For some of you, the New Year has already started, but I’ve been in a lovely position where I’ve been on leave and haven’t yet started “work” – though the work of living is always present!
It’s traditional at this time to year to review the past year and plan for the coming months, so today’s post is a few musings on both.
Last year I noticed I’d been working on this blog for nearly 10 years! Astonishing really, because it was intended to be a learning experience for me during my recovery from a mTBI. It kinda grew like Topsy, and here I am 10 years down the road still blogging, albeit not so often as in the first couple of years. Over that time I’ve commented on a whole bunch of articles, made a few blunders, and put my thinking out in the public arena in a way that Academic journals just don’t really allow.
Some people would argue that my analysis is lightweight because I don’t leap into the depths of statistical analysis and research design in my commentaries. Others think I spend far too much time pondering the psychosocial and – how could I – omitting the biological. Some don’t like my reference to a biopsychosocial “model”, while others wonder what an occupational therapist is doing writing about pain psychology.
Blogging is a personal pursuit without written rules. I muse about things as part of my own processing, plus to hopefully put some useful content out online for those who don’t have the pleasure of ready access to articles. I’m interested in some of the research questions even poorly conducted research articles can pose. I’m intrigued by the relevance (or not) of findings to my own setting here in NZ. I’m fascinated by connections drawn by authors as they ponder the implications of their research question, findings and works by other people.
I write about topics that mean something to me. It’s a completely personal selection, reflecting papers I’ve recently read, topics discussed in social media, patients I’ve seen, and conversations I’ve had.
What’s the impact of blogging on anything or anyone? Well, that depends on the kind of “impacts” you’re talking about. Through blogging I’ve made contacts with clinicians and researchers (and social media people) from around the world. I’ve been able to contribute to some pretty special meetings. I’ve been asked to speak, to write, and have been in touch with so many people who have got in touch with me because of this platform.
My aim apart from satisfying my own curiousity, is to share information and help to translate from academic journals to the real world. Information locked up in journals isn’t likely to help a clinician who can’t access them! And reading, reflecting on, and integrating research into daily clinical practice is difficult. I hope some of what I write about helps to bridge that gap.
Why would an occupational therapist from New Zealand do this? Well the first question I’ll answer is why an occupational therapist – why not? And because occupational therapists are possibly the ultimate scavengers in terms of taking something that’s been explored by another discipline and applying it to their client’s own real-world setting. Occupational therapists apply clinical reasoning to help people DO in the real world, so in a sense we’re really translational scientists, applying what’s known from research into the unique context of our clients and what they need and want to do. As an occupational therapist I think I bring some unique skills to the process of translating research to clinical practice, and besides, I’ve been in this field for a few years now, so I want to temper some of the enthusiasm for whizzbang new things with some of the wisdom from older research. You know, the 1980’s and 1990’s produced some really foundational research in pain and pain management.
Why from New Zealand? What does NZ have in common with the “rest of the world”? We’re a relatively well-developed country, with a partly socialised healthcare system that struggles with many of the same problems as other developed countries with or without a socialised healthcare system. NZ struggles with a biomedically-dominated model of disease holding sway, limiting the availability of allied health professionals who focus on a more wholistic (no, it’s not a dirty word) view of health and wellbeing. Allied health professionals everywhere in the world have difficulty being heard over the clamour of medicine with it’s one-shot, high-tech and super-simple view of disease. Our work is not sexy. Our work involves being with people, and our currency is the time we spend communicating with people. We don’t rely on a brief consultation and a quick flick of a prescription, a jab of a needle or a slice of the knife. Our work is about messy human life, behaviour change, taking the time to listen to what’s important to our clients/patients and step-by-patient-step supporting them to achieve their goals.
Over the 10 years I’ve been writing, I’ve constantly heard bickering between various factions in allied health care. Mainly <puts on teacher face & granny glasses> amongst physically-oriented therapists. Mainly about trivia as to whether treatment X is “better than” treatment Y. Niggling time and again over ridiculously inflated claims, “trademarking” approaches that have been in practice for oh at least 30 years, heated arguments about whether nociception is important (well of course it is, duh), whether biomechanics is important (well yeah, just not all the time wrt pain), whether tape/laterality/neural stretches/posture/”correct technique” and on ad nauseum is crucial. Meh. The differences between us all are far less than the commonalities – and it’s only with the commonalities that we’ll actually make a change to the way pain management is done here in NZ, or the rest of the world.
So this year I intend to focus even more on allied health pulling together, looking for what we have in common, drawing comparisons with a reductionist model (whether that’s biomedical or biomechanical), and encouraging us to get involved in system change. Are you with me?
So 2016 is over, and 2017 is here. As usual, I find the new year to be a time for reflecting on what is important in life, and what I’d like to see more of this year. Usually I’ll want more balance. More space between frantic activity. Maybe even less frantic activity! And I pretty much always want to learn something new. But this year I want to be a bit different. Yes I’ve been thinking about what’s important, and yes I want more balance, but this year I want to work on a new project as part of this blog.
