nurses, graduate research workers, or “other health professionals trained for this intervention.” When cost effectiveness calculations were made, the costs were close to equivalent.  This suggests that allied health clinicians can contribute a great deal, at a reasonable cost, to reducing the distress and over-use of health care resources. I’m not just thinking of the dollar value saved by people not attending for unnecessary treatments, but also the human cost saved, and that by treating this group of people appropriately, other people can access those treatments otherwise absorbed by people with health anxiety.
  3. Interestingly, many people were identified as having health anxiety – 5769 scored more than 20 on the HAI. 3935 declined to participate. 1389 were excluded because they didn’t meet the DSM-IV hypochondriasis diagnosis. People don’t like being told they’re anxious about their health. Somehow the message they get is that their problem is not real. Or they think it’s being trivialised.

Go watch someone who is really stressing about their health, it’s no trivial matter. And the more reassurance we give in the form of investigations the longer they stress.  I wonder what would happen if we took the time to listen to what the person is scared about, the meaning they give to their experience, and how this relates to their life, would that investment improve the lives of people with health anxiety?

The link between general health anxiety and treatment seeking for chronic pain (and wanting a “real” diagnosis, “real” treatment, “something to take the pain away”) is pretty close. I wonder what would happen if we ALL got better at responding appropriately to health anxiety?

I wrote about health anxiety in 2010 – here’s a link to one of the posts, or you could use the search function on the blog.



Hadjistavropoulos, Heather D., Asmundson, Gordon J. G., LaChapelle, Diane L., & Quine, Allisson. (2002). The role of health anxiety among patients with chronic pain in determining response to therapy. Pain Research & Management, 7(3), 127-133.

Tang, N. K. Y., Salkovskis, P. M., Hodges, A., Soong, E., Hanna, M. H., & Hester, J. (2009). Chronic pain syndrome associated with health anxiety: a qualitative thematic comparison between pain patients with high and low health anxiety. British Journal of Clinical Psychology, 48(Part 1), 1-20. doi: 10.1348/014466508×336167

Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, Dupont S, Finnis S, Green J, McLaren E, Murphy D, Reid S, Smith G, Wang D, Warwick H, Petkova H, & Barrett B (2013). Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet, 383 (9913), 219-225 PMID: 24139977

Which comes first: Doing or knowing?

ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.