Cognitive Behavioural Therapy

Managing sleep problems – a medication-free approach (i)

I’ve recently completed two posts on assessing sleep problems in people experiencing persistent pain, and today I turn my attention to strategies for managing sleep problems – without medication. Why without medication? Because to date there are no medications for insomnia that don’t require a ‘weaning off’ period, during which time people often find their original sleep problems emerge once again… I’m not completely against medications for sleep or pain – but I think they need to be used with care and full disclosure about the effects, side-effects, and the need to eventually withdraw from them.

The approach I’m advocating is a modified form of cognitive behavioural therapy for insomnia (CBTi). CBTi is a form of treatment that is now considered to be first line therapy by both the British Association for Psychopharmacology (Wilson, Nutt, Alford, Argyropoulos, Baldwin, Bateson et al, 2010), and the American College of Physicians (Qaseem, Kansagara, Forciea, Cooke, Denberg et al, 2016). It includes sleep hygiene, cognitive therapy for the thoughts and beliefs associated with sleep, and sleep restriction for those who clinically need it. The modified version I advocate is based on Dr Guy Meadows ACT-based approach and I’ll cover that next week, but I’ll describe the classical CBT approach first.

Basic principles

The basic idea behind a CBT approach to insomnia is that although the initiating event may be out of our control, it’s unlikely to be maintaining the problem – and the factors maintaining the problem are typically the habits people have, and the thoughts and beliefs about their sleep problem.

Sleep is a behaviour that is infinitely malleable, as anyone who has travelled far enough on long-haul flights will know (and parents of small babies as well!). There are cues we use to decide when we should head to bed, and how long we should stay asleep. Bodies in turn respond to these cues and modify automatic processes such as digestion, urine production, and body temperature to ensure we stay asleep for as long as needed. When those cues change – for example, we’re in a new time zone when it’s light at the “wrong” time, and we’re hungry at the “wrong” time, we have trouble staying asleep until the body adjusts. Some people say we can manage a two-hour time zone shift every 24 hours, but in some sensitive people even a one-hour daylight savings change can upset the apple-cart!

If sleep is a habitual behaviour, then we can manipulate the cues to our benefit when sleep is elusive. We learn to associate things like the routine we follow prior to going to bed, light in the room, the “winding down” process we use, and even the timing of our snacks and drinks as a way to signal to the body/mind that we’re sleepy/tired.

There are three basic steps in CBTi: stimulus control (aka sleep hygiene), cognitive therapy, and sleep restriction – with the usual relapse prevention steps an essential part as well.

Sleep hygiene (stimulus control)

The basis of sleep hygiene is to control the stimuli associated with going to sleep so that we clearly indicate to the body/mind that it’s time to get to sleep. That means some basic “rules” around what we do in the time preceding getting into bed, and what we do when in bed trying to sleep.

The golden rule is that the bed is for sleep and sex – not for worrying in, not for watching TV or using the computer or phone or tablet, not for arguing in, not for talking on the phone. If you’re awake in bed for longer than 20 minutes, it’s time to get out of bed until you’re sleepy/tired (more on this in a moment), keeping the lights down low, doing something tedious or boring, then returning to bed to actually sleep.

Simple, commonsense things like keeping the room dark and warm, blocking out the worst of the noise, NOT using a TV or radio or any other noise-making device to go to sleep, ensuring caffeine intake is limited, having a regular bedtime and wake-up time, not taking naps through the day and timing when exercise and relaxation are undertaken are all part of sleep hygiene and most of us are aware of these steps. If they’re not familiar to you, this site is a good one – click.

Cognitive therapy

The cognitive therapy part is about managing the thoughts and attitudes that can exacerbate the sleep problem – things like having a busy mind, worrying about not being able to sleep, believing that it’s crucial to have a certain number of hours of sleep or the next day will be awful, getting that sinking dread as bedtime approaches, following any number of almost (and sometimes actual) obsessive rituals to achieve sleep – and so on…

As usual, with any conventional CBT, dealing with these thoughts involves firstly reality testing – Is it true that you must have a certain number of hours of sleep or the next day will inevitably be terrible? Must the room be absolutely silent or sleep will elude you? Then challenging or disputing those thoughts – “It’s possible I’ll feel tired tomorrow, but I can still function even if I’m not at my best”, “It might take me longer to fall asleep but I’ll get to sleep even though I can hear a clock ticking”.

These simple approaches are reasonably easy to implement – and they are effective. But if sleep is still a problem, and the person isn’t getting more than 4 hours sleep a night, it’s time to bring in the big guns.

Sleep restriction

There are two parts of altering sleep habits that are particularly challenging: getting out of bed after 20 minutes of being awake (especially in the wee hours of the morning!); and using sleep restriction. Neither are easy, yet both are effective.

The idea behind sleep restriction is to reduce the amount of time being in bed while not actually being asleep. Simple huh? So that period from when you first hop into bed and until you actually fall asleep is called sleep latency – and the longer your sleep latency, the less sleep you actually get. You become inefficient at sleeping, and worst, your body/mind learns that it’s OK to be in bed wide awake, and as I mentioned earlier, people begin to associate even going into the bedroom as a negative thing which revs up the autonomic nervous system making it even more difficult to fall asleep.

The nuts and bolts are to work out what time you actually fall asleep, and only go to bed at that time. So if you stay awake until 2.00 or 3.00am, you only go to bed at 2.00am. And you keep your morning wake-up time the same as normal. Yes, this means you end up being only able to sleep for the time between 2.00am and 7.00am! Ouch!

The idea is to extinguish the “habit” of being awake while in bed, reducing the association between being in bed and wide awake, while getting you absolutely tired and sleepy that you fall asleep into a deep sleep quickly. Once this falling asleep part happens regularly (usually for a week or so) then it’s possible to begin a very gradual process of bringing the bedtime back to a more reasonable hour – I usually suggest 15 minute increments, returning to the previous step if falling asleep begins to be difficult.

The process is reasonably difficult – not because it’s hard to stay awake (after all, the person has been practicing it for some time!) but because of the mind chatter. It’s truly tough when your mind starts having a go at you, suggesting you can’t sleep, or you’ll be so incredibly tired you won’t cope, or you’ll be cranky and that it’s dangerous and how on earth  will you go at work without any sleep? And this is where having access to a really good clinician can be helpful, although there are apps that provide a pretty good alternative if a human isn’t available.

For a detailed examination of the literature on sleep restriction therapy, Kyle, Aquino, Miller, Henry, Crawford, Espie & Spielman (2015) provide a really good systematic analysis of how sleep restriction is employed in research trials.  For a plain language version of CBTi, this is a good description – click

As I mentioned above, I’ll be going through a slightly different version of CBTi – an Acceptance and Commitment Therapy approach to insomnia that is also gaining popularity and an evidence base. Come right on back next week for that exciting episode!


