Rehab fails: What goes wrong in pain rehabilitation (1)

Well obviously I’m not going to cover everything that goes wrong – and certainly not in one post! But inspired by some conversations I’ve had recently, I thought I’d discuss some of the common #fails we do in rehabilitation. Things that might explain why people with pain are thought to be “unmotivated” or “noncompliant” – because if the rehab doesn’t ‘work’ of course it’s the person with pain who’s at fault, right? So for today, here goes.

Starting at the wrong intensity

One of the main things that happens when someone’s in pain is to reduce overall activity level. Pain has been called “activity intolerance” and it’s common for people to stop doing. So naturally when a clinician is developing an activity or exercise programme, the aim is often to simply increase how much movement a person does in a day. So far, so good. Muscles and cardiovascular systems improve when we use them.

But guess what? There’s a person inside that body! And people have minds. Minds with opinions about everything and in particular, anything to do with doing. There’s often a “should” about how much movement or activity to do. This rule might be based on “pain is a sign of tissue damage” so anything that increases pain clearly “should not be done”. There may equally be a “should” about how much exercise this person used to do, or wants to do, and often mental comments about “what kind of a person does this amount of exercise.”

I’ve heard good clinicians say that their patients “have unrealistic goals” – this is probably because the person’s mind has an opinion about what he or she “should” be able to do!

What can good therapists do about this? Well, firstly to ignore the person who inhabits the body is plain wrong. Secondly, flashy gadgets like coloured tapes or special elastics or foam thingies probably won’t do much for the person’s opinionated mind except to temporarily distract — oooh! shiny!!

Something I might do would be to ask the person what level they think they can begin at – beginning where the person is at, and moving at his or her pace is a solid foundation for developing a relationship where experimenting with movement becomes about the person and his or her relationship with their body. I think one of the aims of movement rehabilitation is to help the person develop trust in their own body and how it moves, so enhancing playfulness and experimentation can be a good start.

I might ask the person “what shows up when we begin doing this set of movements/exercises”? By “showing up” I’m talking about thoughts, images, sensations in the body that pop into a person’s mind (minds are soooo opinionated!). We might need to guide the person to notice quick thoughts or images, to put words to emotions and feelings, and to get in touch with fleeting sensations in the body.

Some of the things I’ve heard people say include: “only weak losers would call this exercise”, “I used to be able to lift 40kg sacks of cement and now all I can move is this pathetic 5kg dumbbell”, “he wants me to do what?! I hate boring exercises”, “but what am I going to feel like tomorrow?”

What do we do with these thoughts?

First: make room for them to be present. Don’t quickly deny them “Oh of course you’re not weak”, “5kg isn’t pathetic”, “exercise is great fun”, “you’ll be fine, you can do this”. Saying these sorts of things dismisses the validity of the person’s fears and won’t win you any friends.

Second: empathic reflection. Indicate that you’ve heard what the person has said, validate that this is their experience, their thoughts. Something like “it’s a long way from what you used to lift, and that’s hard”, “it’s tough beginning to build up again”, “you’re worried that this is going to be unrewarding”, “you’ve had pain flare-ups before, and it’s hard to deal with”.

Third: Ask the person where they’d like to begin, put them in control of the intensity. Then ask them “how do you think that’s going to pan out” – in other words, will their option get them to where they want to be? What’s good about it? What’s not so good about it? from their perspective not yours! The idea is to establish how workable the person’s starting point might be. It might be perfectly fine, even if it’s not your choice!

Fourth: Affirm that the choice is the person’s – and that this is an experiment that will be reviewed at the next session. You might say something like “So you’d like to try doing 5 minutes of walking instead of the treadmill that I suggested, because you think this shouldn’t flare your pain up as much. What’s your choice now that we’ve talked about the good and not so good? We can review it next time.”

