Groupwork

Springboard: Beginning to live life again


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

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

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

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

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

What’s inside Springboard?

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

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

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

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

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

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

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

Each of the six sessions has a focus.

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

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

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

What to do when one size does not fit all


Alert: rant ahead.

Early in my career working in persistent pain management, it was thought that “chronic pain is chronic pain is chronic pain” and pretty much anything that helped one person would help the next. Over time we’ve learned a lot more about persistent pain: the mechanisms differ a lot between neuropathic mechanisms and nociplastic mechanisms. Even within these groups, the mechanisms are very different. We’ve also learned a lot more about the psychosocial variables that are associated with prolonged disability and distress when pain persists. Some of the earliest work by Turk and colleagues found that by using the Westhaven-Yale Multidimensional Pain Inventory, people could be classified into four subgroups (Kerns, Turk & Rudy, 1985). While the names of these subgroups could do with some updating (to avoid negative labelling), there’s a large body of research supporting the four groups they found.

When I first worked at Burwood Pain Management Centre, the WHYMPI was the workhorse pre-assessment questionnaire used to help clinicians understand more about the person they were seeing. Interestingly, at the time there were two group programmes on offer: one was the three week full time residential pain management programme, and people who were admitted to this programme were those with high levels of distress and disability, often with very unhelpful beliefs about their pain, and needing the intensity of the full-time programming to help them make changes that would be sustained when they went home. The other was an outpatient programme, two sessions a week for six weeks, and this was intended for people who had more disturbance in their relationships with others, who felt unsupported and as a result were distressed. Also in this group were people who were generally managing well but needed to learn some new skills so they could get on with their lives.

Times change. Neither of those programmes are running in the same way as they were and there’s been an increase in individual sessions with single discipline input right around the world. Some commentators point out that changing funding models has led to the rise of single discipline intervention (Loeser, 2006), others discuss the ethical dilemmas raised by funding that is allocated on outputs (numbers of people seen) rather than outcomes (how well those people who have been seen are doing, and especially how well they do over time) (Loeser & Cahanda, 2013). This discourse has spilled over into how clinical guidelines have been developed (Chou, Atlas, Loeser, Rosenquist & Stanos, 2011), and this in turn has led to policy and funding decisions made at local level.

The rise of interventional pain treatment (Manchikanti, Pampati, Sigh & Falco, 2013) has been observed right around the world, including in New Zealand. Interventional pain treatments aim to reduce pain intensity via non-surgical means, often through anaesthetic injections (blocks), and in some cases by localising the supposed source of nociception through diagnostic blocks, then ablating or coagulating the proteins around the nerve, to stop transmission (Cohen, Stojanovic, Crooks, Kim, Schmidt, Shields et al, 2008). These latter procedures apply to a very small proportion of people with back pain, nevertheless they are popular – albeit not always applied to the cohort of people originally intended (Bogduk & McGuirk, 2002).

Alongside the rise of interventional procedures, in New Zealand there has been a shift from passive physiotherapy modalities (acupuncture, heat packs, interferential, ultrasound) to active management – which pretty much looks like exercise in New Zealand. New Zealand’s ACC funds community-based pain management programmes that are intended to be tailored to the person’s needs, have a multidisciplinary team approach, and use a multifactorial model of pain. While these programmes superficially look progressive and innovative, results from a recent study colleagues and I have carried out, sadly it looks much like exercise plus psychology, and the teamwork aspect is minimal. More concerning is the rise of “cookie cutter” programmes, limited understanding and use of the carefully collected psychometric information completed by patients, and inappropriate referrals to the services.

The landscape of publicly funded pain management in New Zealand is fraught with problems. Each district has a health board consisting of elected plus appointed members. District health boards have the task of allocating the money central government gives them, according to the needs and wishes of the community. Note that in NZ, accident-related rehabilitation is funded by our national accident insurer (we only have one, it’s no-fault and 24/7). Given we have patchy community service provision for people with pain following accidental injury, you’d think our district health boards would have some consistent approach to helping the one in five Kiwi’s living with pain lasting more than three months. Now while not everyone who has persistent pain will need help to manage it (think of those with osteoarthritic knees and hips who are not quite ready to head to surgery), amongst those who have the most trouble with pain are also those with a history of trauma. Christchurch and the Canterbury area have had, over the past 10 years, over 10,000 earthquakes (the last noticeable one was only last week – take a look at geonet), the Kaikoura earthquakes, and the mosque shooting. During the five or so years after the earthquakes, the city’s children were disrupted by changes to schools (thanks, Hekia Parata and the National Party – you are not forgiven). What all these events have in common is the impact on people with pain. And you guessed it, there is no coherent national approach to pain management, no pain plan or policy.

We know there is a relationship between traumatic events, particularly those in early childhood, and persistent pain (eg Ne4lson, Simons & Logan, 2018). We also know that victims of crush injuries, traumatic amputations, and bullet wounds are likely to experience greater neuropathic pain which is particularly hard to treat. People with persistent pain, especially when it’s been around for some years, are also likely to have poor sleep, mood problems, anxiety problems, and in many cases, will have had repeated surgeries and be given a multitude of pharmaceuticals to help reduce pain and distress.

The problem is that when these are applied without the support of a team, they may well be applied without finesse. They may reduce pain, a little (though this is arguable given how poorly analgesics perform – and the misapplication of the WHO analgesic ladder, Ballantyne, Kalso & Stannard, 2016). But we know that pain intensity and disability are not well-correlated. So while the focus on reducing pain via injections, ablations, surgery, pharmaceuticals and so on is helpful on it’s own it doesn’t necessarily change a person’s sleep pattern, their low mood, their lost job, their fear of moving, the relationship that’s fallen apart, the loss of sense of self…

Worse: when pain management is poorly coordinated and doesn’t target the real needs of people who live with pain and who don’t respond to these efforts (the majority of people with neuropathic pain, for example), people don’t stop seeking help. They pop up in all sorts of places: primary care practices (to the GP who is over-worked, poorly supported and often poorly educated about pain); via Emergency Department (where, although the pain may have been present for a long time, it must be treated as an acute pain problem because that’s what EDs do); admitted for investigations, to provide “respite” for family, to be reviewed yet again by a clinician who is not well-informed about pain because our training in pain is pretty poor (Shipton, Bate, Garrick, Steketee, Shipton and Visser, 2018). They are invisible to NZs health system because they’re not coded as having pain as their primary problem. And people with persistent pain don’t die, and the public’s attention (and media) is focused on deaths. Like the long-lasting Covid-19 patients who continue to have trouble from Covid-19 months after their initial infection, people with persistent pain just hang around. And medical-only approaches simply do not work to treat rehabilitation needs. Rehabilitation is where it’s at. But rehabilitation is no longer a focus of in-patient care in hospitals (neither should it be) – but there are few places outside of hospitals that are funded and staffed to help.