Kyle, S. D., Aquino, M. R. J., Miller, C. B., Henry, A. L., Crawford, M. R., Espie, C. A., & Spielman, A. J. (2015). Towards standardisation and improved understanding of sleep restriction therapy for insomnia disorder: A systematic examination of cbt-i trial content. Sleep Medicine Reviews, 23, 83-88.

Manber, R., Simpson, N. S., & Bootzin, R. R. (2015). A step towards stepped care: Delivery of cbt-i with reduced clinician time. Sleep Medicine Reviews, 19, 3-5.

Qaseem, A., Kansagara, D., Forciea, M., Cooke, M., Denberg, T. D., & for the Clinical Guidelines Committee of the American College of, P. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine, 165(2), 125-133. doi:10.7326/M15-2175

Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., . . . Wade, A. (2010). British association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. Journal of Psychopharmacology, 24(11), 1577-1601. doi:10.1177/0269881110379307

Do pain management programmes really influence “doing” in daily life?

Disability and coping are two of the most important targets in persistent pain management, along with distress and pain intensity (the latter perhaps being the most difficult to influence). A question, however, is whether existing measures of disability truly capture the activities or occupations that people most value. For example, if house cleaning is just not my thing, even if my functioning improved over the course of a programme, would I choose to spend that new capability on vacuum-cleaning or out there in the garden?!

The Westhaven-Yale Multidimensional Pain Inventory (MPI)(Kerns, Turk & Rudy, 1985)  is a true workhorse of pain management measurement: It’s a measure that provides, via the subscales, an estimate of the complex inter-relationships involved in pain-related disability and distress. Three profiles of coping approach have been derived from the MPI indicating “Adaptive Coping” – the person is likely to continue to improve and engage in living well if they carry on as they are; “Interpersonally Distressed” – the person is experiencing difficulties with relationships and is feeling unsupported by others around them; and “Dysfunctional” – the person is struggling with their pain, and both disability and distress can feel overwhelming.

But the disability components of the MPI don’t really indicate the kinds of activities that people might be passionate about – or those that are relevant to their lives. The items are about general activities people “typically” do – in a North American setting. I know they’ve been validated in many different populations but they still represent a general idea of activity and function rather than the unique and idiosyncratic occupations that people do. (What's the difference? An occupation is the unique way I perform the important tasks of my day - the way I dash around the house while simultaneously cleaning my teeth, getting the dogs outside, making sure the curtains are opened and the appliances off just before I head out the door! We could call this "getting ready for work" but the way I do it, and the way you do it is probably very different!)

Why is that important? Well, because people value different occupations differently, and because values drive motivation, a broad measure of disability may not capture the true value of a pain management programme. And this is why the Canadian Occupational Performance Measure (COPM) (Law, Baptiste, McColl, Opzoomer, Polatajko & Pollock, 1990) is often used by occupational therapists to establish exactly what it is a person wants to be able to do. Goal Attainment Scaling is another option.

The study

In this study by Persson, Eklund, Lexell & Rivano-Fischer (2017), the aims were to assess longterm changes in MPI profiles over the course of a year; to look at associations between “Adaptive Coper” profiles at follow-up and improvements in occupational performance; and to look at factors at baseline that might be used to predict changes over time. Participants were, as usual, attending a tertiary pain management centre at a University hospital. They took part in a 21 day programme (oh the luxury of time!), and were seen by a team working together (oh the luxury of a co-located team!) including a psychologist, physician, physiotherapist, occupational therapist and social worker (oh for interprofessional teamwork!). The measures taken at pre and post were the MPI, COPM, and background demographic details.

Now here’s where the analysis gets pretty technical: dropout rates and pre-treatment differences amongst the MPI profiles were analysed using Matt-Whitney U, Kruskal-Wallis, chi-squared and independent t-test. Cross-tabs were used to describe the distribution of the MPI profiles. McNemar’s test was used to assess changes over time on each of the four profiles, and ultimately the participants were grouped into four profiles: never AC (Adaptive coper); losing AC; gaining AC, and stable AC, and these groupings were used to analyse associations between changes in MPI profile and changes on COPM from baseline to follow-up. And this, folks, is why occupational therapists NEED to learn statistical analyses! Because they went on to use univariate and multivariate logistic regressions to see whether demographic factors would predict these profiles at follow-up, incorporating satisfaction and performance scores on COPM.

What did they find?

More participants started the programme with a profile of dsyfunctional or interpersonally distressed than adaptive coper – and at both discharge and follow-up the adaptive coping group increased to be the largest subgroup. 20% of the participants ended up in the “gaining AC” group, 11% the “stable AC” group, 6% formed the “losing AC” group, and 63% were never in the adaptive coping group at all. Not so terrific in terms of broad outcome measures, but pretty consistent with other programmes around the world.

On the more individualised outcome measure of the COPM, people in the never AC group showed least clinically relevant improvement, both the stable AC and gaining AC groups showed more improvement on occupational performance and satisfaction with performance than the never AC group, while the stable AC group improved more than the losing AC group in terms of occupational performance changes.

Long-term changes showed those who started as AC were more likely to stay that way over time, and baseline scores for occupational performance were significantly associated with being AC at follow-up – in other words, people who felt OK about what they could do in terms of occupation, tended to become more capable and less disabled over time as measured by the MPI. More importantly, those people who had higher baseline scores on occupational satisfaction were 1.3 times more likely to shift to the AC group over time. “Clinically relevant improvements on performance and satisfaction with performance at 1-year follow-up, in occupations prioritized by the participants, were associated with having an AC profile at follow-up.” (p. 6).

Confidence in doing important occupations breeds confidence in other parts of living with persistent pain.

What does this all mean anyway?

Well, importantly, people who shifted from one of the other profiles to adaptive coping over a year showed clinically relevant improvements in occupational performance and satisfaction with performance – the authors suggest these findings show improvements on and satisfaction with “doing and performing” important occupations. Not being classified into adaptive coping at any time was associated with least improvement in occupational performance and satisfaction. There is an association between “doing/performing” and “coping/adapting” that hasn’t really been studied. Perhaps starting with things people enjoy instead of beating them over the head with things they’ve never been interested in could improve pain management outcomes. Pain management programmes DO influence doing in real life – if real life doing is used as therapy!

The authors also point out that “30–47% of participants who did not show an AC profile at follow-up still showed clinically relevant improvements on occupational performance and on
satisfaction with occupational performance.” (p. 8) This suggests that the MPI coping profiles only represent one part of the outcomes that are important to individuals: occupation being the individualised daily doings that people value very highly, and pointing to the need to explore individualised outcome measurement in more studies. Given that patient-centred pain management is based on individual goals, using only generic measures is likely to give misleading outcomes about treatment efficacy.


