Uncategorized

Pain – or pain-related disability?


I’m struck at how often clinicians focus on pain intensity when how much pain intrudes on life matters more. I wonder whether new therapists might not have read some of the old studies looking at the relationship between pain intensity and disability – because while there is a relationship there, it’s not nearly as strong as we might think.

Let’s define a couple of terms first: pain is, I think most of us can agree, “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”. (click for full definition and notes)

Disability isn’t quite as clear-cut a term and it’s gone through a few permutations over time. Probably the way I define it fits more with “functional limitations” – but the diagram below from WHO describes their model of disability .

In other words, disability is the combined impact of all of these aspects of health on a person. Pain arises from some kind of health condition (yes, even pain where we’re not entirely sure of the “diagnosis” and where we can’t quite yet be definitive about what’s going on). In turn, pain influences body functions (and perhaps structure – certainly there’s a lot of evidence showing altered neural networks while someone is experiencing acute pain, and changes are also present in persistent pain conditions. See the refs below – but interpret cautiously, this is an emerging area of research).

All of the relationships above are bidirectional, meaning that there’s no linear path from one aspect to another – it’s complex.

What this means is that we shouldn’t be one bit surprised that the relationship between experiencing pain, the health condition, what a person wants to do, how much they participate, and their context is not at all straightforward. Yet so often I see research papers looking at altering one aspect of a disorder or disease, measuring pain as the primary outcome, and being a bit surprised that even though the pain might have reduced a little – the person isn’t “taking advantage of it.”

A good example of this is returning to golfing after knee arthroplasty. Prior to surgery many people have taken to golf carts so they can get around the course. After surgery, with less pain in most instances, you’d think people would go back to walking the course – it’s a great way to keep fit, it’s not as difficult to do as a bunch of gym-based knee exercises, and it makes for an enjoyable game. What actually happens? Jackson, Smith, Shah, Wisniewski and Dahm (2009) found that over half (57%) returned to golf within 6 months, with 81% playing golf as much or more often than before surgery. They reported less pain with 83% reporting no pain – 28% had walked the course before surgery, so what percent do you think would carry on walking now that their pain was less?

Go on.

Guess.

Only 14% walked the course after surgery.

No relationship between walking and age, sex, BMI, pain, receiving advice not to, bilateral or unilateral prosthesis, or current golfing handicap.

Even in acute musculoskeletal pain, where we know that to wait until all pain has gone will harm the person (think of your ankle sprain) it seems clinicians would rather address pain intensity than the impact of pain on what a person wants and needs to be able to do. Case in point: Adam Meakins recent back pain.

There’s an assumption that people seeking treatment want their pain dealt to over and above anything else. How true is that, really? As clinicians we might ask the person “what’s your goal from treatment?” and they may reply “get rid of my pain” but that’s a superficial approach to understanding treatment seeking.

I’d love to hear clinicians dig just a little deeper – like “so if pain was less of a problem, what would you be doing?” Because we know that people seek treatment for back pain because of the effect on what the person wants to do – Ferreira, Machado, Latimer, Maher, Ferreira and Smeets (2010) showed this in a meta-analysis over a decade a go.

Is it either/or though?

Well by now readers of this blog should know that I don’t think anything is as simple as a dichotomous yes or no. Of course pain intensity matters – but what I often see, especially on social media, is an almost exclusive focus on pain intensity and “proper” form and “exercise” with little attention to what it is the person wants to do.

Because the unknown part of the Jackson et al (2009) study is why these people didn’t resume walking, even though they were in less pain, and were playing golf more.

I’m picking the reasons lie within those pesky contextual factors – who is around the person, their physical environment, community attitudes and beliefs, their fears and anxieties, what’s thought to be normal or expected – the bread and butter of occupational therapy, and coincidentally, the most complex part of health to research and understand. No wonder there are those who prefer the conceptually simple mechanistic, biomedical approach – these psychosocial (emphasis on the social) can’t be rote learned and spat out in an exam, they need conceptual understanding and unique, individualised solutions.