I’ve been writing for so many years, and one of my main reasons for doing so is to bridge the gap between what’s found in research, and what clinicians are doing in their practice. I want to inform and I want to infuse that information with a strong sense that alongside what we know from research we need to remember these things:
- We work with people – not doing things TO people (even if we do things to people), but we have a window of maybe an hour in a clinic in which everything we say and everything we do is pondered over by the people we see. And believe me, people will interpret what we say and do and then make their own decision about what happens next.
- We could all become a patient. That’s a bit humbling because we don’t expect we’ll develop a problem, but pain is indiscriminate – it will affect anyone and everyone. Trouble recovering is somewhat more discriminating – some people are at more risk than others, but here’s the thing: there are SO MANY variables that have been known to influence recovery that we can never be truly certain that we’ll be able to dodge that bullet. So, you and I can become a patient, and our recovery may also be complex, and we may need to swallow the bitter truth that rehabilitation is plain hard work.
- People don’t exist in isolation. Most of our treatment philosophy and techniques focus on the person with pain. Just that person. Not their family, their employer, their friends or colleagues or mates. Just that individual. But we know that people live within a community. And that community is pretty big – especially when we think of the connections made around the interwebs! And for every time we see “a person” we ALSO need to see “a person-in-context”.
- We get it wrong. We all do. We fail. We don’t reason clearly. We get hooked up in our own biases. We ignore things. We look for things that confirm our own beliefs. We notice things we want to notice, and conveniently ignore things we don’t want to notice. And we often don’t even know we’re doing it. That’s a constant and ongoing tendency we all need to work hard to counter.
- Research often omits important variables. This world is complicated. There are so many factors influencing what happens, when, where and why. Researchers can’t control everything. And because people are messy, complicated and ornery beings, the people we see (and ourselves) don’t always fit within the parameters of what’s been found in a research study. This doesn’t mean research findings aren’t important, it just means we need to temper our tendency to adopt a new and groovy thing just because a piece of research suggests it’s very cool. And we need to recognise that, especially here in NZ, studies conducted elsewhere in the world may not work as well here in our country. And that applies everywhere and to all human-oriented research. Context is critical. What people want and believe in is also critical. Qualitative research begins to bridge the gap between experimental designs and individual variability – but it’s often considered less valuable than quantitative research.
- People living well with chronic pain need to inform our practice. Why? Because we can learn so much from people who have been able to see life differently. Who have taken gems from wherever they’ve found them, been able to integrate those gems into their daily lives, and are now in the best position to help us learn what worked for them – and most importantly, why it’s worked.
- We’re biopsychosocial beings. People are biological beings, with psychological processes that influence their actions, many of which have been picked up from the social context in which they live. Those psychosocial factors are integral to living, not some add-on, after-the-fact mess that only applies if our treatments don’t work. We ALL actively process what happens to us, and interpret these things in light of what we already know and what we think might happen next. Yes I know this model is incomplete. I know some people can think of it as reductionist. Others think it’s messy and non-scientific. Still others believe it’s useless and impractical. But whether it’s an “accurate” way of thinking about people or not, I think it can be a helpful framework from which we can begin to explore situations where people are involved.
The new project
I’ve written thousands of words. Usually about 1200 once a week on this blog alone. My intention this year is to collate that writing and sort it into some semblance of order. I intend to post short summaries on topics and link to some of my older work for details. And maybe, just maybe, there could be a book at the end of it! Whatever I manage, this year I will be learning new things, and I will be posting them up here. So keep visiting! Ask questions and comment. Be part of the conversations that can change our approach to helping people with pain. Want to join me?
Do you recommend pacing as a strategy for your clients/patients? If so, would you please consider taking part in a survey I’m conducting, looking at health professional’s beliefs about the underlying motivations for using pacing. The findings from this study will inform a future study in which I will explore the daily use of pacing as a strategy by people who live with chronic pain. The usual ethical consents have been granted, and your involvement is entirely voluntary, confidential, and anonymous.
I’m looking for health professionals from any discipline, but only if you personally recommend pacing to your clients/patients.
Please spread the word!
I’m away from my desk, visiting Auckland this week, so this post will not be in my usual format. Having time away allows me breathing space to think about things (even more than usual), and I’ve been thinking about values and their place in our lives.
We all have values, things we believe are important. Values underpin the decisions we make, our priorities, and even the way we interpret events that are usually considered value-free. Value judgements are part of being human, I think. They can be prosocial – or not.
When I looked up values, this definition appeared: the regard that something is held to deserve; the importance, worth, or usefulness of something. Some values are explicit, things we’ve deliberately decided to place importance on, while others are implicit, things we’ve not fully thought about but have emerged as part of our culture or family or upbringing.
In pain management values are imbued in all we do. Some people explicitly value reducing pain intensity as their ultimate goal. Others value reducing distress associated with experiencing pain. Still others consider that enabling people to reduce the disability associated with pain to be the most important part of pain management.
I wrote recently that pain and suffering are two distinct constructs. That pain is an experience associated with the threat of tissue damage but doesn’t necessarily equal suffering. That suffering is about loss of “self-ness” or losing aspects of who and what we expect from ourselves or believe about ourselves. I believe we can always find ways to help people retain or regain a sense of self, even when it may not be possible to alter the experience of pain itself. And that reflects the value I place on being able to express who I am. And my values inform how I work with people.