Kerns IVRD,TurkDC, Rudy TE. (1985) West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 23:345–56

Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. (1990). The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy. 57(2), pp82–7.

Persson, E., Eklund, M., Lexell, J., & Rivano-Fischer, M. (2017). Psychosocial coping profiles after pain rehabilitation: Associations with occupational performance and patient characteristics. Disability and Rehabilitation: An International, Multidisciplinary Journal, 39(3), 251-260.

Pain reduction doesn’t (always) reduce disability

The relationship between pain and disability is a particularly vexing one in primary care. It would be great if it was possible to get rid of pain and be assured that any lingering effects on function would be similarly abolished, but it just doesn’t seem to be quite that simple.

Many different approaches to managing this situation have been suggested. One is to argue that people should be referred for a quick pain reduction injection – for those who have pain that is thought to respond to this approach. Another is to just “reassure” and review often. And still another is to provide a cognitive behavioural approach usually reserved for those referred to a secondary or tertiary treatment centre.

For several reasons I find the first and second options above not particularly satisfying. 

For the avoidance of doubt, I want to make sure readers are aware that I am not agin pain reduction techniques. In fact, they’re a very good thing because, and this is the important point, they allow people to get back doing what is important to them. There are a few “provided that’s” to this because, as I’m going to show, people who have had a bout of pain don’t always “get back doing what is important to them”.

The second option of providing reassurance is also less than satisfactory because despite this approach being endorsed in numerous guidelines for managing acute musculoskeletal pain, very few specific recommendations as to how to provide reassurance have been given. Reassurance can be both unsatisfying to the person on the receiving end, and in some cases, increase the likelihood that the person remains fearful of moving and continues to look for more reassurance (Linton, McCracken & Vlaeyen, 2008).

Why doesn’t “taking the pain away” just return the person to the way they were?

Good question, glad you asked it!  While abolishing the pain does, in many cases, return the peripheral nervous system and tissues to normal, this situation doesn’t apply to the central nervous system – and most particularly, those parts of the brain concerned with appraisals and judgements, anxiety and emotion, and memory.  Let me explain.

When we are born, we arrive in the world with a functioning set of reflexes that respond quickly to input that startles the nervous system out of “comfort”. Loud noises, textures against the skin, new tastes – all of these provoke a startle response and we cry in protest. Thankfully most of these responses settle down as the nervous system habituates to those features of the environment that reoccur, but our responses are shaped by how adults around us respond to the same events, and how they respond to our behaviour.  This is the effect of social and cultural influences.  At the same time, we begin to develop preferences – some genetically shaped, others from what we observe and imagine about other people, and some from our own processing of the external and internal world.

It’s these factors that influence our responses to sensations that our brains ultimately determine are harmful or potentially harmful – and our brains let “us” know about this in the form of our experience of pain.
We develop tolerances to experiences as we’re exposed to them over time. Think of the sensation of biting into a


Some of you will be thinking “Ouch! No way I’d do that!”, while others of you will be thinking “Yeah baby! Bring it on!”
The way we appraise, or think about/judge a situation influences our emotional response to it.  This in turn influences what we are prepared to do about it.

Returning to the chilli pepper, even the next day after having had the HOT CHILLI PEPPER, you can remember the experience. (As an aside, this ability to remember what has happened – and then predict what might happen in the future – is what I drew on when I suggested that you think about it. ) You also made some decisions in your mind when I asked you to think of it, based on your appraisal of the sensation, and your emotional response to it.

When we experience pain, even if that pain goes after a while, we judge it and we have feelings about it, and we make decisions about what we will – or won’t – do if that situation arises again.

And this is why reducing pain but failing to also address thoughts and beliefs about what has happened and the possibility of it happening again does not always give the outcome we are hoping for.

The papers by Lamb and colleagues demonstrate that group CBT for low-back pain can be delivered in a cost-effective way in primary care, with good long-term effectiveness.   Isn’t it time this approach was seriously implemented?

Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-eff ectiveness analysis Lancet, 375 (9718), 916-923 : DOI:10.1016/S0140- 6736(09)62164-4

Lamb, S., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E., & Underwood, M. (2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) PAIN DOI: 10.1016/j.pain.2011.11.016

Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.

A brief review of cognitive behavioural approaches for pain management
Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems.  While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health.  In fact it has only been in the last few years that research into the process of change in pain management have been conducted.

What defines a cognitive behavioural approach?

  • The assumption that people can learn to accept their chronic pain
  • That people can broaden their self-concept beyond being “a patient” into being “a person with pain”
  • That people can learn or re-explore skills to deal more effectively with their pain (Morley, Biggs & Shapiro)
  • Managing or living well despite pain
  • Pain behaviour that limits living well becomes the target
  • CBT provides the skills to (ultimately) change behaviour
  • Provided by any/all members of the interdisciplinary team (common treatment model)

What are the goals of this approach? (NB in no particular order!)

  • To reduce pain intensity
  • Increase functional activity, including work
  • Reduce/rationalise use of health care
  • Reduce distress
  • Improve quality of life

One of the main aims of this approach is to ultimately help the person with pain become his or her own therapist – to effectively self manage pain.

How do we do this?

The exact combination of strategies and approaches that “do the trick” in this kind of approach is not yet known.  It could even be that the specific techniques that people learn may not, in themselves, be all that important.  Maybe it’s the emphasis throughout treatment that there is hope for a life even if pain is present that helps patients become people again.  Research simply doesn’t tell us this yet.

Certainly, in the years that I’ve been working in pain management, the core elements have changed little, with perhaps, the addition of graded exposure and the mirrorbox and laterality work for certain problems.

How do we begin with this approach?

  • Assessing what the person with pain considers to be the main problem (the problem/s that pain “causes”, rather than pain alone)
  • Asking why he or she is looking for help right now (what were the triggers? It could be the person, or someone else who has initiated the treatment-seeking)
  • Identifying the changes he or she wants to see (how will the person know treatment has been successful?)
  • Listing the behavioural difficulties the person is currently having

Some of the ways I do this are to ask the person “what would you be doing now if pain was less of a problem?”

There’s a reason I use that phrase “less of a problem”, because I pretty much don’t refer to pain intensity again.  Pain is likely to be present and to fluctuate throughout treatment and afterwards.  I want to model that it’s the fear of pain, rather than the pain itself that is most disabling.  Even when pain is intense, it’s more helpful to relax and go “with” the pain than be fearful and tense the body to resist it.

A first step is often to introduce a model of pain and how it affects the individual.  This is a personalised model of pain, individualised for this person – but based on what we currently know about pain from research.  Various explanations can be used, but I draw from what the person tells me about their experience of pain to generate their specific model.