Barroso, J., Wakaizumi, K., Reis, A. M., Baliki, M., Schnitzer, T. J., Galhardo, V., & Apkarian, A. V. (2021, Mar). Reorganization of functional brain network architecture in chronic osteoarthritis pain. Human Brain Mapping, 42(4), 1206-1222. https://doi.org/10.1002/hbm.25287

Ferreira, M. L., Machado, G., Latimer, J., Maher, C., Ferreira, P. H., & Smeets, R. J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. https://doi.org/http://dx.doi.org/10.1016/j.ejpain.2009.11.005

Geuter, S., Reynolds Losin, E. A., Roy, M., Atlas, L. Y., Schmidt, L., Krishnan, A., Koban, L., Wager, T. D., & Lindquist, M. A. (2020, Jun 1). Multiple Brain Networks Mediating Stimulus-Pain Relationships in Humans. Cerebral Cortex, 30(7), 4204-4219. https://doi.org/10.1093/cercor/bhaa048

Jackson, J. D., Smith, J., Shah, J. P., Wisniewski, S. J., & Dahm, D. L. (2009, Nov). Golf after total knee arthroplasty: do patients return to walking the course? American Journal of Sports Medicine, 37(11), 2201-2204. https://doi.org/10.1177/0363546509339009

Wager, T. D., Hu, B., Jepma, M., Krishnan, A., Schmidt, L., Roy, M., Atlas, L. Y., Goldstein, P., Yao, Z., Woo, C.-W., & Zheng, W. (2020). Pain-Evoked Reorganization in Functional Brain Networks. Cerebral Cortex, 30(5), 2804-2822. https://doi.org/10.1093/cercor/bhz276

One plus one may not always equal two


If it hurts – take notice, and avoid it. Learn from it. If there are other people around, make sure your behaviour is noticeable so they take care of you and don’t do what you just did. If they look after you, you’ll probably do the same thing again when you hurt, if they don’t you probably won’t.

This is one description of pain behaviour and how it works. It’s the only part of our pain experience that we can share directly with one another (actions and words). The “doing” part is also the part that is most affected by pain – even distress is signalled to others – so it’s unsurprising that a lot of attention has been paid to how therapists can change behaviours that are unhelpful.

Many of us start with offering an explanation. Language is something that sets humans apart from other creatures because we learn concepts, and associate one concept with another through it (see Beeckman, Hughes, Kissi, Simons & Goubert (2019) for excellent insights into relational frame theory and pain). I’m sure there are many clinicians who’ve tried to give information (to “educate”) to a person and found it works well. And then there are those who just don’t get it. There are three main points that people who respond well to “education” seem to find useful: (1) pain doesn’t mean my body is damaged (the old “hurt does not equal harm” message that originated with Fordyce. Butler (2017) offers us a selection of Fordyce’s wisdom – and wit); (2) thoughts, emotions and experiences affect my pain (again, something the cognitive behavioural therapists have been sharing with people since the beginning of multidisciplinary pain management programmes); and (3) I can retrain my over-protective nervous system (yes, another thing we’ve been doing in pain management for many years… not that we are unlearning pain, we’re helping the nervous system settle down and becoming less distressed by the experience).

We quite like talking to people – maybe because it appeals to our often dictatorial mind (read A Liberated Mind for a new take on this!). And so for people experiencing pain, we talk. But talk on its own isn’t super-effective. After all, for every one time we hear “pain doesn’t mean my body is damaged” we can Google and find literally hundreds of messages telling us our spine is fragile, our joints are damaged and pain is a sign there is harm.

So what is more potent than words? It’s learning by experience. Doing.

A brand new analysis of “sufficient conditions” for psychological therapy was published in Pain (Batho, Kneale, Sutcliffe & Williams, 2021).

Now I do have some reservations about calling this “psychological” because that word is loaded with meanings, not all of them helpful. Truth to tell, we humans use psychological approaches effortlessly in daily life – and it’s not “in the head/mind/emotions” which is almost inevitably what people first think of when they hear it…

In this analysis (which is complex – go read the paper!), the authors investigated 38 studies, did some horrendous statistical analysis and compared the ten most effective treatments with the ten least effective treatments. What they found was quite surprising, and I’m still pondering what it means.