This lengthy post is written out of frustration because too often I’ve seen conversations about pain management saying “oh it doesn’t work” – true! Nothing works well. But most things work a bit. Our problem is twofold: we can’t predict who will and won’t respond very well (though the old WHYMPI and similar psychometric measures/profiles do offer some guidance); and we have little national cohesion around sharing resources. We need to better monitor the impact of our treatments so we can quickly add, or remove, treatments to target particular problems. And all of the providers must have skills for working with people who have persistent pain.

Let’s do better. Let’s clamour for more nationwide planning. Let’s raise the profile of the allied health workforce who do the majority of rehabilitation with people living with pain. Let’s make our teams TEAMS not sets of individuals working in parallels. Let’s have some leadership around the value of pain management, and why it’s important. Let’s bring this whole issue to light. Let’s do it.

Ballantyne, J. C., Kalso, E., & Stannard, C. (2016). WHO analgesic ladder: a good concept gone astray. BMJ, 352, i20. doi:10.1136/bmj.i20

Bogduk, N & McGuirk, B. (2002). Medical Management of Acute and Chro5nic Low Back Pain. An Evidence-based Approach. Pain Research and Clinical Management, Vol3. Elsevier.

Chou, R., Atlas, S. J., Loeser, J. D., Rosenquist, R. W., & Stanos, S. P. (2011). Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? J Pain, 12(8), 833-839. doi:10.1016/j.jpain.2011.04.012

Cohen, S. P., Stojanovic, M. P., Crooks, M., Kim, P., Schmidt, R. K., Shields, C. H., . . . Hurley, R. W. (2008). Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine Journal: Official Journal of the North American Spine Society, 8(3), 498-504.

Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The west haven-yale multidimensional pain inventory (WHYMPI). Pain, 23(4), 345-356.

Loeser, J. D. (2006). Comprehensive Pain Programs Versus Other Treatments for Chronic Pain. The Journal of Pain 7(11), 800-801.

Loeser, J. D., & Cahana, A. (2013). Pain medicine versus pain management: ethical dilemmas created by contemporary medicine and business. Clin J Pain, 29(4), 311-316. doi:10.1097/AJP.0b013e3182516e64

Manchikanti, L., Pampati, V., Singh, V., & Falco, F. J. (2013). Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to 2011. Pain Physician, 16(4), E365-378.

Nelson, S., Simons, L. E., & Logan, D. (2018). The incidence of adverse childhood experiences (ACEs) and their association with pain-related and psychosocial impairment in youth with chronic pain. The Clinical Journal of Pain, 34(5), 402-408.

Shipton, E. E., Bate, F., Garrick, R., Steketee, C., Shipton, E. A., & Visser, E. J. (2018). Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain and therapy, 1-23.

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.

Should we take their word for it? Patient-reported vs observed functional outcomes


Pain is a subjective experience. There’s no direct means to measure what it is like to be in pain. Disability, or the impact of pain on what we do in daily life is, on the other hand, able to be observed as well as reported on by people with pain. A question that has always fascinated me is the relationship between what an individual says they can or can’t do, versus what they can be observed to do.

One of the more common ways to determine disability by observation is the “functional capacity evaluation” – and readers of my blog will know that I’m not especially fond of them when they’re used to determine “work fitness”. There are instances though, where they make sense – particularly if the individual with pain is able to gain confidence about what he or she can do. Just don’t use them to predict whether a person can carry out a full working week.

Alternatively, and for reasons of convenience and cost, self-report measures of disability are often used. These are thing like the Oswestry Disability Index (Fairbank & Pynsent, 2000), or the Oxford Scale for hip and knee function (Dawson, Fitzpatrick, Carr & Murray, 1996).  These pen and paper assessments are completed by patients, have excellent psychometric properties, and are often used for both assessment and outcome measurement.

The question is: do they represent the real world experience of the person with pain? How accurate are they, really?

In the Orthopaedic Surgery Department where I work, physiotherapists conduct a functional assessment of all people who have been referred for hip and knee joint replacement. The activities used are aligned with the Oxford hip and knee questionnaires. What’s interesting is how poorly the two are correlated. Physiotherapists recognise that many people report difficulty performing things like going up steps, kneeling and so on, but when they are asked to do those same movements in the clinic, they have excellent motor function and manage them well. Why? and which version of the “truth” do we use?

I don’t have the answer, because physical performance and self-reported disability are influenced by many different factors, but I am interested that in a recent study conducted by the IMPROvE Study Group in Denmark, researchers found that using AMPS (Assessment of Motor and Process Skills – an assessment approach developed and used by occupational therapists) and the SF-36 Mental Composite Score showed distinct differences in outcomes six months after a two-week interdisciplinary pain management programme for people who met the 1990 American College of Rheumatology classification for fibromyalgia.

What does this mean?

The first point is that the programme these people attended demonstrated good outcomes in the things that matter most: daily activities, self care and motor performance. Participants became more able to do the important occupations that you and I need to do each day.  Group content doesn’t look any different from the pain management programmes I’ve seen around the world. Lots of information, sharing experiences with one another, exercise including how to increase daily exercise, developing ways to return to usual activities of daily living, and some psychology sessions as well as an opportunity to meet with the rheumatologist. Interestingly, two weeks is not enough time to develop changes in muscle strength – yet function and activity levels increased. It’s not a “training” effect, at least not physical training. Two weeks, 35 hours a week, is not an enormous amount of time in which to deliver a programme of this type – but it’s clear it can and does make a difference for people who had fibromyalgia diagnosed roughly 1 – 3 years ago.

The second is that the two outcome measures are not measuring the same thing.  Using the SF-36, change was minimal, and not clinically significant, neither were changes at six months statistically significant. Using AMPS, however, individuals demonstrated a clinically relevant improvement in performance in both motor ability and process ability (ADL). Interestingly, the researchers report that there were large interindividual differences – something that grouped data cannot show.  Self-report measures show what the person believes he or she can do.  AMPS provides external validation of performance, or what the person will do, or does do when observed. And from this study, it looks like AMPS is more sensitive to change, and to individual differences, than the well-known SF-36. AMPS also provides information on the quality of performance, something that is missing from the SF-36.

In terms of the research design, the assessors, all occupational therapists trained in AMPS and who had just recently been recalibrated (checking to see how consistent and how closely they remain true to the original training) did not know which of the two groups individuals had come from (control or programme).