Most times, it seems to help people to discuss a current neurobiological model of pain – and this is often where “Explain Pain” or similar descriptions can be really helpful.  Taken at a pace that people can manage, and using their own examples, helps people to quickly grasp information that many medical students only begin to learn in 3rd and 4th year of study.

How does this step help?

Cognitive behavioural theory suggests that people appraise or judge situations very quickly, on the basis of past learning, current arousal state, and future predictions.  Automatic thoughts then generate an emotional response.  This emotional response influences behaviour.  The relationships between these four factors can be bidirectional.

By giving people a more accurate and more realistic view of their pain – as something that can be understood (at least in part), and managed, and isn’t signalling harm – people can be far less distressed by it.  You can think of how your knowledge that a flu jab is a helpful way to prevent getting the flu and how this helps you cope with the sting of the needle, and compare it with how you would interpret and respond to being stuck with a dirty needle wielded by a hoodlum in a dark alley! The thoughts and beliefs we hold about sensations influence emotions and behaviour.

Eliciting an individual’s automatic thoughts about pain, and helping them recognise that the way they view their pain may be accurate-but-unhelpful, is one part of the cognitive behavioural approach to pain management that all members of the team need to reinforce.

The remainder of a cognitive behavioural approach to managing pain is focused on helping people engage with activities they value, and doing so in a way that (1) is manageable for now and (2) recognises the sensitive nervous system can be stirred up quickly by things other than physical activity.  Skills are developed to set goals, manage gradual increases, problem solve ways around obstacles, manage arousal levels, and work with thoughts and beliefs that become stirred up by doing things differently.

What about people who are really, really fearful of moving and avoid things? Take a look at that reference below – it’s a review of the approaches that have been used for people in this situation.  More on it very soon…

Bailey, K. M., Carleton, R., Vlaeyen, J. W., & Asmundson, G. J. (2010). Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review. Cognitive Behaviour Therapy, 39 (1) DOI: 10.1080/16506070902980711


I had a nice email from James Hardie from Moodjuice website, an NHS Scotland site developed for both health professionals and individuals to access self help resources.

For patients, the site starts by saying “Emotional problems are often the mind and body’s way of saying that something needs to be changed in our life” – I like that!  I like the way the patient area is based on practical problems like housing, childcare, hobbies and interests, meeting people, relationships and so on.

For professionals, the feature that really appeals to me is the “build your own resource” area.  This enables you to put together the most relevant handouts for the person you’re seeing – a lovely feature! Then you can print the whole lot off, and it’s a pulled-together document that looks a far cry from some of the tatty photocopied things I’ve seen in the past.

The resources in the professional area is designed to be used alongside individualised sessions, so it’s not a “plug and play” kind of site – but it does provide a great range of tools that you can use.

My one tiny criticism? The site doesn’t clearly indicate who developed it – well, it does, but it’s buried in the menu’s right away from the front page. I’d like to see that information on the front page, along with the dates the material has last been updated (just a wee point).

Anyway, here are the pages for the Chronic Pain page

and the Problem Solving Information page

and the Challenging Thoughts page


CBT approach in the real world

While there are many papers published about the outcomes from using a cognitive behavioural approach, there are very few describing the process ‘in the real world’. This leaves a gap for many clinicians who may read about it, maybe have training in delivering this type of intervention, or work in a team where it’s an integral part of practice – but who may not know how it ‘works’ except as it’s delivered in a pen-and-paper, sitting-in-a-clinic-room kind of way.

Today I’m describing one way I go about integrating a CBT approach into my work.    This case study is a compilation of several people I’ve worked with, in order to protect patient privacy.

Simone has neuropathic pain in her dominant hand. She’s a tough cookie who worked in a shearing gang. She’s tiny, has a command of the cussing vocabulary that has to be heard to be believed, and she’s very reluctant to use her hand although she has really good movement.

Simone’s always been a physical kind of person and loved riding motorbikes, rock climbing and gardening. She doesn’t think any of these things are manageable now, and so she spends most of the day ‘pottering’ in the garden or with friends or, as she puts it ‘death by DVD’.

Her goals are to get fit again, to decide on her ‘next best steps’ for returning to work, and to feel more confident about using her hand BUT she’s made it very clear that she’s not going to do ‘pretend’ activities like handcrafts or ‘just holding the bike throttle’ – she wants to start doing proper things again.

Oh my, where do we start!

We’ve started by reviewing what she knows about pain management – naming all the different types of strategy that can be used, and ranking them in order of priority for review. Simone said she needs to ‘get fit again’ and sees exercise as a big part of this; she also recognises that she can be quite inconsistent in her activity patterns, and although she knows about activity pacing, she doesn’t like doing it.

I asked her about her daily routine and she laughed saying that she just ‘does’ and hates planning, so instead I gave her 12 cards representing the amount of energy she has to ‘spend’ over the course of a day. I asked her to allocate her cards into three areas of living: self care, fun and work. She divided the cards quite evenly, so I then asked her whether this was how she wanted to spend her energy. She said no and that it was very different from her pre-accident pattern, so I asked her to show me what that looked like. She pushed almost all of the cards into the ‘work’ pile, and kept only one for self care and two for fun.

I asked her what was different about her self care now compared with before, and she described the process of showering – and while she talked, I was able to identify her automatic thoughts about each task. She said she always thought it should be enjoyable but now it just felt hard. She said she didn’t think she should have to ‘think’ about how she undressed, washed herself, dried herself, and got dressed again. Now she felt her body was skinny and ugly and her arms ‘wouldn’t work properly‘, and so she avoided looking at it, and didn’t use moisturizer and didn’t shave her legs any more.

She was very articulate about the automatic thoughts and images that she had while showering and we were also able to identify some of the emotions that were generated by these thoughts, and how this affected what she did.

I used a whiteboard to jot down the situation, her thoughts, linking to her feelings and on to her actions, and Simone was quick to say that these thoughts weren’t helping her.  NB all the underlined phrases above refer to automatic thoughts she was having.

We haven’t yet explored these thoughts nor tried to do anything with them (maybe we won’t do anything, just notice and do what is important?) – but part of understanding her situation is about listening to her thoughts as I’ve outlined above. This is Simone’s ‘lived experience’, but it’s absolutely possible for her to evaluate her situation differently and come to a different conclusion about them.

For a very quick example, I might ask her what does it mean to ‘have’ to think about each movement she does?  What does it say about her? What does it mean to have a rule that says showering ‘should’ be easy – when clearly, showering for her is not. If she says she feels ‘dumb’ or ‘useless’, I may explore other situations in her daily life now where she feels ‘dumb’ or ‘useless’ – and help her notice her emotional response to this.  What effect does having this emotion have on her actions? On what she does and how she goes about it?

