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:


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

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
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

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


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.
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.
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/
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
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

A wish list for a pain management programme
After coming up with some of the content and structure for a programme, and discussing the need for a stable clinical team with effective skills in group-based CBT and an applied behavioural focus, today I thought I’d add in something about selecting, assessing and follow-up that’s required.

I get absolutely frustrated with reading and hearing about interventions that are either not required to furnish, or don’t consider outcomes – both psychometric questionnaire results (thought to indicate change in the ‘real world’) and real world outcomes.  The art of making sure that what we do makes a difference, and knowing how to do this well seems to be quite lost on many clinicians and it really frustrates me.  I’d find it professionally unsatisfying if I carried out an intervention and never had a clue as to whether it made a difference long after I’d finished seeing the person, so I can’t understand why so many clinicians (a) don’t measure outcomes (b) measure them poorly either through inadequate pre-treatment measures, inappropriate timing of post-treatment measures, or using irrelevant measures (c) measure outcomes using only psychometric questionnaires, or unidimensional measures.

I’ve mentioned outcomes first because part of selecting people for a programme is about taking baseline measures so that you know where you’re starting from, and you can ensure the programme is appropriate for the person’s needs.  Selection also includes identifying the person’s readiness to move towards self managing pain, because if someone’s not ready they can become resistant (just think of all the ways people avoid doing what they don’t want to do! And include yourself), become ‘innoculated’ against the concepts (‘tried that, it didn’t work’), and influence group process negatively.

Just as a surgeon selects people for surgery after careful assessment, and declines surgery for people who are unlikely to benefit from it, so we need to be similarly selective in pain management.  Pain management programmes are not ‘the last resort’ after everything has failed, they are a positive step forward for people who need to and want to take over the management of their own situation.  Like any other self management programme like alcohol and drug rehabilitation, until the person is ready to do what will be very difficult and life-long, it’s unlikely they’ll benefit.

Every participant for a pain management programme needs to be comprehensively, and recently, assessed from a biopsychosocial perspective. Medical issues need to be managed before programmes commence, and the person needs to be reassured that they are safe to begin to do things again – and I’m afraid, this almost always needs to be reassurance from a doctor.  Psychsocial issues influencing the person need to be identified – note the word psychosocial. Without considering the social it’s unlikely the situational and contextual factors that often constrain behaviour change, including things like litigation, family, case management issues and work issues.  These factors influence beliefs, attitudes, behaviours and emotions and it’s critical that the person is seen as one person within a whole network of others.

When screening to establish readiness for pain management, other factors to consider are concurrent activities like vocational management, other investigations and pending treatments, evne things like holidays and training.  Some of the other areas that might make it difficult for someone to participate are communication style, cognitive functioning, learning style, fatigue, activity level, and needs that don’t ‘fit’ with the majority of the programme participants and content or structure.

I’ll post a screening semi-structured interview later today, that I’ve used to help identify whether a participant is ready and appropriate for a group pain management programme.

All participants need to have some baseline measurements taken before a programme.  In fact, there should be one set at comprehensive assessment, and a second set before a programme, another set at completion of the programme, then at least two, but preferably three times after – I think 1, 4 and 9 months later, or thereabouts.  As time progresses, the intervening variables confound outcomes, and the number of respondents also drops, so it can be a challenge to obtain enough responses and for them to reflect programme changes over time.

What to measure and how?  I’ll leave that for another day, suffice to say that questionnaire results are not enough.  Not that they’re unimportant, because they are – but until they have had predictive validity established within the community in which your patients live, they may not reflect much useful information.  Real world actions are far more valid, but are much more difficult to measure accurately – on the other hand, I think I’d like a valid measure that actually measures something important and useful, than to measure something irrelevant but do so incredibly accurately.  Otherwise we could all give participants a blood test for glucose levels and be done with it!

References?  Loads and loads of ’em.  Where do I start?

The first and probably most comprehensive reference is either of the two editions of Pain Management: Practical applications of the biopsychosocial perspective in clinical and occupational settings by Main, Sullivan & Watson.  The first edition was by Main & Spanswick, it’s a Churchill Livingstone publication under the Elsivier imprint.  The first edition contains almost a ‘recipe’ for how to run this type of programme, while the second edition contains more conceptual material but provides excellent information to support clinical practice.