From this study, I draw a couple of conclusions:

  1. Using both observed performance and self-report gives a broader picture of the impact of pain on daily life. That the two measures don’t correlate well is fine – they’re measuring different things. It’s good to be reminded that what a person says they have trouble with doesn’t necessarily reflect what they can do in usual setting, nor the quality of the performance. Both measures are useful, and it might be worthwhile using both. An unanswered question, of course, is what the participants thought. How did they view their performance? It would have been nice to see something like the Canadian Occupational Performance Measure included in the outcome measures.
  2. While group analyses may not show much difference, within the group, some individuals responded very well. It’s worthwhile considering some different analyses that can show the variation within a group – and then start the search to find out the characteristics of those people who responded well, and this is another reason I like the single subject experimental design approach to clinical outcome measurement.
  3. Occupational therapists, trained to understand occupation made a significant and unique contribution to this study. Many disciplines fail to recognise the specialist expertise of occupational therapy: this study shows that by assessing and focusing on activities that matter to individuals, and directly measuring the impact of interventions on occupation, a more detailed analysis of progress is achieved. Time to wave the occupational therapy flag I feel!

In answer to my question, should we take their word for it? I think the answer is – not exactly. We need to spend time understanding the differences between self-report and observed performance, not as a way to ‘catch a person out’, but as a way to more adequately assess what matters to people who experience chronic pain.

Amris, Kirstine, Wæhrens, Eva E., Christensen, Robin, Bliddal, Henning, & Danneskiold-Samsøe, Bente. (2014). Interdisciplinary rehabilitation of patients with chronic widespread pain: Primary endpoint of the randomized, nonblinded, parallel-group IMPROvE trial. PAIN®, 155(7), 1356-1364. doi: http://dx.doi.org/10.1016/j.pain.2014.04.012

 

Dawson J., Fitzpatrick R., Carr A., Murray D. (1996). Questionnaire on the perceptions of patients about total hip replacement surgery. Journal of Bone and Joint Surgery, 78:185-90

Fairbank JCT & Pynsent, PB (2000) The Oswestry Disability Index. Spine, 25(22):2940-2953

Better ways to meet the needs of people with chronic pain


I’ve worked in chronic pain management in New Zealand for about 20 years. In that time I have never, ever heard of a chronic pain management centre without a waiting list. There are always more people than places for them to go. This situation hasn’t changed one iota, and it’s the same everywhere in the developed world. It’s also going to get worse because of the aging population with chronic health problems. Somehow, though, the urgency with which we need to address this problem just hasn’t reached health policy-makers and budget-holders. Chronic pain is still pretty invisible.

If tertiary care waiting lists are enormous, then who ends up taking on the majority of care? By and large it’s General Practitioners, who by their own admission don’t feel confident, and neither do they have sufficient time, to deal with the needs of people with chronic pain. There is conflict between the focus of a GP and that of the patient, and implementing back pain guidelines for example, has not been entirely successful (Breen, Austin, Campion-Smith, Carr & Mann, 2007; Coudeyre, Rannou, Tubach, Baron, Coriat, Brin et al, 2006; Williams, Maher, Hancokc, McAuley, McLachlan, Britt et al, 2010).

What can be done?

The strategy most commonly recommended is some form of stepped care approach. This begins with simple advice and simple analgesia. It’s usually carried out by a GP, or in some cases (such as accident patients in New Zealand), other primary care clinicians such as physiotherapists, osteopaths and chiropractors can also provide this – although not usually involved in prescribing.

When this approach fails, or after a certain length of time, the next step adds in  some sort of reactivation, involving a physiotherapist or similar, and perhaps a screening questionnaire to establish the presence or absence of risk factors.

When this fails, the person may then be seen by an interdisciplinary team or at a chronic pain management centre.

But someone this approach hasn’t worked – because, at least in Christchurch, people will have had their pain for roughly four years before finally being referred to the pain management centre. This delay might be because of limited chances of getting in to the service, or it might be because patients haven’t been to see their GP about their pain, or it might be because they’re still wending their way through the acute services in pursuit of a cure or cause for the pain. Whatever the case, it’s not good for people.

Some ideas rely on using technology to provide greater collaboration and communication between both the person with pain and his or her virtual team (Kroenke, Krebs, Wu, Yu, Chumbler & Bair, 2014). I think this idea has a good deal of merit, although in the article I’ve cited I think some opportunities were missed. In this study, participants were randomised into two groups – one group received usual care, while the other received automated symptom monitoring via voice-recorded phone calls or the internet, along with one face-to-face meeting with a nurse care management, who discussed medications with a pain physician, followed by a phone call to discuss the care plan, and two other calls, one at one month and one at three months. Additional calls were provided on the basis of symptom records.  Patients in the intervention group benefited, with reduced scores on pain severity and interference as recorded by the Brief Pain Inventory.

What this study missed doing was use clinicians to support increased functioning and manage emotional distress. While there would have been an increase in cost, the outcomes would have, I feel, justified this expense.

Who should deliver this kind of intervention? Well, for my money, I’d go for occupational therapists, physiotherapists, perhaps nurses, social workers and counsellors. People working at the limits of their scope of practice.

You’ll note I don’t think psychologists should be involved, and not because I don’t think psychologists are very good people – but in a stepped care approach, I think their skills should be reserved for people who also present with psychopathology, things like depression, anxiety, and so on. Let’s instead use clinicians who have skills specifically aimed at increasing engagement with normal activity (or occupation, if you want to be pedantic).

I think there are other ways allied health can be used, reducing the demand on medical time.

What about group clinics where people from two or three medical practices can meet together once a week with an occupational therapist and physiotherapist? A time when people can learn new skills, be encouraged to set goals, have social support and also have a chance to learn about their pain and how to live despite it. Combine this with the prescribing practices described in the Kroenke et al (2014) study, and I think you have a great beginning for a primary care approach for people with chronic pain. If you included the local pharmacist in the mix, you’d have a very effective approach that maximises the use of clinical skills amongst a group of people who sorely need help.

If individual patients needed extra help, they could arrange appointments at the group clinic, and be seen by clinicians who already know them, and who are in contact with the primary care GP.

Because, while its the person with pain we want to help, there are other goals as well – relieving the burden of care of GP’s, reducing the use of emergency departments for what is a chronic health problem, limiting the number of health professionals the person needs to see, and using what already exists in the community.

Another alternative is to regularly provide “education” sessions to people with chronic pain. Combine this with giving people a clear indication of what to expect from seeing each health professional, and leaving the responsibility to make an appointment with those professionals, and we have the beginnings of a system based on patient’s readiness. This has already been implemented in Western Australia.