They established that “interventions using graded exposure, graded exercise or behavioural rehearsal (exposure/activity), and interventions aiming to modify reinforcement contingencies (social/ operant) reduced disability levels when either approach was applied but not both.” [italics mine] They also found “exposure/activity can improve distress levels when combined with cognitive restructuring, as long as social/operant methods are not included in treatment.” [italics mine]

It pleased me to find that graded exposure or reactivation, when applied in the absence of social and operant contingencies, reduced disability and distress. And that social/operant approaches reduced disability on its own. The reason I’m happy is that graded exposure and reactivation with a dab of “let’s notice your thoughts and check out whether they’re helping you” are very common approaches used across occupational therapy, physiotherapy, chiropractic, osteopathy, coaching and a whole bunch of therapists who work with people in pain. Graded reactivation with information has been the mainstay of pain management since at least the 1980’s. We know it’s helpful. Graded exposure has gained popularity since the mid-1990’s and we know that it’s helpful too. And we use social reinforcement just because we’re humans.

In the analysis, ACT was used in only one study. ACT doesn’t do cognitive restructuring and instead, uses six interwoven processes that together support psychological flexibility. I use ACT as my primary approach, both for myself in daily living, and with people who come to see me for help with their pain.

What I like about ACT is that it’s flexible, allows people to notice what their mind tells them, but helps them to step back from that dictator within to make a choice about what to do. It’s the doing part (based on what matters in a person’s life) that I enjoy because it involves both graded exposure and graded reactivation. And if a person doesn’t relate to what they’ve been told about their pain, we don’t have to offer another explanation, we can help the person work out what works for them in the context of their own life.

So where are we with this now? Given that we can’t stop being social animals, and that we respond to one another without knowing it, I’m not sure we can avoid inadvertently using social and operant approaches as therapists. What we can do, though, is become more knowledgeable about behavioural approaches in pain management and rehabilitation – and that undoubtedly means learning a whole lot more psychology. Perhaps we might need to reframe our own understanding of psychology so we feel more comfortable with it – a bit like explaining pain and cognitive functional therapy have both helped us feel OK to step into doing what has often been the territory of psychologists.

Batho, A., Kneale, D., Sutcliffe, K., & Williams, A. C. C. (2021, Oct 1). Sufficient conditions for effective psychological treatment of chronic pain: a qualitative comparative analysis. Pain, 162(10), 2472-2485. https://doi.org/10.1097/j.pain.0000000000002242

Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., & Goubert, L. (2019, Oct). How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain. Journal of Pain, 20(10), 1141-1154. https://doi.org/10.1016/j.jpain.2019.02.013

Butler, S. (2017). The wit and wisdom of Wilbert (Bill) Fordyce (1923-2009). Scandinavian Journal of Pain, 16(1), 160-163.

Leake, H. B., Moseley, G. L., Stanton, T. R., O’Hagan, E. T., & Heathcote, L. C. (2021, Oct 1). What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education. Pain, 162(10), 2558-2568. https://doi.org/10.1097/j.pain.0000000000002244

“Research says” – and why lived experience matters


It’s no secret that I enjoy using social media to discuss topics associated with pain. After all, I wouldn’t have been blogging for as long as I do if I didn’t find this medium interesting in some respect!

At the same time, social media “debates” can truly be unhelpful, unpleasant and even harmful. Yet possibly one of the most harmful communicative strategies that I see is reference to “research says”. What? you say – but, but you LIKE research! Well yeah I do – but research is not a neutral “Truth” that means we can simply grab a published paper, find the results we like, then hang on to that for the rest of our careers!

What do we mean when we say “Research says”?

You know the Background part of a paper? And you know the Discussion section? The only bits read by some people – if they go past the abstract? These sections are important, but not perhaps for the reasons you might think. When I first started reading research papers, I used to think the Background was intended to highlight an unanswered question, and the Discussion was to put the answer (from the Results) into context and to establish “where next”? And there’s truth to this perspective. But it’s a beginner’s look at research. It’s a start to understanding the context of a piece of investigation. Reading these sections does give an insight into how the authors want to frame their piece of research.