Further references:

Fordyce, W E (1976). Behavioral methods for chronic pain and illness.  CV Mosby, St Louis, MS.

Turk, D, Meichenbaum, D, Genest, M. (1983). Pain and behavioral medicine: a cognitive-behavioural perspective.  The Guilford Press, New York.

Loeser, J., Sullivan, M. (1995). Disability in the chronic low back pain patient may be iatrogenic. Pain Forum, 4: 114-121

Main, C., Parker, H. (1989). The evaluation and outcome of pain management programmes for chronic low back pain.  In Roland, M., Jenner, J. (Eds.) Back pain: New approaches to rehabilitation and education.  Manchester University Press, Manchester, pp 129-156.

Keefe, F., & van Horn, Y. (1993). Cognitive-behavioral treatment of rheumatoid arthritis pain maintaining treatment gains Arthritis Care & Research, 6 (4), 213-222 DOI: 10.1002/art.1790060408

A wish list for a pain management programme
As I review the last few people I’ve had the privilege to assess, I can see numerous factors that have lead them down the road to chronic disability from their persistent pain.  One of the most common would have to be multiple medical assessments with medical management that has failed to address the person’s disability, while in some cases actually increasing the person’s beliefs that they are not in control of their lives.  An example? A man I saw who, four years after the initial event firmly believes the annular tears must ‘heal’ before he can return to work.  Two orthopaedic surgeons indicated to him that surgery wasn’t an option (and he didn’t want it anyway) but also advised him ‘these things take time to heal’ – or at least that’s what he heard.

Another reason for ongoing disability is the failure of pain management programmes to address the person’s beliefs about pain.  As Bill Fordyce is reported to have said ‘Information is to behaviour change as spaghetti is to a brick’ – hence my concern when I read a very authoritative book written by three highly respected clinicians and researchers where ‘education’ is the term used for the process of helping the participants develop a new understanding of their pain and their role in managing it.

Education, information and teaching are often words used around the concept of helping people reconceptualise their pain.  Sadly, without very good skills by the clinician, this can turn into an ‘information dump’ and leave the participants only slightly less confused than before!  The processes that seem to work better involve ‘guided discovery’ or Socratic learning, and experiential learning with the opportunity to reflect.

There are arguably four broad groups of techniques for helping people to understand their pain and their role in pain management for themselves.

  1. Learning the various connections between thoughts, situations, and emotions
  2. Gathering evidence from their own experience, and becoming more objective about the patterns of thinking that each person has
  3. Using mini experiments to try different approaches out
  4. Exploring underlying beliefs and assumptions

This process is collectively called ‘collaborative empiricism’ where the participants and the facilitator join together to explore experiences and understand what is going on.  In a group setting this becomes a process where the participants both become exposed to their own processes, but also the processes of others – and by the end of the programme, become adept at being therapists for one another, asking questions rather than giving advice or feedback.

The process of helping participants become their own therapists is not easy.  It requires the facilitator to be very knowledgeable about pain in order to correct myths, and it also requires the facilitator to be very adept both with Socratic questioning and guided discovery as well as group facilitation.  No wonder facilitators get tired after a group session!

Often, clinicians who get involved in pain management group programmes come from a background of clinical psychology or occupational therapy.  Unfortunately, having professional registration does not mean that the clinician has specific skills or training in pain management or group facilitation.  It does take time to develop these skills.  Unfortunately in the literature on pain management within groups, there is a real dearth of research looking at the necessary skills clinicians require to help develop effective group therapy.  Instead, the majority of research into cognitive behavioural approaches for pain management is carried out by psychologists, with the assumption that this training is sufficient.  It’s great to read in Main, Sullivan and Watson’s book Pain Management 2nd edition (2008) that the skills required are emphasised rather than the professional discipline.  Certainly many other health professionals have specific training and skill in group therapy, amongst them social workers and occupational therapists.