The reason I focus on supporting GP’s and using allied health instead of medication management is that we know medication has a limited effect in many forms of chronic pain (Turk, Wilson & Cahana, 2011). We also know that even when pain is reduced, without addressing underlying fears and specific concerns, people may not return to normal activity. The majority of predictive factors for ongoing disability associated with chronic pain are psychosocial – pills don’t fix beliefs, entrenched behaviours, family situations and not having a job. And a seven minute consultation with a GP cannot possibly address these things either. What does help is skilled, effective and specialised help from clinicians who understand “doing”. People with chronic pain don’t need pills, nor do they always need mental health management – what they DO need is a focus on practical ways to get on with life. I think that’s a better way to meet the needs of people with chronic pain.

 

Breen, A., Austin, H., Campion-Smith, C., Carr, E., & Mann, E. (2007). “You feel so hopeless”: a qualitative study of GP management of acute back pain. European Journal of Pain: Ejp, 11(1), 21-29.

Coudeyre, Emmanuel, Rannou, Francois, Tubach, Florence, Baron, Gabriel, Coriat, Fernand, Brin, Sylvie, . . . Poiraudeau, Serge. (2006). General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain Vol 124(3) Oct 2006, 330-337.

Kroenke, K., Krebs, E. E., Wu, J., Yu, Z., Chumbler, N. R., & Bair, M. J. (2014). Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. Jama, 312, 240-248. doi: 10.1001/jama.2014.7689
10.1001/jama.2014.7689.

MacNeela, Padraig, Gibbons, Andrea, McGuire, Brian, & Murphy, Andrew. (2010). “We need to get you focused”: General practitioners’ representations of chronic low back pain patients. Qualitative Health Research, 20(7), 977-986.

Turk, Dennis C., Wilson, Hilary D., & Cahana, Alex. (2011). Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226-2235. doi: 10.111/j.1468-1331.2010.02999.x

Williams, C. M., Maher, C. G., Hancock, M. J., McAuley, J. H., McLachlan, A. J., Britt, H., . . . Latimer, J. (2010). Low back pain and best practice care: A survey of general practice physicians. Archives of Internal Medicine, 170(3), 271-277.

Not just neural plasticity – health system plasticity


ResearchBlogging.orgIn chronic pain management there seems to be a pretty consistent pathway for people to finally get to interdisciplinary treatment.  First a referral from the primary care physician or GP to one or more specialist medical people – maybe an orthopaedic surgeon, or a rheumatologist, or a psychiatrist, or a neurologist.  This person will carry out investigations, get the results, make a determination that the problem is “not theirs” – and suggest some kind of management, or a referral to another kind of orthopaedic surgeon, or a rheumatologist, or a psychiatrist, or a neurologist… who will repeat the same.

Finally, after many investigations and referrals and consultations, around 3 years later, the person makes it to a chronic pain management centre.  (btw I am using those specialties as indicative only – could be other types of specialties too).

Once the person makes it to a pain management centre, there again is a kind of process that typically involves a medical assessment and possibly some intervention (injections, medications), and often a psychosocial and functional assessment.

Finally … the person begins self management. If they’re willing and not searching for another option or “cure”. (Remember, patients have been well-trained by this stage to hope there is something else out there to fix their problem completely.)

Now what if our health system became as plastic as our neurobiological system? What if, as evidence mounts, the pathways to management of chronic pain could change?  What if people with pain were given information so they could be informed about chronic pain – and then choose their own “next best step”?

In our own small way, a colleague and I developed a different pathway for people referred to our Centre.  We, like so many tertiary pain management centres, have a waiting list.  Some people can’t be seen within the Government-determined timeframe of six months and are sent back to their GP.  We decided to identify those people and invite them to participate in a new form of programme.  Here’s what we did:

  • Sent an invitation to attend a chronic pain seminar
  • We made it clear there would be no medical management and no individual treatment
  • At the seminar, we had a talk by one of our pain physician’s who pointed out the limited options available from a medical point of view, and outlined that chronic pain is a disorder of the nervous system, that there are different kinds of chronic pain, and that hurting doesn’t mean there is ongoing damage.
  • We then invited participants to consider attending a six week, two hours a week, group programme
  • The programme included all the usual pain management information and strategies but was delivered in a mini-lecture format, with a workbook that included home learning activities each week.
  • The programme was conducted by two occupational therapists and one physiotherapist, with the doctors involvement only at the seminar.

The numbers attending this pilot approach were quite low – a combination of winter, earthquakes, and the usual problems people with chronic pain have with transport, readiness to change, and self regulation.  It is, however, a different way of thinking about delivering pain management, and could be one way to help people access self management for their pain.  Because otherwise? They could very well continue the cycle of referral to one or more specialist medical people, more investigations, more inconclusive results, more decisions that the problem is “not theirs” – and more referrals… All the while that person and the person’s family are living in limbo.

It’s a little radical – changing the way we deliver health to side-step the wait to access self management. But what we tried to do is not the first, nor the only way to do this.

Davies, Quintner and colleagues (2011), in Western Australia, have published this study examining the effects of a brief, group-based self management programme, delivered to people before they see a specialist, with any ongoing consultation initiated by the patient. Wow! Now that’s different.

Their programme was only slightly different to ours: six-session program run over 2 days led by clinical psychologists, an occupational therapist, a physical therapist, and pain medicine physicians to impart their knowledge and to share skills.

Their aims were: (i) a reduced demand for individual new case outpatient appointments; (ii) reduced clinic waiting times; (iii) increased efficiency of clinic utilization with reduced unit costs; and (iv) improved patient outcomes and satisfaction.

Is this what they achieved? In their own words: preclinic group education for patients with persistent pain attending our Pain Medicine Unit reduced the overall unit cost per new patient and decreased the new to follow-up ratio of  attendances, reflecting the increased number of new patients appointed and reduced need for follow-up appointments. This resulted in significantly reduced waiting times for new patients to access the pain units while increasing the total number of individual patients seen.

Working in a large, tertiary pain management service within a large health service organisation can mean change is S L O W! Organisations just don’t change that fast, health delivery culture is conservative at best and stagnant at worst, and there still is a focus on a biomedical model in many centres.  This can get in the way of responding quickly to emerging needs, or thinking about different ways to conduct business.  Innovation is not always supported.

While our small project was too small to indicate whether it would be helpful or not, this one in Western Australia supports our approach.  And, for what it’s worth, I’m not sure that the specific clinicians delivering it, or the timeframe it was delivered in, are particularly significant.  It’s the concept of offering self management before medical management, and patient-initiated appointments for any further input.  Now that’s responding to need – a health system with plasticity!
Davies S, Quintner J, Parsons R, Parkitny L, Knight P, Forrester E, Roberts M, Graham C, Visser E, Antill T, Packer T, & Schug SA (2011). Preclinic group education sessions reduce waiting times and costs at public pain medicine units. Pain medicine (Malden, Mass.), 12 (1), 59-71 PMID: 21087401

Semi-structured Screening Interview for Participants in Group Pain Management


It’s not always easy to work out who will make the most of a pain management programme.  While some clinicians have a ‘take it or leave it’ approach, others spend a long time ‘preparing’ people for inclusion in a programme – or is there another way?  We do know that not everyone who attends a programme will ‘fit in’ – some people have difficult communication skills (or lack of), some are not able to focus for the time needed for a 9 – 4 daily programme, some have ‘other issues’ that interfere with participation (like chaotic lifestyles or alcohol/drug problems), and some are simply not looking for what a programme is intended to address.