Fifth: Review how it went at the next session! Note down the rationale the person had for the level of intensity they chose, and then review how well that intensity worked from this perspective. For example “you wanted to do 5 minutes of walking because it wouldn’t flare you pain up as much, what did you notice? What showed up? How well did it work?” Notice all the open-ended questions, the reminder that the person thought this intensity wouldn’t flare their pain as much, and the focus on workability. Because at the beginning of a movement or exercise programme, what you’re looking for is adherence, sticking to the level of intensity chosen. Habits take time to make, and often adhering to a programme is because the opinionated mind is having a go at the person, interfering with their willingness to stick with it. If we avoid that roadblock, we have at least one point on the board.

Your opinionated mind might now be telling you that “oh they’ll never make progress at that pace”, “they’ll do themselves an injury if they lift that much”, “this is just pandering to their lack of motivation”

Be careful! At this point you could reflect on what’s showing up for you. Are you worried their outcomes will reflect badly on you? Do you only have a few sessions with the person and need them to get somewhere or you’ll have failed? Make room for those uncomfortable feelings. Let them be present and listen to what your opinionated mind is telling you. Maybe remind yourself that outcomes don’t depend on you – they depend on the person sticking to the programme, and a programme that doesn’t start because the person’s mind tells them it’s not worth it is a #rehabfail Remember also that you’re aiming for the person to gain confidence in their body, learn to listen to what happens when they try something out – the repeated progress reviews you do with the person are the actual active ingredients in therapy, they’re the bits that help the person to reflect on what works, and what doesn’t. That’s gold.

ps The technique I’ve described above is – gasp! – a psychological approach, based on ACT and motivational interviewing. You won’t find a specific study examining this approach in journals (at least not in a cursory search like I did!), but it’s an application of well-studied approaches into a movement or exercise context. It’s the same approach I use in contextually-relevant occupational therapy. Reading Bailey et al, 2020, affirms to me that we have a way to go to define and measure adherence, so I feel justified in using these strategies!

Bailey, D. L., Holden, M. A., Foster, N. E., Quicke, J. G., Haywood, K. L., & Bishop, A. (2020, Mar). Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review. Br J Sports Med, 54(6), 326-331. https://doi.org/10.1136/bjsports-2017-098742

Eynon, M., Foad, J., Downey, J., Bowmer, Y., & Mills, H. (2019). Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 29(5), 638-650. https://doi.org/10.1111/sms.13403

Levi, Y., Gottlieb, U., Shavit, R., & Springer, S. (2021). A matter of choice: Should students self-select exercise for their nonspecific chronic low back pain? A controlled study. Journal of American College Health, 1-7. https://doi.org/10.1080/07448481.2021.1960845

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.

Why are there not more occupational therapists in pain rehabilitation?

A question I’ve asked myself many times! As a small profession with a long history (as long as physiotherapy, TBH), it does seem odd that there are many, many pain rehabilitation services where never an occupational therapist has darkened the door.

Some of the reasons lie within the profession: in general, occupational therapists are busy being clinicians and have little time for research. In New Zealand, few occupational therapists pursue higher degrees, and many avoid statistical analyses, experimental design, randomised controlled studies. In fact, some occupational therapists have argued that the tailored approach used by therapists means randomised controlled trials are impossible – our interventions too complex, too individualised.

And it is difficult to describe occupational therapy in the kind of broad terms used to describe physiotherapy (movement), psychology (mind, emotions, behaviour), medicine or nursing. Occupational therapists often deal with the everyday. Things like organising a day or a week, getting a good night’s sleep, returning to work, managing household activities. Not sexy things with technical names!