Something that has been investigated very recently is the stabiliy of membership within a clinical team working in group pain management.  Interdisciplinary teamwork has been identified as a strength in pain management – it requires that each profession become very familiar with a common model (cognitive behavioural approach within a biopsychosocial model), with each other’s strengths, and ultimately, to be able to work almost across disciplines to support each other’s interventions.  This takes time.  The communication between team members must be very strong, and decision making processes including conflict resolution need to be well-established.

A paper recently available by Amanda Williams and Henry Potts looked at two factors that they thought may affect outcomes achieved after group CBT for persistent pain.  Both group membership (who the participants were in the programme) and staff turnover were examined.  The data was collected over 16 years (3050 participants), and included pre- and 1-month post-programme questionnaires.

Their findings?  ‘Linear regression showed that high periods of staff turnover were significantly
related to poorer outcomes on self-efficacy and distance walked at end of treatment, with the
effect on self-efficacy persisting to 1 month follow-up.’

I’ll discuss the group membership findings in another post, but it’s interesting to see the areas that were directly influenced by staff turnover.

Membership of the teams were ‘… multidisciplinary teams of psychologists, physiotherapists, occupational therapists and nurses, with doctors working across teams. This meant that patients usually related mainly to a core team of four staff members, but up to seven if staff were part-time. The inpatient treatment programme remained largely consistent in content and process over the years covered by this study.’

One of the psychologists, one of the physiotherapists and one doctor remained constant throughout the study period.  New staff were usually less experienced than those who had left, and worked under supervision for several weeks before commencing with the programme.

The results showed ‘for each change in staffing, patients on average had a PSEQ score that was 1.2 points lower, a Normalized catastrophizing score that was 0.04 standard deviations higher, and walked 4.6 m less at the end of treatment.’

Some very useful ‘managerial’ aspects are considered in this paper: Therapist emotional wellbeing has been reasonably consistently related to better outcomes.  The treatment unit had periods of strengthened institutional support and growth and others when its future was uncertain. It is likely that these difficult periods were reflected in poorer team cohesion as well as in turnover, and that staff who were expending energies on the unit’s survival had less to offer patients.

I wonder what steps organisations take to address these issues, particularly when calls to ‘be efficient’ often demand therapists see more patients in less time.  In the end, outcomes are what matters – what is the point of seeing a large volume of patients, only to have them return as re-referrals later?

It’s clear that a combination of the right treatment for the right patient is important – but it seems equally clear that the role team members play, the level of skill, the level of support and the team processes are also important.

Williams, A., & Potts, H. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain Pain DOI: 10.1016/j.pain.2009.12.011

Attention Please! Attention management for chronic pain
A debate that’s been going on for some time is the role of ‘distraction’ in pain management.
So many of the people I see have told me they ‘just ignore’ the pain, or ‘I try to distract myself’, or similar, that there isn’t much doubt to me that people habitually use attention management as a coping strategy – yet the research findings have been quite mixed, especially with respect to ‘distraction’ and ‘ignoring’ pain.

Pain is naturally an attention-grabber. That’s one of the main purposes of acute pain, IMHO, to attract attention and direct the person to DO something in response. Of course in chronic pain, there is little to DO, so the person needs to redirect attention away from pain and back into the task at hand.

As I posted late last year, this process of redirecting attention detracts from the cognitive reservoir, so there is more effort needed to carry out tasks, it is more fatiguing, and it requires effective self regulation which also becomes depleted over time. (As an aside, I wonder whether one of the features of resilient people is that they have more effective self regulation skills, so they achieve more despite chronic pain – just a thought!).

The results from attention management are mixed, but despite this, many if not most CBT programmes include something on attention management such as attention diversion, imagery, and more recently, mindfulness.  The theory behind these interventions is derived from several models: Fear-avoidance model suggests that by avoiding activities, the negative thoughts about the pain become dominant and the individual becomes hypervigilant.  An information processing model suggests that there is only a certain amount of ‘brain space’ available to actively process information (a little like a torch shining into a dark room illuminates only what is within the beam of light), so whatever is salient, novel, intense and so on will ‘grab’ the attention, leaving the rest of what is going on to be ‘in the dark’ so to speak.