While there is no guaranteed way to accurately select who is ‘in’ and who is ‘out’, the process that I’ve used  (in conjunction with the team with whom I work) follows a ‘motivational’ approach.  This leaves the person in charge of whether they want to be part of the programme, but also allows the team to decide whether the person meets the criteria for entry.

This is the process…

Everyone who is referred to the programme has completed a Comprehensive Pain Assessment (CPA) consisting of a medical, psychosocial and functional assessment.  All the biomedical and pain reduction recommendations from this assessment are completed before the person is able to be considered for the programme.  This ensures that the person isn’t expecting these approaches to remove the need to learn how to live despite the pain.  Over the years I’ve worked in pain management, I’ve found it difficult to work pain reduction efforts alongside a pain management focus – it’s hard for the person to avoid the temptation to think that pain management won’t be needed because the pain ‘will go away’.

The screening appointment is for around an hour, sometimes a little longer.  Two clinicians from the pain management programme team are involved – and we try to make sure the people who are involved in the screening are not the same people as were involved in the CPA, to ensure a fresh look at the situation.  We follow a semi-structured interview process, and at this point we don’t ask for further questionnaires but instead rely upon the CPA results and our discussion to make our decision.

The first part of the interview, after establishing the purpose of screening, is to find out what has changed (if anything) since the person attended the CPA.  We want to know what their response is to the recommendations, whether they’ve been implemented (eg medication changes, investigations), and whether the recommendations have made any difference to the person’s pain.  Often we find that medication changes that have been recommended are not implemented – maybe because of side effects, or reluctance to use medication at all, or because of miscommunication between the pain management centre and the person’s own GP.  We also ask about any other or new medical problems that might have arisen, and if there have been any other life changes since the CPA.

This part is a bit like drawing a line underneath the ‘pain reduction’ aspect of managing pain, but it also helps us gauge the person’s response to the idea of their pain being ongoing, and whether they’ve started to accept the chronic pain model.  Our key question is whether they’re still thinking that further investigations or treatment might ‘find the cause and fix it’, because this can make being part of a pain management approach quite difficult.

We then ask about their understanding of their pain, the effect of their pain on important parts of their life, and what they are currently doing to cope.  The purpose of this part is to firstly understand where they are coming from, and secondly to come alongside them to determine whether their coping strategies are giving them the life they want.  One of the key questions is ‘How well are these ways of coping working for you?’.

In the language of ACT, I suppose at this point we’re aiming to develop a sense of ‘creative hopelessness’, or a sense that maybe there needs to be a new way of doing things so they focus less on the work of getting rid of their pain (and all the associated aspects of ‘being a patient’) and more on living a good life (being a person again).  We’re also asking whether they think they need to make any changes for the future – creating a discrepancy between what they’re doing now and what they really want in life.

We move on to what they think life might look like if things were different, if pain was ‘less of a problem’ for them.  We’re quite explicit that we’re not aiming to reduce pain, but we also make it clear that pain can interfere less.  We’re gently probing to find out what the person might want to be able to do (ie their goals) if they were to be part of a programme, so we might ask about how they would know whether a programme had been successful, what ‘living well’ might look like, what they’d like to regain from what has changed since their pain started.

At times during thist section of the screening, we may reflect on the concerns the person raised during the original CPA – things like sleep, leisure activities, family relationships, work and so on may be the sort of thing the person may want to be able to discuss.  This part of the screening aims to develop a sense of hope and looking forward, and to see what sort of specific goals the person might have.  We’ve found that goals that are contingent upon reducing pain are generally not helpful, and by identifying whether there are other things the person wants, we’re able to help them generate positive and personal reasons for being part of this programme.

Around this point we’ll usually ask the person about what they know about the programme, and we’ll go through a brief outline of the purpose, approach and structure of the three weeks.  We’ve already pointed out at the beginning that there are no guarantees that the programme will be the right thing for this person, or that the timing of the programme will be right – it’s our aim to let the person know that the screening is a collaborative process, and if they decide it’s not the right approach, or the timing isn’t right (or we have reservations about their suitability for it), then that’s OK, the door is open for them to come back when they’re ready for it, or have made the sort of changes we require.

There can be many reasons for someone to decline being part of our pain management programme – and for us to determine that the programme’s not the right thing for that person at this time.  So we make sure we’re clear about the requirements –

  • it’s a group programme so how do they feel about being in a group?
  • it’s all day, everyday for three weeks and missing sessions because of a flare-up isn’t OK, so how do they feel about that?
  • it can be challenging, we will be asking them to do things they may be afraid of (particularly movements and activities that could increase their pain), are they up for it?
  • it doesn’t involve ‘hands-on’ therapy, does this match with what they’re expecting?

We usually take some time at about this point to talk together as a screening team, and allow the person to ponder what we’ve discussed.  We’re considering many things, and we’re still developing a feel for what it is that we’re using as guidelines for inclusion and exclusion.  Some of the things we’re looking for are:

  • a sense the person wants to make changes in life
  • readiness to accept their pain as unlikely to be abolished, and readiness to stop actively seeking pain reduction
  • some ideas about what life might look like if things were to change
  • the absence of litigation or pending disputes/mediation (these make it difficult for the person to focus during the programme)
  • mood, concentration and general ability to sustain the 6 hours each day (we don’t mind the person getting up and moving around, but sleeping half the day probably won’t be helpful!)
  • any investigations or other medical things being complete
  • whether a group-based approach (which is necessarily general in nature) will address the specific concerns about their pain, and whether they have the communication skills to manage a group setting

After our screening team discussion, we return to the person and ask whether they have questions about the programme.  We’re most likely at this point to let them know our thoughts, and establish whether they’re ready to consider the programme – and the timing of the programme.  There is little point in someone coming to a self management programme if they’re also coping with other life changing events like moving house, or the arrival of a new baby!  The programme is intensive and we make that very clear, but we also let the person know they have support throughout the three weeks, and in the period up to six months after the programme.

I suppose it’s a matching process where the expectations of the person and our knowledge of the content of the programme are compared.  Even if someone isn’t ready for the programme at that time, we’re able to record this and review them in the future.  Our report summarises our discussion, and even if the person doesn’t attend or needs something else, we think this report is useful and can guide both the person and their health care team towards the most appropriate option for them.