So… what does a good occupational therapist offer in pain rehabilitation? These are only some of the things I’ve contributed over the years:

• graded exposure in daily life contexts like the shopping mall, supermarket, walking at the beach, fishing, catching a bus, driving
• self regulation using biofeedback, hypnosis, progressive muscle relaxation in daily life contexts like getting off to sleep, at work in between clients, while doing the grocery shopping, while driving
• effective communication with partners, children, employers, co-workers, health professionals in daily life contexts
• guided discovery of factors that increase and reduce pain in daily life contexts like the end of a working day, over the weekend, at the rugby, in the pub, on your own, in a crowd, at home
• information on proposed neurobiological mechanisms as they influence pain and doing/participating in daily life contexts, things like attention capture, distraction, memory, emotions, stress, excitement
• values clarification about what is important to a person’s sense of who they are in their daily life
• progressive meaningful movement in daily life contexts
• goal setting, planning, managing and progressing overall activity levels in daily life
• positive, pleasurable activities to boost mood, reduce anxiety and live a life more like the person wants

What characterises all that I offer? It’s context. One of the major challenges in all our pain rehabilitation is that people feel safe when in safe surroundings, with people who elicit feelings of safety. When things are predictable – like in a clinic setting – and when clinicians are present, people feel OK to do things they simply can’t do (or won’t do) elsewhere.

Life is complex. Contexts are highly variable, often chaotic, multiple demands on attention, priorities, values – and when a skill is developed in a controlled environment, like a clinic or office, it’s nothing like the real world. This, folks, is the unique contribution of a good occupational therapist.

Someone posted an image once, on the one side was physical therapy. On the other was psychology. And the question was posed: who bridges the gap between these two professions? I say definitively that this is the occupational therapy space. We are knowledge translators. We are the bridge between clinic and daily life. It is our domain, the entire specialty area of this profession. And it has been since the professions’ inception, way back in the early 1900s.

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There are occupational therapists who let us down. These are the therapists who focus exclusively on occupational participation without factoring in that we are also a rehabilitation profession. These occupational therapists provide equipment to people who are sore: the new bed, the shower stool and rails, the kitchen stool and trolley, the bed and chair raisers. Now there may be good reason for installing these gadgets – in the short term. They might keep someone safe in their environment so they can do what’s important. AT the same time they can, and do, reinforce the idea that this person cannot do, and certainly cannot change. While installing these things can mean a person is able to do – the person also learns to avoid doing these movements. This is such an important concept in pain rehabilitation – because progressively working towards being able to manage normal activities without aids is what we’re aiming for! An occupational therapist installing these things without reviewing and supporting the person to no longer need these things is just like a physiotherapist offering a person a back brace or splint and never reviewing whether it’s needed.

Why is it difficult to acknowledge occupational therapy’s contributions? Partly our rejection of a biomedical model based on diagnosing disease. Occupational therapists are about the person’s illness experience, our model is wholistic, biopsychosocial, integrative. It’s hard to articulate our contributions without using a lot of words! Or making it seem so dumbed down that people view the exterior actions (cleaning teeth, having a shower) without recognising the myriad contributing factors that influence whether this action is carried out successfully.

Occupational therapists have relied on qualitative research to examine the lived experience of people dealing with persistent pain. Rather than pointing to randomised controlled trials of broad concepts like “exercise”, we’ve tended to describe the individual and unique experiences of people as they regain their sense of self. Not something easily measured like range of movement or cardiovascular fitness, or even simple measures of disability and self efficacy. Peek behind these descriptions you’ll find synthesised strategies that integrate values, committed actions, sense of self, cognitive defusion, behavioural approaches – messy things that aren’t readily translated into simple cause and effect experiments. Multifactorial approaches that recognise that life is a contextual experience.

I contend that one of the major failings in pain rehabilitation is helping people reclaim their sense of self again. Self concept is ignored in favour of changing a person from a couch spud to a gym attender. Even psychologists can forget that when instilling new strategies, the person in front of them has to learn to integrate these new things into their world – and that means adjusting their sense of who they are. That’s the hidden work people living with persistent pain have to do, rarely supported. And yet it’s the thing people most want to resolve when they’re dealing with this experience. Who am I? Can I be me again? If I can’t be the old me, can I at least get something of what was important to me back again?