Mindfulness brings another style to attention management.  In mindfulness, the possibility that sensations can be recognised as simply that: sensations without emotive labelling (‘that is prickly’ rather than ‘I hate that prickly feeling’); leaves the individual able to engage with the sensations (ie feel them) but not buy into the emotional burden of judging those feelings.

A well-written but not empirically-tested manual for attention management was used in this study by Elomaa, Williams and Kalso (2009), to specifically look at the effects of attention management provided in a structured way, and within the context of a group programme.  The authors indicate that there were no other cognitive coping strategies provided as part of this programme, and that the facilitator followed the manual and allowed group discussion using CBT principles to help develop the skills.   The participants did, however, receive treatments aimed at reducing pain during the programme.

As usual, a battery of questionnaires was given to participants and these included the Pain Anxiety Symptoms Scale, the Fear Avoidance Behaviour Questionnaire, the Pain Vigilance and Awareness Questionnaire, and a Depression Scale.  Measures were taken at five time points (initial assessment, pre-treatment, post-treatment, 3- and 6-month follow-up). Information about pain location, duration of pain and work status was collected at every time point.

The treatment consisted of modules, which share a common CBT structure, from orientation, assessment, and reformulation/re-conceptualisation of the main issue to skills teaching, rehearsal, generalization and homework exercises.  If you’re interested, I’ve given the link to the manual above, and this paper also outlines the content of each of the six sessions provided.

57 participants were recruited to the programme, 41 started treatment, and five either  didn’t complete all the sessions, or didn’t complete the questionnaires.  Reasons for not participating were due to work issues, or ‘physical health’ (the details of physical health problems aren’t discussed).   27 of the 31 participants included in the analyses were women, most were married or in a relationship, half were not working or retired, and mean pain severity during the programme was 7.0 (SD = 1.5), 21 were concurrently receiving medical treatment for their pain.

Over the study period, pain intensity dropped, interference from pain dropped, and anxiety measures for experiencing pain also dropped.  There was no change in mood scores.  In the follow-up period (to 6 months postprogramme), pain intensity and pain interference continued to drop (although not as much as in the first time period); pain-related anxiety and fear-avoidance beliefs also dropped, but vigilance to pain didn’t continue to drop.  An interesting finding was that the people who attended the six month follow-up had lower FABQ scores and better self-rated working ability than those who only attended the three month follow-up.  Interference from pain was also lower in this group.

A further aspect of this study is that the use of techniques after the programme was also examined.  This is important, because some studies have shown that people typically don’t use any of the coping strategies 12 months after completing a pain management programme (see my post about this here).

Cutting to the chase for clinicians: What can we make of this?

The first thing is that there are some limitations to this study, apart from sample size – people were also receiving medical pain reduction treatment which could influence pain intensity (well, it’s meant to!!), and may also influence distress, catastrophising and function.  The measures used were all self-report, and most of the respondents were women who were not particularly depressed, although their pain intensity was quite similar to the people attending Burwood Pain Management Centre.

A couple of interesting things for me: it’s good to know there is a manual that can be used to deliver a systematic set of attention management strategies. This is one way at least to ensure that people who receive pain management have some consistent content (although there is no obligation for anyone anywhere to include this!).  Would that more programmes had some standardised components, although I’m one of the first to roar if I HAD to deliver a standard programme!  Despite this, it’s a start to learning more about the individual content of pain management that might be effective, rather than seeing it as one big black box.

Another interesting thing is that these psychologists consistently recognised the need to integrate the coping strategies into daily life. What a groundbreaking thing!  Perhaps that could be something that people delivering exercise programmes could consider too?!  Or instead, suggest that an occupational therapist be involved in delivering and helping people generalise and personalise their skill repertoire.  Just a thought.

Elomaa, M., de C. Williams, A., & Kalso, E. (2009). Attention management as a treatment for chronic pain European Journal of Pain, 13 (10), 1062-1067 DOI: 10.1016/j.ejpain.2008.12.002

McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale
(PASS-20) preliminary development and validity. Pain Res Manage

Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs
Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low-back
pain and disability. Pain 1993;52:157–68.

McCracken LM. Attention to pain in persons with chronic pain: a behavioral
approach. Behav Ther 1997;28:271–84.