Simone has described patterns of thoughts that are very judgmental about her capabilities.  While a psychologist may explore some of the origins of this, and the effect on her mood and especially her vulnerability to depression, what I’m inclined to explore is how her automatic thoughts and underlying ‘rules’ are affecting her willingness to engage in activities that she previously enjoyed – like having a shower – and both be aware of this vulnerability in terms of goal setting (she’s not keen on doing this!), and help her generate some more positive self statements she can make when trying a different approach. I’ll also ensure the goals are achievable but also ones she really values.  If they’re ‘too easy’, she’ll judge them as not worth the effort while if they’re too difficult and she can’t see why she should persevere (ie they’re not important to her), she may give up.

I’ve suggested already that she treat each new method as an experiment.  We don’t fail at experiments – we can learn from each attempt. When she tries a new approach, we’ll go through the things that worked well, and the things that she would do differently.  I’ll also use motivational approaches to encourage her to recall why she used to enjoy showering – she loved it because she felt energised, she could pamper herself (remember that Simone was working in a very masculine environment), and she was able to take some time out.  These are important things she can focus on as she develops strategies to return to this very important activity.

Shannon, E. (2002). Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA Australian Occupational Therapy Journal, 49 (1), 48-52 DOI: 10.1046/j.0045-0766.2002.00291.x

Strong, J. (1998). Incorporating cognitive-behavioral therapy with occupational therapy: a comparative study with patients with low back pain. Journal of Occupational Rehabilitation, 8(1), 61-71.

Occupational Therapy & the Cognitive Behavioural Approach For Pain Management – ii

ResearchBlogging.orgIn the first post on my commentary of Robinson, Kennedy and Harmon’s review of occupational therapy for chronic pain, I argued that they have misinterpreted the cognitive behavioural approach to pain management, and in particular, that they appear to hold an outmoded view of pain as either biological/organic or psychological, and refute the place of psychosocial models in occupational therapy practice.

Yesterday I distinguished between cognitive behavioural therapy and a cognitive behavioural approach – while the therapy is often primarily concerned with ‘talk’ therapy followed by behavioural changes to improve mood for example, a cognitive behavioural approach is a broader concept that is based upon the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.

In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Today I want to move into two points: how an interdisciplinary team works (with a specific focus on role blurring and duplication of input), and more on the way in which occupational therapists can use so-called ‘psychological’ approaches to help people engage more fully in their lives.  BTW I think maybe other disciplines can use some of this too.

Interdisciplinary and multidisciplinary are two words bandied about a lot when it comes to pain management.  Sometimes they’re used almost interchangeably – but when it comes down to it, there are important differences between the two.

In a multidisciplinary team, each team member retains an independent, usually discipline-specific, approach or model for working with the patient.  Although the team works concurrently with the person, and there may be common goals, multidisciplinary teams do not necessarily need to integrate their treatment, nor have a common over-arching treatment model or approach.  Some poorly coordinated multidisciplinary teams can actually provide serial ‘mono-therapy’ – just the same as seeing several separate clinicians one after the other.

Interdisciplinary teams work differently.  Firstly they hold a common model or understanding of the problem.  In pain management, this means the team accepts the tenets of a cognitive behavioural approach as I outlined in yesterday’s post.  Then the team works with the person/client/participant to develop a combined understanding of the person’s problems or situation, and collaborate to generate shared goals.  While a newly formed team may function somewhat like a multidisciplinary team in some respects, over time each clinician develops a shared understanding of each other’s contributions – and very often can function at a basic level within some of the domains of concern of each other’s discipline.  They continue to provide discipline-specific input, but always with a view to the overall model and the client’s goals.

For example, after 18 years, I have some knowledge of medications and their side effects, so it’s not surprising that I can talk with someone about when to take medications and what the side effects might be.  I might do this because I’m working with the person to help them get up and schedule their day, and help with a better sleep pattern.  It’s also no surprise that the physiotherapist and the clinical psychologist, nurse and social worker can be heard discussing activity management – even asking how the person is going to apply skills in daily activities!

This can at times be somewhat disturbing, especially to new clinicians.  They might ask “How can I be sure these other team members know what to do? What if they do it wrong? Why are they doing what I should be doing? What if things get left out?”

As I’ve learned, two things help to make interdisciplinary teams work well – really good induction and mentoring as the new clinician settles in, and time.  It’s during the latter that communication needs to be open and robust discussion about why various approaches are used, and who might be the best person to have the main focus on a goal.  Role contributions change over time too, as team membership changes.

Does working this way lead to duplication? Yes, to a certain degree.  Provided that team members are consistent in what they say, ensure no goals are omitted, and focus on the case formulation, I’m not so sure that duplication is always a bad thing.  Maybe it’s better described as being consistent, providing back-up to each other, and more importantly, allowing the patient/client choice about who to approach to talk about topics. Most times, in an individualised programme, teams seem to work best with a combination of clinicians who can address psychosocial aspects, functional/physical aspects, and help the person integrate what is learned into his or her life.

A proviso – team members need to be competent in the techniques they use, and they must ensure the goals they can contribute most effectively to are being addressed. As someone pointed out, an occupational therapist or physiotherapist who dabbles in ‘a bit of CBT’ on the side is not likely to be helpful if they then omit something like how to schedule or plan a day, or progress activity levels over time. At the same time, I keep on saying, when is there a better time to elicit automatic thoughts and beliefs than when engaging someone in activity? When better to discuss whether the thoughts are helpful, accurate or helping the person achieve what is important and valued in life? And carried out with competence, working with thoughts, beliefs, emotions and behaviours in this way is both effective and efficient.

Mainly for occupational therapists, I want to turn to how it’s possible to integrate so-called ‘psychological’ approaches into occupation.  Be warned now – this may be continued!

If occupational therapy is about helping people engage more fully in valued occupations, I’d argue that we need to use the most effective tools to do so.  In pain management, a cognitive behavioural approach has consistently been demonstrated as effective – and occupational therapists, while somewhat silent on the publishing front, have been involved in most of the major pain management programmes.

Occupational therapy is not a ‘talk’ therapy – it’s all about doing.  It involves identifying what is important or valued in a person’s life, and helping them engage in those occupations.  While part of this involves talking and planning and ‘educating’, the purpose and outcome is for the person to then be equipped to engage in those activities or occupations themselves.

During planning and ‘educating’, it’s common for the person to raise objections to doing things differently.  These objections are – yes really – automatic thoughts!  In other words, they’re cognitions or beliefs, or maybe even attitudes or rules about how the person thinks things ‘should’ be done.  Robinson, Kennedy and Harmon seem to construe this situation as one in which what the client believes should be accepted without question.  I argue that unless the belief supports the person engaging in occupation, it is a valid target for an occupational therapist to address. While the belief may be part of the person’s ‘lived experience’ to date, it’s amenable to revision and change so he or she can see themselves and their opportunities differently, and re-engage in what is important.