Let’s pick it apart a bit. As Schostak and Schostak (2012) put it: “Each text is itself a framing of voices and their agendas, shaped to present a debate slanted towards a conclusion.” They go on to say “…whilst acts of framing bring and impose order, those very processes of ordering and categorisation select and edit so that some things are chosen
to be foregrounded, others to be background and yet others to be excluded.”

In other words, these pieces of writing offer a selected view of what is going on in this part of the research and knowledge landscape. It’s understandable that people new to an area of study might not know what else is being said, or what else has been prioritised – but it’s rather less forgivable in people who have been working in, or studying or teaching in an area for many years.

So how do we “interrogate” research so we go beyond accepting the literature review and discussion at face value? And why does it matter?

I’ll answer the last question first.

It matters because Truth with a capital T is not really a thing, at least not when it comes to pain. Pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Further to that,

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

In particular, I want to draw your attention to the first note: “Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors.” My interpretation of this is that my experience of pain is mine. And while some people may have similar experiences, the particular way I experience pain is unique. It’s different from anyone else’s.

For clinicians – and researchers – respecting the unique experience of the person in front of us (or participating in a research study) is crucial. Yet we mainly read about GROUPED experiences in research, many of which are reduced to a single number on some questionnaire or scale.

One of the unspoken assumptions in much of our research, particularly quantitative studies, is that although we lose detail by grouping information, we retain essential information. Another assumption is that only the essential data really matters. Those details, that nuance, the individual isn’t relevant, or at least, it’s less relevant than the consistent information.

So interrogating, reading research critically matters – not only reading the methods section, but also reading the background and discussion. Because the background and what is selected from previous research and writing is used to frame what is thought important, while the discussion is used to illustrate and situation the importance of the research results. The reader’s job is to read these sections and look to the voices that are put in the foreground (thought important) and to look at those placed further back, or perhaps not even included.

And one set of voices often omitted are the people who live with persistent pain, those who experience acute pain, and those who care for and are affected by pain of any kind. We have yet to move pain research and management towards an inclusive “nothing about us without us” stance. Our research is dominated by studies about but not with people in pain.

How do we interrogate research?

Some key points (because people write whole books on this!)

  1. Hold all research very lightly.
  2. Never consider a single study to be sufficient.
  3. Read widely. Read the background to the research and ask “Who isn’t included?” and “Which voices are foregrounded, which voices are backgrounded?”
  4. When reading, ask yourself who will gain benefit from this? Who might lose?
  5. What assumptions (explicit or implicit) are held when asking the research question, deciding on a method, analysing the results, and situating the piece in other research literature.

I really like the “cheat sheet” below for stretching my critical reading muscle.

And at the foreground for me is always “how is the voice of people experiencing pain represented in this paper?”

This is a great piece on critical reading – click – from Pavel Zemilansky and OpenOregon.

This piece from Massey University is also very helpful – click

And this is the book – click – by Schostak and Schostak

Le Pub Home Brew


Now I’m the kinda woman who enjoys a bevvie or two – and I do love to talk! Combine them both with my favourite topic of pain, and you end up with Le Pub Home brew…and I’m speaking THIS SATURDAY!!

My topic? Let’s stop focusing on pain, because we have a few elephants in the room we need to discuss.

Come and join me as I poke and prod at assumptions made about why people come asking for help with their pain, why clinicians often focus on the wrong thing, why we need to listen to the messages buried beneath the “take my pain away” call – and why the skills clinicians have HAD to draw on during lockdown might just well be the Most Important Skills they have (psssst! Call them “soft skills” at your peril!).

I might wander into some philosophy, some sociology, and probably I’ll tread on some toes and push my own agenda to have more people recognise what occupational therapists already know about context, meaning, values and being flexible.