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What I’d like to see are more occupational therapists being confident about what our profession offers, being willing to step up and be the resource we know is needed. We don’t need to be defensive about this – but we do need to be sure about the validity and relevance of why our contribution is so important. I think the results from research showing how short-lived positive results of pain rehabilitation really are speak for themselves. Maybe the missing link is knowledge translation into daily life contexts?

Three letter acronyms and what they mean – CBT, DBT, CFT, ACT – not alphabet soup!

Once you begin to dip your toes into psychological therapies, it doesn’t take long before you begin to see TLAs all over the place. So today I’m going to post on two things: some of the TLAs, and why or how we might consider using these approaches in pain rehabilitation.

The first one is CBT, or cognitive behavioural therapy. CBT grew out of two movements: behaviour therapy (Skinner and the pigeons, rats and all that behaviour modification stuff), and cognitive therapy (Ellis and Beck and the “cognitive triad” – more on this later). When the two approaches to therapy are combined, we have cognitive behavioural therapy where thoughts and their effect on emotions and actions are the focus of therapy, with a secondary focus on behaviour and how behaviour can be influenced by (and influence) thoughts and emotions.

In pain rehabilitation, cognitive behavioural therapy is used primarily by psychologists, while a cognitive behavioural approach is what underpins most of the multidisciplinary/interprofessional pain management programmes. These programmes were very popular and effective during the 1980’s and 1990’s, but have faded over time as insurers in the USA in particular, decided they were expensive and should instead be replaced by what I call “serial monotherapy” – that is, treatments that were provided in a synthesised way within interprofessional programmes are often now delivered alongside or parallel to one another, and typically with very limited synthesis (or case formulation). A question yet to be answered is what effect this change has had on outcomes – my current understanding is that the outcomes are weakened, and that this approach has turned out to be more expensive over time because each discipline involved is seeking outcomes that fit with their priorities, and there is far more opportunity for duplication and gaps in what is provided.

Cognitive behavioural approaches underpin the “Explain Pain” or pain neurobiology education approach. The theory is that people who hold unhelpful beliefs about their pain can become fearful of what the pain means. Once they hold more helpful or realistic beliefs about their pain, that emotional zing is reduced, and it’s less scary to begin moving.

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Cognitive behavioural approaches also underpin cognitive functional therapy. In cognitive functional therapy, as a person begins to move, the therapist asks about what’s going through their mind, and establishes through both movement experiments and information, that they’re safe to move, and can do so without fear (O’Sullivan, Caneiro, O’Keeffe, Smith, Dankaerts, Fersum & O’Sullivan, 2018).

When carrying out graded exposure, in the way that Vlaeyen et al describe, a cognitive behavioural approach is integral. In this approach, the classic relationship between avoidance and a stimulus (bending forward, for example), is challenged in a series of behavioural experiments, beginning with movements the person fears the least, and progressing over time to those the person fears the most.

There’s good evidence from psychological therapies, and also from within pain rehabilitation research, that it’s the behavioural aspects of therapy that do the heavy lifting in pain rehabilitation (Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski, 2018).

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And, in the words of Wilbert Fordyce, psychologist who first started using a behavioural approach for persistent pain management “Information is to behaviour change as spaghetti is to a brick”.

So don’t expect disability (which involves changing behaviour) to shift too much without also including some strategies for helping someone DO something differently. And if a person doesn’t accept what you’re telling them – sometimes it’s more effective to try helping them do things differently first, and use that experiential process rather than talk, talk, talking.