When using a problem-solving process to review how a person has managed a new set of occupations, or way of approaching an occupation, feedback and evaluation is a vital component. It’s at this point too that an occupational therapist can review how helpful thoughts and beliefs are – and help the person look at the situation (and beliefs) in the light of new evidence.  They can then be helped to generate new beliefs and change their behaviour (or engagement in occupation).

I’ve gone over the word limit again today, so yes, there will be more tomorrow on this important topic.  I hope it’s generating food for thought and that what I’m writing serves as encouragement for ‘non-psychologists’ to learn more about how to work with thoughts and beliefs as they work with people.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

“Pain Management. A Handbook of Psychological Treatment Approaches” (1986) edited by A. D. Holzman and D. C. Turk.Pergamon Press

Occupational therapy & the cognitive behavioural approach for pain management

ResearchBlogging.orgI have always resisted being labelled. I am much more than my gender, my marital status, my diagnosis, my professional background.  I also feel quite uncomfortable about being told what I may or may not do (maybe that’s where my kids get it from?!). I don’t like being told what is and isn’t ‘my role’ or someone else’s role.  I’m interested in what works and doing it well and at the right time for the right reason.  Today’s post is the first of a two-part commentary on a paper by Robinson, Kennedy and Harmon published in the American Journal of Occupational Therapy this month in which it is argued that occupational therapists who offer cognitive behavioural therapy ‘without sufficient attention to occupational therapy’s professional domain could lead to occupational therapists’ duplicating the interventions of other multidisciplinary team members.’ (Robinson, Kennedy & Harmon, 2011).

The paper also includes critiques of the ‘acceptability’ of psychological interventions, and suggests that ‘the use of CBT reflects psychosocial understandings of chronic pain that are frequently incompatible with clients’ interpretations of their experiences.’ They go on to say ‘many therapists have adopted the evidence to support psychological interventions without critical consideration of these interventions’ role within their professional domain or their acceptability to clients.’ The tone of this part of the paper strongly suggests that by using a CBT approach, occupational therapists do not directly address the occupational needs of people with chronic pain, and that if they do use it, it may not be acceptable to patients, and it could lead to duplicating service delivery.

Where do I start with this? There are several points that I think Robinson, Kennedy and Harmon may have misinterpreted about a cognitive behavioural approach to pain management and to the ways in which interdisciplinary pain management works.  I want to add here that I hope some of the funders of treatment services for people with chronic pain in New Zealand will also take a good look at their assumptions about both of these things as well.

A cognitive behavioural approach to pain management is not exactly the same as cognitive behavioural therapy for depression or anxiety.  In pain management, while cognitive behavioural therapy as used for mood management can be one of the therapeutic strategies used, the CBT approach is broader than this.  Basically, the CBT approach conceptualises the problem of disability and distress as due to inaccurate understandings about pain (such as hurt = harm, or that pain must dictate behaviour), and thus, inappropriate activity levels are maintained, and these in turn lead to negative mood states.  Of course, these relationships are usually reciprocal, and this is a very simplified version of the approach.

The aims of a CBT approach are to:

  • Help the person reconceptualise themselves as able to manage and do despite experiencing ongoing pain
  • Help the person set new behavioural goals to reduce disability (aka ‘re-engage in occupations’ to use occupational therapy jargon)
  • Reinforce progress and acknowledge achievements
  • Identify obstacles to progress
  • Help the person acquire skills to overcome these obstacles (Medical Practice Guidelines, Hunter Integrated Pain Service, Updated July 2005)

One of the main features that distinguishes a cognitive behavioural approach from the majority of other treatments for pain is the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.  In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Robinson, Kennedy and Harmon describe and critique ‘psychosocial understandings of chronic pain’ and to me what they say smacks of the old dualist notion that mind and body are separate.  When they say “…the clinician may discount the presence of an organic cause and interpret the person’s experience within a psychosocial model”, it suggests to me that the authors have not really come to grips with pain as a function of the brain’s interpretation of incoming information from the body (or lack of input from the body).  “Organic” factors or not, pain is an experience and is therefore ‘psychological’ – and it’s also biological because the brain is made up of cells and other ‘organic’ material.  We’re not talking here about mystical ‘energies’ or forces!

But their biggest reservation about CBT being used by occupational therapists seems to be twofold: that clients don’t like so-called ‘psychological’ approaches, and that these approaches don’t “directly address the occupational needs of people with chronic pain.”

While some people that I see don’t initially feel happy with a nonmedical approach to their pain, it doesn’t take long to establish that people are aware of their beliefs about their pain, and they can also see how their beliefs lead to emotions and behaviours – and vice versa.  The heart of the CBT approach is that it is collaborative.  By working together to identify the various factors that influence pain and disability (occupational performance limitations), people with chronic pain are readily able to apportion relevance to biophysical/biomedical, psychological and social components that affect their ability to do what they want.

While the authors don’t quite go as far as saying that therapists shouldn’t give patients accurate information about our current knowledge of pain, they do imply that by using a psychological explanation (sic),  patients are “de-legitimized by the suggestion that psychological factors are at play in the chronic pain experience…” I think that if clinicians fail to explore the relevance of thoughts and emotions and values etc, and instead support patients misunderstanding of their pain as fixed, permanent and unable to be modified, then they do their patients great harm.  And when better to explore thoughts and beliefs than when the person is getting in and out of the car or walking up and down stairs? Who better to do this than the clinician standing beside them as they do this?

One of the most important goals for pain management is to reduce disability or increase functional activity.  In fact the purpose of using a CBT approach is to increase the person’s ability to choose to engage in the things they want to do.  For this reason I strongly refute the idea that by using a CBT approach therapists may not be “critical[ly] consider[ing] these interventions’ role within their professional domain…”.  As I said before, who and when better to explore thoughts and beliefs than the clinician who is standing beside the person while they practice getting in and out of the car or walking up and down stairs?

I have reached my word limit for today – there will be more though, because there are several other points I need to make in response to this review.  Read on if you’re keen to see why I believe both occupational therapists and physiotherapists (and psychologists, nurses, social workers and other allied pain clinicians) are justified working in pain management using a cognitive behavioural approach, why I fail to see that this approach should be confined to clinical psychologists, and why I believe the CBT approach (and others aligned to a CBT approach such as ACT) should be employed at the earliest opportunity and right through until the person with pain is able to manage their situation independently.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

Pulling it all together – biopsychosocial assessment

Over the past little while I’ve been writing about how a comprehensive pain assessment can be carried out.  Today it’s time to pull that information together to develop a formulation, or set of possible explanations for why this person presents in this way at this time – at least for one or two aspects of his presentation.