’nuff said: click on the link below and get in on the conversation (BYO home brew)

5 Things I Learned from Lock-down


As New Zealand emerges from the most severe lock-down levels to greater freedom (but still not back to life as usual) I’ve been reflecting on what I’ve learned – no, not a new language, new baking skills, or sudden competence in using R (see here for a great tutorial), but things about myself. Odd though it may seem, I’m leaving lock-down with a sense of wistfulness. You see, the time from the end of March to end of April has been a lovely time for me.

I’m lucky, I have a good job, my work hasn’t changed much (well, a bit), my family are safe, I live close to the beach and a park, and the weather has been kind. It’s autumn in Christchurch, and it’s been mainly fine. The bird life has been flourishing. The foot traffic past my house has been families – Mum, Dad, kids on bikes and in pushchairs. Apart from the occasional drop-kick lighting fireworks or playing the Zombie Apocalypse Siren, and hammering from 7.00am to 11.30pm, our neighbourhood has been peaceful. And yet I know so many people in New Zealand and around the globe who are really struggling. Strange times indeed. So what have I learned?

  1. Solitude is not the same as loneliness. Solitude is being alone and being OK with it. Loneliness is being alone when you don’t want to be. Being with my own thoughts, listening to the murmuring of sounds around me, letting my mind wander then gently bringing it back to focus is a pleasure, almost an indulgence. Having headspace to let what passes through my mind just pass by, without music or talking or anything interrupting my musing is a pleasure. Better still: being with someone who also appreciates being together in silence. I’ve learned to love solitude.
  2. Some kids will remember this time with gratitude. I’ve watched whole families walking together, making huts from driftwood, spotting the teddies in the windows, making low-tech memories of time being together. I have a fairy door (and a fairy) at my gate, and watching the little kids search for the fairy (who flies from tree to tree each day!) is such a joy. I’ve seen Mums and Dads out cycling with their kids then heading home to do the DIY together. What a treasure! I’ve learned (again) that families need time being families.
  3. Some things stay the same – especially if you live with pain. Even though my days have been peaceful, my pain has not. With changes to my routine, the weather, sleep, and world events playing on my mind, my life with fibromyalgia still needs managing. I’ve had aches in places I don’t usually have aches, and the things I do to live alongside my pain still need doing. For me these things are: making sure I carry on with mindfulness (I savour those moments when I can be with my thoughts but not part of them), go for my walk for headspace and body movement, keep my sleep/wake routine reasonably consistent, and eat normally (hah! there’s chocolate and alcohol and crisps. I may have slipped up a little there…). I’ve learned that pain management is really life management.
  4. Comparing myself with others is a waste of time. Yes, there are people out there learning new things, self-improving all over the place, doing their on-line socialising (and CPD), being creative and producing a lot. Good for them! I admire their achievements, and I’ve even contributed to a few of those online Zoom talks. Meanwhile, I thought I’d have been truly productive in the studio making loads of silver jewelry (those of you who don’t know – that’s my ‘hobby’ that seems to have taken over my photography, painting, sewing and everything else!). I’ve created a few pieces – but when I caught myself feeling pressured to come up with a “COVID19 Collection” I realised that this pressure wasn’t me. It was my mind being competitive and wanting to prove something to others. The need to belong can lead me to also want to be acknowledged as Something Special. Better than. As good as. Because, of course, underneath that is “I’m not good enough as I am”. So I decided to let that rope go. I don’t have to compete. There isn’t a prize for She Who Produces The Most because in the end, life is a process not a goal. I’ve learned (again) that comparisons are one way my mind beats up on me, and my mind doesn’t know everything.
  5. Resilient people are adaptable people. Resilience is a word many people in Christchurch, NZ, are well and truly over. Since 2010, and the 10,000 earthquakes since, plus the Port Hills fire, and the terror attack on Al Noor Mosque, people in Christchurch have been challenged more than many in our wee country. Resilience doesn’t mean we’re unchanged. Resilience means we change with circumstances and we develop new ways of being, ways of expressing who we are and what matters to us. I sometimes think people believe resilience means “Oh you’ve bounced back and life goes on as it was” but for me the events since 2010 have had a profound effect on my life. I can’t walk through my city without seeing earthquake-wrought changes. I see bumper stickers saying “they are us” and “kia kaha“. I walk past the memorial wall Oi Manawa when I head in to work. The new streetscapes, city buildings, ongoing roadworks and repairs – all part of the way my city has changed. That underground subversive element in Christchurch has touched so much of our lives. Resilient people have found ways to express who they are despite the enormous impact of events over the past 10 years. I’ve learned that holding on to what I value while finding new ways to express these has given me freedom and growth – but I’ve had to let go of the form, the habitual, the routines that used to frame them. It’s painful. It’s tiring. It’s real and raw and hard work.