Group-based CBT for pain in primary care


ResearchBlogging.org
I briefly discussed yesterday the content of this six-session group-based cognitive behavioural approach for chronic pain, delivered in the community. Today I want to look a little more closely at the way the programme was delivered and how the findings might differ from what happens in New Zealand.

To refresh your memory, this is a study of around 700 people with sub-acute or chronic ‘troublesome’ low back pain, recruited via their GP, who were randomised into two groups – while both groups received ‘advice’ in the form of ‘The Back Book’, the CBT group also received the CBT programme, while the other group were able to seek their ‘usual care’. The programme was delivered to groups of roughly 8 participants by a single therapist, and the therapist could be from a number of different health professions (physiotherapy, occupational therapy, psychology etc). Each session was intended to be 90 minutes long, and include guided discussion and some individual attention about the exercise component. Content was along the lines of ‘standard’ CBT for chronic pain management.

The study was commissioned by the UK’s National Institute for Health Research Health Technology Assessment Programme, and was a ‘pragmatic’ trial – in other words, assumed to be pretty much how it would be delivered long-term, with ‘real’ patients from differing backgrounds and so on.  What’s nice about the whole process is that there have been several papers published on it over the time the project was run, so it’s well-documented and it’s easy for other providers and researchers to see how the team went about it.  Very helpful if you’re wanting to establish something similar elsewhere!

I was firstly interested in how participants were recruited to this study.  The study indicates that people were recruited from GP surgeries, either because they’d been seen by their GP or practice nurse, or identified through clinic records.  One of the ongoing problems with self-management for pain is the difficulty obtaining suitable referrals – both health providers and patients often want a ‘medical’ approach with diagnosis and removal or reduction of pain – so it’s not always easy to find people who are ready for self management or a CBT approach. This paper doesn’t discuss how the participants were approached – which would have been nice to know.  It does, however, discuss how many were approached but declined to participate: over 460 to the CBT group, 75 of these didn’t proceed, while 233 received the advice with 6 withdrawing from the study.  Probably not unexpectedly, many withdrew from the study because of the number of questionnaires!

The ‘completion’ criteria used to establish whether participants had completed the CBT component of the study was very interesting to me – participating in the initial assessment, and attending 3 of the six sessions.  I think this is quite a conservative ‘completion’ criterion, given that each session planned had very specific aspects of the CBT approach within it – those that didn’t attend all six sessions would have missed out on what I’d think were quite important aspects.  Of course, we don’t know which aspects of the CBT approach do the therapeutic ‘work’, so maybe it’s moot!

Now for the good news: Compared with advice alone, advice plus cognitive behavioural intervention was associated with significant benefits in nearly all outcomes at 3, 6, and 12 months.  Not only this, but more participants in the CBT programme were satisfied with their treatment.  BUT, the mean total health-care costs per person for low-back pain (including the intervention) over 1 year were £224·65 for advice alone, and £421·52 for advice plus cognitive behavioural intervention. The mean cost per person was £16·32 for advice alone and £187·00 for advice plus cognitive behavioural intervention. The difference in total health-care costs was attributable almost entirely to the additional cost of the cognitive behavioural intervention.  It’s not cheaper to deliver a CBT approach compared with advice plus usual care – and, unfortunately, there were no significant differences in the use of NHS or private health care between groups during the year of the study.  Darn.  This type of programme shouldn’t be seen as a cost saving exercise – it’s something else entirely for me.

For me it’s about some of the longer term benefits as well as the breadth of the benefits to the individual. Here’s what I mean: The study authors suggest that “the short-term effects (≤4 months) are similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care.” They go on to add that “Unlike many of these other treatments, the benefits of cognitive behavioural intervention were broad ranging and maintained at 12 months, suggesting that these benefits will translate into substantial health gain at a population level.”

My point is that unlike manipulation and acupuncture, the skills these people developed can be used anywhere, don’t require health care provider input once they’ve been learned, and can be applied to several types of health problem. They don’t just address pain reduction and range of movement, but also influence overall disability, fear of moving despite pain, confidence to do things despite pain, and mental health.

Once the calculations are carried out (and, no I’m no health economist), it seems that the Quality Adjusted Life Years (go here for a brief discussion of QALY) for the CBT approach are much greater than for the control group (advice only). By comparison with the costs of other treatments I can think of (like injections or surgery), the up-front cost of this approach is much less.

In New Zealand, unless your back pain develops from an ‘accident’ as defined in the ACC legislation, you’re not very likely to get consistent advice a la The Back Book. This means that simply by providing The Back Book to people with back pain, the ‘control’ condition in this trial probably got something that many people in NZ don’t get: consistent advice that moving despite pain is good for back pain, and brief coverage of some of the methods to help manage distress and pain. One study by Cameron Crawford, Kathleen Ryan, and Edward Shipton (2007) found that 90% of people with low back pain were managed by the GP alone, but few of the GP’s considered psychosocial yellow flags – and their orientation towards managing low back pain was primarily biophysical. Whether this meant that people seeing their GP received advice to continue with activity, or whether this advice was supported by any printed material is unknown but it seems probable that few patients received the consistent information provided by The Back Book in this study.

The study authors make several points about this approach by comparison with other ways of managing low back pain in the community.
1. The primary intention of the BeST programme was to challenge beliefs and change a range of behaviours in people with low back pain. This is quite a different approach from the pain reduction focus of most treatments found in the community setting for low back pain.
2. Over 95% of the intervention contact time was directed toward psychological goals. This is in contrast with the ACC-sponsored focus ‘Activity Focused Programme’ in New Zealand which often consists of little more than regular attendance at a gym or other fitness activity.
3. The authors estimate that direct supervision of exercise occurred in less than 20% of participants for less than 5% of the intervention time. This is quite different from many physiotherapy-based approaches in New Zealand, where direct supervision is a requirement.
4. The programmes were delivered by experienced clinicians (an average of 9 years post-graduate experience) from a range of backgrounds, mostly physiotherapists, with a single therapist involved. Training in the programme took only two days. This is also quite different from the AFP approach adopted in New Zealand by ACC which mainly involves multiple professionals and the CBT component must be delivered by a clinical psychologist.
5. The outcomes, while significantly different for the CBT approach as compared with the control group, were not enormous in real terms – only 1 – 2 points on the Roland Morris Disability Questionnaire. Despite this, the authors say “there is evidence of moderate effect with the BeST intervention, there is no evidence of harm within the sample, and it is accepted that the consequences of developing and sustaining chronic low-back pain are important at the individual and societal level.” They go on to add “small to moderate effect sizes are important at a population level and that pragmatic trials will yield lower effects. The results of the cost-utility analysis re-enforce the conclusion that this is a clinically worthwhile intervention” and finally, they state “Recent UK and US clinical guidelines have made positive recommendations for other therapist delivered interventions on the basis of results from trials with smaller or unsustained effects.”
I can’t say that New Zealand health services have made similar errors – there have been no recent guidelines for managing low back pain published in New Zealand for some years.