For example, if the person’s pain is low back pain, where surgery has failed to improve the person’s pain, but he has maintained working in a teaching job where physical demands are reasonably light, but is having trouble with sleep, feels irritable, can’t manage things like mowing lawns, and is very careful not to bend because he was advised after surgery to avoid bending because it may affect healing.   Limited forward flexion, side bending, back extension, cardiovascular tolerance moderate on step test, reports fatigue getting worse through course of weekGuarding noted, rubbing back, grimacing, would not complete box lift test from floor, or box to top shelf  (no weight in either situation) due to concerns about increased pain and potential harm.

Each of the underlined phrases represents a finding that needs to be put together with the information from questionnaires and clinical examination/observations from the team to form a set of hypotheses that can be tested within therapy to (a) establish whether they hold true and (b) help to ameliorate the pain, distress and/or disability the person is experiencing.

What do you think is going on for the person described above?

Remember that the people I see have chronic pain, most of them have had this for many years, and most of our treatments reduce pain by maybe 30%.

From a biomedical perspective, if it’s established that surgery has been ineffective, one of the most likely diagnoses is ‘chronic low back pain with central sensitisation’. This diagnosis can’t be confirmed with any specific test, but is most likely if the person describes multiple persistent pains, possibly migraine, often highly sensitive to side effects from medication, low mood, irritable bowel and, in women, pelvic pain especially that associated with menstruation.

The main management from a medical perspective is a tricyclic antidepressant, if that’s ineffective something like gabapentin or pregabalin, failing that, and atypical SNRI or similar, and often a combination of these medications.  In some people there is a nice response – pain is alleviated, sleep is improved, and the person feels much better.  In most people, the response is somewhat more muted, and in some there is no improvement at all.  Even the best response is not often more than a 30% reduction in pain.  At least in our experience.  At this point I’ll remind everyone that I’m not a doctor, this is not medical advice, and this is what is carried out in the center in which I work.  For more references on central sensitisation, you can’t go beyond papers by Prof Clifford Woolf, this one is from 2007 and is full text, online.

Unfortunately, having a diagnosis, as you can see, doesn’t really help us with the management of our man’s disability and distress. Even if his pain reduces by our mystical 30%, he still avoids a lot of movements, his sleep pattern is poor, and he believes his back may be damaged if he does movements that bring on his pain.

And even if we’re very good at giving him ‘education’ about his pain – as I’ve said before, quoting Bill Fordyce, ‘Information is to behaviour change as spaghetti is to a brick.’ Information or education alone is often/usually insufficient for someone who is stuck in a pattern of avoidance and disability – after all, a spider phobic in New Zealand knows there are very rarely any poisonous spiders here, but is still fearful! (I know because I was one).

Let’s take a look at one of the psychosocial and functional strengths this man brings to his situation: He’s maintained working as a teacher, despite poor sleep, and lots of functional limitations. We can ask some questions of the information we’ve assembled about how he’s able to do this – what are his values? what routines support his getting out to teach every day? what strategies does he use to maintain standing, walking, sitting – and concentrating, remaining calm despite feeling irritable – as he teaches?

At the same time, we can ask similar questions of his functional limitations: what factors contribute to his difficulty bending? What are his beliefs about bending? What maintains this behaviour – internally (he may get a stab of pain when he bends, or he may anticipate that he will get pain when he bends, or he may get pain that starts after he’s done some bending – hardly an incentive to bend!), and externally (what do people around him say when he bends and grimaces? what do important/powerful people say about bending? eg his surgeon), what muscle groups are working over-time to maintain his guarded posture – and so contribute to his pain and subsequent avoidance?

In the space of a few minutes, I’ve started to put together some areas to flesh out the simple picture we get from just knowing his diagnosis.  Now let’s start to draw in what else we know from theory and clinical experience.

Hypothesis one: because this man holds strong values about following through on a commitment, he may be mindful of his pain while teaching, but is able to put this aside in the classroom.  Theory base? If I used ACT as a framework, values are ‘chosen qualities of purposive action’, in other words, they’re what lies beneath committed actions.   One way this man could be maintaining this action could be because he has developed an awareness that his thoughts are not him.  So he can experience pain, but allow this awareness to flow past him as he continues teaching.

We could to test this hypothesis by asking him about his values and his awareness of his thoughts about pain while teaching, and we could see if he uses this same approach in another activity that he also feels is aligned to an important value.

Hypothesis two: he avoids bending because of several things – he believes he may harm himself, this was initially reinforced by advice from his surgeon post-operatively, and later by the images he has in his mind of his vertebrae ‘above and below the fusion taking more of the strain’.  Additionally, he experienced pain on several occasions when he inadvertently leaned down to pull his socks on after surgery, and he is fearful of having that pain again because it gave him a fright and reminded him of the pain he had before his surgery.  Finally, his partner reminds him to ‘be careful when you’re moving, dear’ because she’s heard him groaning when getting in and out of bed during the night.

To test this set of hypotheses we can provide him with good information about his back, we can remind him that the surgeon was talking about immediate post-operative care, we can show him his X-rays and we can tell him about the studies that show degeneration of vertebrae above and below a fusion is no worse than if his back hadn’t been fused.  If his anxiety reduces, and he is more able/ready to approach doing those movements, our hypothesis is confirmed to a degree.

Then we’ll need to use graded exposure to help him work out that bending doesn’t inevitably lead to an increase in pain – and more importantly, even if he does experience an increase in pain, this doesn’t mean he ‘can’t cope’ with it, or that he will end up needing further surgery.  We can help him deal effectively with any increase in pain by using breathing, mindfulness, positive coping statements, and ensuring our graded exposure has been developed appropriately. 

If, by following this process, he begins to reduce his avoidance and he reports that his anxiety is reduced (and we could even monitor this using biofeedback), our hypothesis is confirmed, again to a certain degree.

The final thing we might do is ensure his partner is involved in the initial explanation and reasoning for these approaches so she is reassured, and help her develop some coping strategies for her own distress at seeing her partner sore – perhaps by helping her say something encouraging like ‘good to see you have a go at that’, or breathing techniques, or a coping statement like ‘he’s learning how to do things again, this is a good part of his recovery.’

If, by his partner responding more positively to his attempts at doing things he has previously avoided, our patient starts to do more while in her presence, again our hypothesis is confirmed and we have done the right thing.

Some references for these types of approach? Your wish is my command.

Vowles, K. E., Wetherell, J. L., & Sorrell, J. T. (2009). Targeting acceptance, mindfulness, and values-based action in chronic pain: Findings of two preliminary trials of an outpatient group-based intervention. Cognitive and Behavioral Practice, 16(1), 49-58.

van Wilgen, C. P., Dijkstra, P. U., Versteegen, G. J., Fleuren, M. J., Stewart, R., van Wijhe, M., et al. (2009). Chronic pain and severe disuse syndrome: long-term outcome of an inpatient multidisciplinary cognitive behavioural programme. Journal of Rehabilitation Medicine, 41(3), 122-128.