How does all this fit into a blog about pain? If pain doesn’t challenge clinicians and people experiencing it, I’ve wasted the last 30-odd years of my clinical career, not to mention my hours of social media involvement!

Change, as a clinician, can be tough – letting go of the form of what we offer (because … science) while holding on to why we ever started working as clinicians requires flexibility.

And solitude – to reflect on what it is we really want. We do it for families, those closest to our hearts (our own families, and others), so people can be who they really are.

Comparing ourselves with others leads to a popularity contest, and the self-management approach to pain is most definitely not a popular meme. I am not part of the Instagram/Twitter/TikTok/whatever meme culture. I don’t do short, snappy sound bites. There are, as far as I can see, no short-cuts or quick fixes for learning to live well with pain. There are only connections between people who care, who are willing to be vulnerable, who will let go of some things in order to take on new things in the pursuit of what matters.

This is what I’ve learned from Lock-down.

Why focus on pain management (rehabilitation)? Response to comments


My response to comments is that at this time self-efficacy (confidence you can do things despite your pain) is really low. Self-efficacy, like love, isn’t a finite resource though, although the energy required to keep on coping (balancing all the multiple demands that persistent pain has on you) can exceed current capacity. Both self-efficacy and energy are renewable resources and change over time. Love expands as we add to it. Self-efficacy increases as we have more successes. Energy renews as we find ways to fill our buckets up faster than the holes leak it out.

This post was written for health professionals, health professionals who may be inadvertently undermining what little self-efficacy an individual has by promoting a focus on what they do, rather than on what the person is using to deal with their situation. Health professionals who may well be told they must record pain intensity before and after Every. Single. Treatment. Who may not recognise just how much effort it has taken for a person to come in for a session – especially when feeling guilty or ashamed that “homework” hasn’t been achievable.

I think pain heroes do need to be celebrated. All we hear about in the media are people suffering, wanting techno-fixes and ways to get rid of their pain without recognising that for many people pain reduction just is not possible. For those who are able to live well, why not applaud their efforts – I’m not talking about their ability to get rid of their pain, but their ability to remain focused on what gives their life value and meaning – even if that’s a small fraction of what they were able to do prior to developing their pain.

I get that sometimes “pain heroes” who do amazing feats are held up as “normal”, but at the same time that’s not the story played out in most of our general media, I wonder if it’s more like the stories bandied about as examples of the latest new-fangled treatment. I often wonder if there were long-term follow-ups carried out on those folks, would they still be as positive as they were at the time their story was made?

Pain reduction as a goal doesn’t improve confidence to do activities successfully despite pain. Except in as far as a paper cut might not interfere as much with doing life as a migraine. At least some of the confusion arises from misinterpreting the measure: Pain Self Efficacy Questionnaire specifically uses the phrase “despite pain”, but I often hear people describe it as if it was “without pain”. Perhaps there needs to be a different measure “Self Efficacy Questionnaire for Doing Things With Only A Little Pain”, but currently the only measure of pain self efficacy is the one developed by Michael Nicholas.

I think it’s easy to misinterpret research about resilience as if it’s suggesting “thinking yourself out of pain” is the goal. It’s not. And that study in particular doesn’t say that, while neither did mine. In fact, “thinking yourself out of pain” isn’t achievable – good research suggests that attempting to suppress your attention to pain actually rebounds. It’s also not Pollyanna and pretending that pain doesn’t have an impact. What I think it is is a process of coming to grips with the fluctuations we all experience with pain and energy, recognising what we can and can’t do, being unafraid of our pain and knowing that it’s not going to kill us (though we may wish we could die from time to time), and finding small ways to go with our pain rather than fighting against it, wishing it wasn’t present, pretending it doesn’t have an effect when it does, trying to ignore it, or buckling underneath it and losing ourselves.