Where does this leave me now?
Excited that a practical approach to helping people live well without needing ongoing input has been demonstrated.

Keen to look at the gaps in service delivery within New Zealand – particularly with the very large group of people who don’t receive ACC funding for treatment for their pain, and for the even larger group of people who can’t access CBT pain management because it’s not readily available in many centres (unless funded by ACC – and even then, it’s patchy).

Concerned that there doesn’t appear to be a systematic approach to developing community-based pain management using a CBT approach in New Zealand, despite the number of people living with chronic pain.

And concerned that the prevailing view in some sectors of health service delivery is that ‘only’ specific professional groups have the skills to deliver a CBT approach for pain management.

Where to from here?
I guess I want to encourage managers and policy development people to consider the ways pain management services are delivered, and the current focus on pain reduction and a biomedical approach to be expanded to include a CBT approach based in the community. As an old TV commercial used to say ‘One day, Roger Fitch, one day…!’

 

Lamb, S., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E., Nichols, V., Potter, R., & Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis The Lancet, 375 (9718), 916-923 DOI: 10.1016/S0140-6736(09)62164-4

Group-based CBT for troublesome low back pain


ResearchBlogging.org

These two papers have created a bit of a storm in the health news recently – a six-session CBT group programme for chronic low back pain that not only provides good outcomes, but is also cost-effective?  Unbelievable!  And it’s not delivered exclusively by any specific health professionals.  AND it’s delivered in primary care!

My take on this study is, much like others, very positive.  I think it’s wonderful that an intervention that has been used for years in secondary and tertiary health care has been successfully translated into primary care.  It seems to have used a pragmatic study methodology, and pretty fairly represents the kind of person that, at least in New Zealand anyway, misses out on pain management of this kind unless they’re funded by ACC (Accident Compensation Corporation).

Let’s take a look at the methodology first up.

The justification for this intervention is very clearly described in the first paper by Hansen, Dayken and Lamb.  Their brief was to develop and deliver a 6-week CB group programme delivered by a health professional for patients in primary care, who received this in addition to active management, which comprised a session of advice supported by the ‘Back Book’.  The ‘active management’ arm of the study then allowed these participants to seek any other treatment they wanted, while the researchers reviewed outcomes at 12 months after the intervention.

Hansen, Dayken and Lamb identify that “CB [approach] may be useful in modifying … health behaviours and risk factors [for disability from LBP] through targeted action on beliefs and positive coping strategies.”

Their research questions were:

• What does the research on risk factors for chronic LBP identify as potentially important health behaviours, beliefs and psychological constructs to incorporate into an intervention?
• What does the CB treatment model consider important in the design of a CB intervention?
• What is the optimal delivery method to balance clinical effectiveness and cost-effectiveness?

CB approaches, as regular readers of this blog will know, suggest that how an individual views his or her situation can influence emotions and behaviours in a bidirectional relationship.  Chronic pain management using this model suggests that by adopting a positive, self management approach, developing effective thinking strategies and learning appropriate problem solving techniques, disability and distress associated with ongoing pain can be reduced.

There has been a great deal of research into the use of CB approaches in chronic pain, sub-acute pain and across a range of types of pain.  Results have been mixed in some instances, but overall show short term positive outcomes for pain and disability, while longer term outcomes have not always been studied (mind you, ‘long term’ for drug trials is often three months!).  There seem to be no major differences between group-based or individual therapy, although group-based approaches appear to be more cost-effective (try telling that to the organisation I work for!).  Similarly there appear to be no major differences between who delivers the intervention, although most studies have clinical psychologists providing the cognitive behavioural components, while mostly physiotherapists deliver the exercise or activity components.

The key targets for this trial were:

• to increase activity levels;
• to manage periods of overactivity;
• to specifically address catastrophising and fear avoidance;
• to improve coping skills.

The rationale for session focus and content is detailed in this paper, and the group eventually arrived at a six-session programme with one additional session prior to the programme for assessment.

Each session is detailed (although not the exact content – but certainly the headings!), and they look very similar to, for example, the content of Turk & Winter’s book ‘The Pain Survival Guide’.

Content covered the following:

Understanding pain

Benefits of exercise

Pain fluctuations

Working out starting point for exercises or activities

How to set goals

Unhelpful thoughts and feelings

Relaxation

Restarting activities or hobbies

When pain worries us

Coping with flare-ups

Group sessions included group-based learning activities (experiential learning), with guided discovery as a primary method for helping people discover, for themselves, the issues and options available to them.

There was a standard agenda for each session:

Structure of BeST group sessions.
Agenda setting
The topics to be covered in the session are outlined at the start of
the session and the participants are asked if they have any
questions or problems that they would also like covered.
Review of homework/setting of homework
All sessions involve some home tasks. These are designed to
allow the participants to practice skills taught in the sessions.
Review of homework allows for group problem solving.
Session/topics
Each session covers one or two new topics as shown in Table 1.
There is also a quick review of the previous session at the start.
Break
Each session involves a 10-minute break to allow participants to
move around or exercise, and for the therapist to check exercise
programmes with participants as required.

A couple of interesting points:

– the sessions were delivered in a community setting

– sessions were 90 minutes long

– sessions were delivered by a range of different health professionals

– group sizes were an average of 8 but between 4 – 12

– each group was facilitated by one therapist

If you’re wanting a simple outline of the rationale for, and the content included in a CB group programme, this paper certainly delivers.  It’s got a good number of references, and although brief, provides the sort of summary that a technically-minded health policy group could cope with.  Abbreviated a little more, it would be a useful summary for a group of managers.

Now to the results:  Lamb, Hansen, Lall, Castelnuova et al (2010) published this study in The Lancet – and it’s had, as I mentioned, wide coverage.  Cutting to the chase, this programme was able to demonstrate effective outcomes both in terms of functional outcomes (reduced disability, distress etc), but also cost effectiveness – The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0·099; the incremental cost per QALY was £1786, and the probability of cost-eff ectiveness was greater than 90% at a threshold of £3000 per QALY. There were no serious adverse events attributable to either treatment.

That last point is pretty good to hear – it’s one of the ‘costs’ of treatment we don’t often hear about when looking at, for example, injections, medications or surgery.

So, to be sure, this study compared a simple ‘advice-giving’ option plus ‘usual care’ with the six week CB approach, so the costs of the alternative were potentially quite low – but at the same time, the outcomes were quite impressive.