Slade, S. C., Molloy, E., & Keating, J. L. (2009). ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23(3), 270-280.

Quartana, P. J., Campbell, C. M., Edwards, R. R., Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review.  Expert Review of Neurotherapeutics, 9(5), 745-758.

de Jong, J ; Vangronsveld, K ; Peters, M ; Goossens, M ; Onghena, P ; Bulte, I ; Vlaeyen, J.  (2008) Reduction of pain-related fear and disability in post-traumatic neck pain: A replicated single-case experimental study of exposure in vivo.  The Journal of Pain. Vol.9(12), pp 1123-1134.

Brain training – it happens all the time
At the risk of seeming untrendy, the trend to rave on about neuroplasticity can be a bit overdone.  Not, I add quickly, because it doesn’t happen, or it’s not important – in fact, quite the opposite – but because it happens all the time.  And at the back of our minds, I think we’ve known this for quite a while.  How else do you think we manage to learn new things even in our elder years?

The reason I’m raising this today is, after yesterday’s post on phantom limb pain and the parts of the brain that are active when we have pain and when hypnosis is used for pain relief, I started to mull over the range of treatments that are used in managing chronic pain.  Now, we don’t have fMRI studies for all the treatments available.  I don’t think I can recall any studies where fMRI is used to study the effects of CBT on pain, or exercise on pain.  This is, in part, an artifact of the fMRI technology – it’s impossible to be physically active while inside the scanner, and scanning occurs in a rather artificial environment that is nothing like that encountered on a daily basis.

But if we move away from any notion that psychological approaches are magical and affect the being through ‘mystical’ processes, we need to draw the conclusion that any of the standard behavioural and cognitive techniques used in pain management must influence the brain somehow.  While we don’t currently know how this occurs, there doesn’t seem to be any other plausible explanation.

Why is this important?  Well, because it means the more we know about how the brain works, and particularly those very complex forebrain processes (see Neugebauer, Galhardo, Maione, & Mackey, 2009), the more we can see how previously ‘mind not body’ processes are actually neurobiological, and how the dualist notion of a distinction between mind and body simply doesn’t work.

And this leads me to introduce a patient of mine to you (details altered for confidentiality reasons).  Let’s call him Jim.  He’s a 64 year old man who crashed his motorcycle and sustained a below knee amputation about 15 years ago.  He successfully managed this, and wore a prosthetic limb most of the time.  Five years ago he started to experience more than his usual phantom limb, he started to have severe intermittent phantom limb pain.  He was still working at the time, and told me he’d close his office door and hold his breath and brace himself every time his pain started.  The episodes were initially once or twice a day, but quickly progressed to several times an hour, and each episode lasted for around a minute.

Jim tried a range of medications, and was part-way through a systematic trial of available meds when he was referred to me because he couldn’t remain working and was highly distressed at giving up his quite responsible job.  I need to explain that Jim had always been an active amputee – he regularly cycled, swam, walked (should I say, hiked/tramped!) for miles, and his general health was excellent.  He’d never had a bout of depression, had never been an anxious man, but was quite driven to excel and very motivated to keep his job.

It’s common to find that there are no medication solutions to phantom limb pain.  Jim was ready to look at how he could regain some sense of control over his life, and most especially, a way to get through the intermittent painful ‘attacks’.

As many researchers and authors point out, knowledge about pain mechanisms, or at least a model of pain, can reduce fear.  In doing this, it can reduce distress.  While we don’t know exactly how this occurs, it’s fairly certain that those parts of the brain that are involved in self regulation, emotion, fear, and decision-making are activated.

In Jim’s case, I began by describing a model of pain – and included in that, a cognitive behavioural model as well.  This model identifies that thoughts interact with the emotional state which interact with behaviours – and all of these in a bidirectional way. 

From this model, Jim was able to identify that as soon as his pain came on, his first thought was “Oh no, not this again”, he immediately felt afraid and braced himself for the onset of pain.  He also held his breath, gripped his desk, gritted his teeth, closed his eyes – and waited.  The effect of this response, even in someone who doesn’t have pain, is exhaustion – just try it yourself!

I introduced diaphragmatic breathing as a first step, ensuring that Jim had an effective relaxation response before we started changing his behaviour at the onset of pain.  Once he’d achieved this, we started by acknowledging his automatic thought, then allowing this thought to go by and instead of bracing himself, using a long outbreath and a cue word “Relax”.  He continued then with four more long breaths out, and by then the ‘attack’ had passed.

In addition to this, we also introduced a mirror treatment.  This consisted of using an old full-length mirror he had at home, sitting with the mirror in between his legs, so he could see his ‘good’ limb.  He then initially looked at his leg in the mirror, and progressed after some time to asynchronous movement of both limbs (while wearing the prosthesis).  While Jim told me that the initial experience was ‘weird’, he was able to experience a reduction of the continuous aching pain he had, and the frequency and intensity of the intermittent ‘attacks’.  This outcome with about 20 minutes use of the mirror each day.  Unfortunately after about 3 months use, the effect faded, and we’re not sure why.  It has never returned despite increasing the novelty, and improving the ‘illusion’ of the limb being his.   Jim told me that while he was disappointed in this, he was happy that he had other ways of coping, both the breathing/acceptance process, and he had developed more confidence to have an ‘attack’ while in the presence of other people, so it became less intrusive.

Some things to note: we can see from Flor’s work (and Moseley’s too!) that this kind of experience affects the brain regions involved in the experience of pain, while the majority of medications either don’t address it at all, or simply work to damp down the overall over-excitement of the nervous system. 

We can also see that it’s important to move beyond just addressing the brain retraining via mirrorbox.  It’s also vital to engage in cognitive and behavioural approaches to counter things like Jim’s concern that other people might think he was weird or pathetic when he had an attack.  The breathing strategy was a nonintrusive strategy that he can use anywhere.

Iannetti, G., & Mouraux, A. (2010). From the neuromatrix to the pain matrix (and back) Experimental Brain Research, 205 (1), 1-12 DOI: 10.1007/s00221-010-2340-1
Neugebauer, V., Galhardo, V., Maione, S., & Mackey, S. (2009). Forebrain pain mechanisms Brain Research Reviews, 60 (1), 226-242 DOI: 10.1016/j.brainresrev.2008.12.014

Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies Expert Review of Neurotherapeutics, 8 (5), 809-818 DOI: 10.1586/14737175.8.5.809

Flor, H., Nikolajsen, L., & Staehelin Jensen, T. (2006). Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience, 7 (11), 873-881 DOI: 10.1038/nrn1991