In the pain management services I’ve worked in, and the approach I take both for myself and with the people I try to work with, using pharmacological, neuromodulatory, surgical and procedural approaches to reduce pain has always been integral to the overall plan. Sadly I have not found anything that provides any pain reduction for me, I have no option but to keep going without anything. If there are things that reduce pain – and the side effects, adverse effects, or interference with the way you want to live your life are acceptable – that’s fantastic! The distinction I made in my post is the focus on pain reduction as the primary outcome. The sense that life cannot go on without pain reduction.  The thing is, life does go on whether we’re part of it, or not (and of course we can choose not to go on, but that’s death, and not an option I’d ever recommend). So, one foot after another, life does go on. I’m arguing for more than a focus on pain reduction. Because that seriously is the only outcome considered by some professionals – and some people with pain. And in pursuing only pain reduction, people lose sight of what already is going on around them. Life goes on hold, and people spend all their energy, time, and focus on how to get rid of pain. That is not living.

Wouldn’t it be great if we had something for those who find their pain overwhelms them. Sadly after working in this field for 30 years I do not think we are any closer to that elusive goal than we were when I began, except perhaps people aren’t going through quite so many useless and invasive surgeries with really nasty side effects as they did in the 1980’s. Do you not think there are so many people already seeking new and innovative treatments? And what would you like to have happen to those who may never see any of those new treatments reach them? It does not have to be an either-or situation.

What I’m finding is there is so much emphasis on pain reduction that few people are willing to provide what is already known to help people’s distress and disability. The unsexy, somewhat boring-but-necessary evils of self-regulation, reframing pain, setting teeny tiny goals, maintaining consistency, activity management, day in and day out exercise programmes, plodding through each small bump along the way. That is the reality for the many, many people who have, like you, not found anything wonderful to whisk the pain away. Demanding better treatments may not bear fruit in your life time. The only new class of analgesics are the triptans for migraine, and they were first discussed in the 1960’s, and only released onto the market in the 1990’s. Do you think there’s something hidden away for only “good” people? Seriously, there is SO much research being undertaken for all manner of wonderful treatments – but I haven’t seen much of this bear fruit in the way that you and all the other people who live with persistent pain would really like. Including me.

So, let me say, in case it wasn’t clear.

I am NOT suggesting there should be no medical interventions for people.

I AM cautious in terms of how successful they are (that’s me, the skeptic, been doing this for long enough to see the trendy things fail in the real world).

I AM suggesting it’s not worth putting life on hold in the hope that there MAY be something “just around the corner” because that’s not the case right now.

I AM arguing that clinicians who focus on pain intensity as the exclusive outcome that matters need to stop and think about what it is that people want to DO with that newfound energy if their pain did suddenly disappear.

Sometimes, in fact often, those things can be done with pain alongside. So it hasn’t happened in many people’s cases – that’s because pretty much nothing DOES work for everyone. But that doesn’t mean we should stop working really hard to continue to help people do what they can do, not letting what they can’t do get in the way of what they can.

And that is what I try to do both personally and professionally, as a person, clinician and educator.

San Diego Pain Summit – only a few days to go, but you’re not too late!


Live Stream package details: Watch the conference on Feb. 23-24 in real time. Note that the conference occurs in Pacific Standard Time. Participate in Q&A and prize drawings.

Package includes 1 year membership to Pain Summit Online, beg. March 1, 2019. Membership includes access to all presentations from 2015 to present. The 2019 presentations will be uploaded sometime in the first few weeks of March.

Live Stream video contains a lag, so you can rewind hours later to watch something you missed.

Approved by the California Physical Therapy Association for 1.15 CEUs or 11.5 hours.

Link to register: https://sandiegopainscience.com/registration-2019/live-stream

Registration closes at 11pm PST on Feb. 22

Discount code for 25% off at checkout: T9SQZGM