Were these patients like the patients typically referred to tertiary pain management centres?  Well, compared with those referred to the facility I work in, no.  They were much less distressed, less disabled, and more of them were working.  Many were retired folk, but there were far fewer who were receiving benefits than those I typically see.

I’ll continue with the review of this paper tomorrow – because there are some interesting things to be learned from it.  I hope this outline of the content at least whets the appetite for more!

Hansen, Z., Daykin, A., & Lamb, S. (2010). A cognitive-behavioural programme for the management of low back pain in primary care: a description and justification of the intervention used in the Back Skills Training Trial (BeST; ISRCTN 54717854) Physiotherapy, 96 (2), 87-94 DOI: 10.1016/j.physio.2009.09.008
Lamb, S., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E., Nichols, V., Potter, R., & Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis The Lancet, 375 (9718), 916-923 DOI: 10.1016/S0140-6736(09)62164-4

Efficiency & pain management


ResearchBlogging.org
I can’t remember a time when people working in health were told ‘Go and spend as much as you like to help people get well’ – in fact, in over 20 years I can only recall being told ‘there is less money in the kitty, we need to look for efficiencies, tighten your belts’!

So it’s no surprise to me that once again, no matter where you look in the world, health professionals are being told to look at ways to be more efficient.   I don’t have a problem with this – if I’m a patient I want to know I can be treated quickly and effectively so I can get back to being a person and not a patient.  What I do have a problem with is when, in the urgency to save money, problems in health care are given a quick fix solution without taking a look at the systems in which the services are being delivered.

With a chronic health problem, the main problem is that patients don’t get cured.  This means that once a person has been seen for treatment, it’s highly likely they’ll return – so along with new referrals to a service, there is a steady stream of people being re-referred, and what isn’t entirely clear is why they might need to be seen again.

Let’s take a look at why people are referred initially to pain management – and what they expect.  Allcock, Elkan & Williams explored, using focus groups, the beliefs, expectations and priorities of a group of patients referred for pain management.  Like my brief study a couple of days ago, they found that the majority of patients were looking for a firm diagnosis and a cure.  The patients they talked with believed there ‘must’ be a cause that could be found, that people around them wouldn’t believe that they had ‘real’ pain without being able to give a diagnosis, and that while they wanted pain killers at the same time they felt ‘just’ getting pain relief was ‘fobbing’ them off.  People didn’t know what to expect from coming to a pain management centre, and their focus was on reducing their pain – even if they felt just getting pain relief wasn’t enough.

Looking at this from a ‘stages of change’ model, my guess is that most people are in a precontemplative stage with respect to accepting that their pain is chronic, and that self management is a good option.  No wonder some people leave a centre feeling bitterly disappointed that the ’cause’ of their pain isn’t clear, and don’t fully accept the idea that self management is a positive option.

While the underlying pathology of chronic pain may change slightly over time, despite some advances in pharmacology, we don’t have an awful lot of medication options for many chronic pain conditions.  Options for something like fibromyalgia are really limited.  But ask someone with chronic pain if they ever stop hoping for ‘something, anything to reduce the pain’ and you’ll probably hear them say no!

Along with the hope for relief, there is a good deal of evidence in the literature that people who don’t feel they have a clear diagnosis, who are distressed or anxious about having pain, who expect that doctors ‘should’ be able to fix their pain, and many of those ‘yellow flags’ or psychosocial factors – these people tend to visit doctors more often than those who are more accepting of their pain.

Faced with a distressed and sometimes angry patient, a GP may well bow to pressure and want to start the process of referring for more investigations, another specialist opinion and yet another referral to pain management centre.

In one pain management centre I know quite well, up to 60% of the referrals received over a five month period were re-referrals of patients who had already been seen in the centre.  What that means is that only 40% of the referrals were for new patients – and given a waiting list cap of six months, it’s inevitable that some people will be turned away.

Now for some hard questions.

Why are people being re-referred?  Well, I actually don’t know in the case of this centre, information isn’t available.  Maybe this group of patients are more distressed, more depressed, more anxious than the average patient – at least, that’s what the literature suggests.  Maybe their health care providers are also more worried about pain, perhaps less confident to deal with people who are distressed.  Maybe their health care providers believe, like their patients, that there ‘must’ be a cause and therefore a cure for the pain.

If these patients have been to pain management before, why haven’t they adopted the self management model?  Maybe this is because they weren’t ready for it, or maybe the services they received weren’t effective (pain management lite, or low intensity pain management of less than 100 hours has been shown to have less effect than an intensive programme with an interdisciplinary team – according to Assoc. Prof. Mike Nicholas).

What is a tragedy is that many will be seen again and given another round of medications, perhaps they’ll get some more pain management – but without measuring the outcomes, we won’t know whether this is effective.  And they may well be re-referred in another 12 months because (1) they haven’t developed a sense of their own ability to manage their pain (2) their GP isn’t confident to support their self management (3) they got a sense of relief from distress at being seen by a ‘specialist’ (4) their GP thinks there ‘must’ be another medication that hasn’t been tried yet (5) and rarely, this time they’ve shifted from wanting something or someone else to manage their pain, and now want to develop self management strategies.

OK, I don’t know whether those reasons are true, they’re a hunch.  But what I do know is that the problem of re-referrals for a chronic condition clogs up health delivery, and that internationally a self management approach has the widest support for chronic conditions.  And yet time and again, people with chronic pain actually receive passive treatments, medication reviews, and more injection procedures.

A study like the Lamb, Hansen, Lall et al., one I’ve cited below demonstrates that even a six session group-based CBT programme of self management, delivered by physiotherapists, nurses, psychologists and occupational therapists (no discrimination here!) could provide effective outcomes that last even up to 12 months after the intervention.  In terms of efficiency (oh yes!) the CBT approach was more cost effective (cost per QALY) than acupuncture, exercise, manipulation, and postural approaches – all of which are supported in recent Clinical Guidelines in the UK and US.  It’s only a pity that a comparison between this approach and medications or injections wasn’t made.

Are these patients like the patients referred to secondary or tertiary pain management? Taking a look at their disability level, the duration of their pain, working status and age/gender – yes.  Is this an efficient way to help people cope with their chronic pain? It seems so – yet I wonder whether group-based CBT will survive in New Zealand.

Lamb, S., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E., Nichols, V., Potter, R., & Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis The Lancet, 375 (9718), 916-923 DOI: 10.1016/s0140-6736(09)62164-4

Allcock N, Elkan R, & Williams J (2007). Patients referred to a pain management clinic: beliefs, expectations and priorities. Journal of advanced nursing, 60 (3), 248-56 PMID: 17908123