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ACT (acceptance and commitment therapy), and DBT (dialectical behaviour therapy) are both what is known as “third wave” cognitive behavioural therapies. They both involve understanding the relationship between thoughts, emotions and behaviours, but add their own flavours to this. In the case of ACT, the flavour that’s added is “workability” and contextual behavioural analysis, with relational frame theory as the underpinning theoretical model. Instead of directly tackling the content of thoughts, ACT focuses on changing the relationship we have with thoughts, and shifts towards using values as directing the qualities of what we do (McCracken & Vowles, 2014). Dialectical behavioural therapy helps people build social relationships that support them, begin to recognise strengths and positive qualities about themselves, recognise unhelpful beliefs about themselves and shift towards more helpful beliefs, and to use coping strategies to help soothe and calm emotional responses. I draw on ACT as my primary framework for pain rehabilitation (actually for my own life too!), but I haven’t seen as much use of DBT in this area.

Compassion focused therapy, the other CFT, is also a psychotherapy designed to help people become compassionate towards themselves and others. The theory behind this are understanding three main “drives”: the threat and self-protection system, the drive and excitement system, and the contentment and social safeness system. When these are under-developed, or out of balance, unhelpful behaviours and unhappiness occur. CFT aims to help people bring the three systems into balance. Given that many of the people who experience persistent pain have also experienced early childhood trauma, and concurrently endure stigma and punitive responses from those around them because of their pain, CFT offers some strategies to help effect change on an unsettled and fearful system. CFT uses self appreciation, gratitude, savouring, as well as mindfulness (non-judgemental awareness), and compassion-focused imagery to help soothe the system (Penlington, 2019; Purdie & Morley, 2016).

Along with these TLAs, you can also find many others. I think for each approach, understanding the theory behind them is crucial. While some of these approaches appear very “psychological”, whenever we begin unpacking them, we can start to see how most of what we offer in physical or occupational therapeutic approaches require us to draw on them.

Skills like guided discovery, motivational interviewing, goal-setting, values clarification, graded activity, helping people experience difference in their own lives, soothe their own body, become more comfortable with a sense of self that has to grapple with pain – unless we’re knocking our patients unconscious, we’re going to be using these so-called “psychological” skills.

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If we are doing good therapy, I think we need to be as excellent as we can in all the skills required. This includes being excellent at the way we thoughtfully and mindfully use communication.

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Psychological therapies all incorporate communication, and responses to people who are fearful of something. Most of us are involved in helping people who are afraid of their pain – and as a result are not doing what matters to them. If we don’t help people do what’s important in their lives, what on earth ARE we doing? For this reason, we need to employ the most effective tools (ie psychological approaches) in just the same way we use goal-setting (psychological), respond with encouragement to someone attempting a new thing (psychological), start with something the person can only just do, then grade it up (psychological), help down-regulate an overly twitchy nervous system (psychological), teach new skills (uh, that’s quite right, psychological!). I could go on.

What don’t we do if we’re using psychological strategies? We don’t dig into deep trauma, substance abuse, criminal behaviour, self harm, psychopathology. Though, we do address some psychopathology if we recognise that depression and anxiety both respond quite nicely to scheduling positive activities, and meaningful movement (ie exercise). Perhaps our artificial divide between “physical” and “mental” needs to be altered?

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy, 98(5), 408-423.

Penlington, C. (2019). Exploring a compassion-focused intervention for persistent pain in a group setting. British journal of pain, 13(1), 59-66.

Purdie, F., & Morley, S. (2016). Compassion and chronic pain. Pain, 157(12), 2625-2627.

Schemer, Lea, Vlaeyen, Johan W., Doerr, Johanna M., Skoluda, Nadine, Nater, Urs M., Rief, Winfried, & Glombiewski, Julia A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Toye, F., & Barker, K. (2010). ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability and rehabilitation, 32(21), 1722-1732.

Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.

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: http://dx.doi.org/10.1016/j.socscimed.2013.11.055)

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: http://dx.doi.org/10.1126/science.847460

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:

This 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: http://dx.doi.org/10.1007/s12160-009-9096-5

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: http://dx.doi.org/10.1016/j.cpr.2010.06.008

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: http://dx.doi.org/10.1097/00002508-200409000-00007

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.

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