Inherent in much of our health practice is the idea that people should be able to remain independent and do what they value. Ideas of independence are value-laden – reflecting beliefs that individuals should be able to make their own decisions. But this doesn’t hold in some cultures where groups or families or a collective are seen as more important than any single individual. I’ve seen conflict occur in a health service where the individual I was working with came from a culture where family orientation, support to remain within the family and receive care was prioritised. The service I worked within prioritised independence and helping the person become more capable and independent, while the person and her family prioritised family relationships and maintaining this person’s dependence on family care. No matter how hard we worked with this person, we couldn’t achieve joint goals because we were working at cross purposes.
Because many values develop within a cultural context, and are implicit and not really ever examined, within healthcare we can be completely unaware of how our values might influence how we work with the person we’re seeing. And vice versa. Some of the challenges we face as healthcare providers can derive from our own unexamined implicit values assumptions.
For example, we might see someone as being unmotivated, as not putting effort in – they may see us as unsympathetic, as not listening to their concerns. They may believe we’re meant to “do the work” for them, we may see this as “being dependent”. They may believe that healthcare should be able to fix everything. We may recognise we can’t. Or we may believe we should be able to fix everything if we try hard enough.
Should values be left unexamined? Should we even think about questioning our own assumptions and those of the people we see as clients?
I don’t advocate trying to change someone’s values, but I do advocate sitting beside them and examining them. I think we need to recognise that values exert an influence over what we do, how we do it and what we prioritise. Mostly I think we need to look at our own implicit assumptions, and judge them against a criterion of workability within a context.
What this means for me is taking the time to question myself whenever I hear myself using the word “should”. I use some of the old cognitive therapy strategies of downward arrow (https://sites.google.com/site/psychospiritualtools/Home/psychological-practices/identifying-core-beliefs) to check in with why I think something is important. And then I ask myself whether it’s workable – and whether it takes me closer to, or further away, from the life I want to live.
Here’s a thought: what about trying this yourself. Ask yourself why it’s important to do whatever it is you do, then ask yourself how well is it working. You might be surprised at what comes up for you. I’d love to hear your thoughts!
There’s no doubt that low back pain presents a major healthcare problem in all parts of the world. It’s probably the most common form of musculoskeletal pain around, it can be highly disabling – and its management is one of the most contentious imaginable. As someone once said “if there was an effective treatment for low back pain, there wouldn’t be such a range of treatments available!”
I want to take a step back and consider people living with nonspecific low back pain only, it’s by far the most prevalent, and while no-one would say there is a single diagnosis that can be applied to all forms of back pain, there seem to be some similarities in how this kind of pain responds.
What we’ve learned over the past year is that acetaminophen hardly touches the pain of nonspecific low back pain Machado, Maher, Ferreira, Pinheiro et al, 2015). This means anti-inflammatory medications (NSAIDs) are the most likely group of medications to be prescribed, or perhaps codeine. Exercise was the recommended treatment for osteoarthritis of the hip and knee, suggesting that this approach might also be recommended for low back pain.
Turning to exercise, it seems that there is no clear indication that any particular type of exercise is any better than any other exercise for low back pain (not even motor control exercise)(Saragiotto, Maher, Yamato Tie, Costa et al, 2016), and all exercise improves pain and disability – and even recurrences (Machado, Bostick & Maher, 2013). What seems important is that people get moving again, and do so quickly after the onset of their back pain.
Graded exposure has also been in the news, latest being a study using graded exposure for elderly people living with chronic low back pain, where it was found to not only improve function (reduce disability) but also found to reduce pain (Leonhardt, Kuss, Becker, Basler et al, in press). OK, pain reduction wasn’t reduced a great deal, but neither have many treatments – and at least this one has few adverse effects and improves disability.
Where am I going with this?
Well, recently I made some apparently radical suggestions: I said that
- sub-typing low back pain doesn’t yet seem to be consistent;
- that no particular exercise type seems better than anything else;
- that ongoing disability is predicted more by psychosocial factors than by physical findings – even when injection treatments are used (van Wijk, Geurts, Lousberg,Wynne, Hammink, et al, 2008).
- that people with low back pain seem to get better for a while, and often find their back pain returns or grumbles along without any particular provocation;
- and that perhaps treatment should focus LESS on reducing pain (which doesn’t seem to be very effective) and LESS on trying to identify particular types of exercise that will suit particular people and MORE simply on graded return to normal activity.
- Along with really good information about what we know about low back pain (which isn’t much in terms of mechanics or anatomy, but quite a lot about what’s harmful and what doesn’t help at all), maybe all we need to do is help people get back to their usual activities.
For my sins I was asked not to remain involved in the group planning health system pathways (I also suggested maybe osteopaths, chiropractors, massage therapists and both occupational therapists and psychologists might also be good to be involved – maybe that was the radical part because I can’t see an awful lot radical about my other suggestions!).
Here’s my suggestion – when one of the most difficult aspects of low back pain management is helping people return to normal activities within their own environment (work, home, leisure), why not call in the experts in this area? I’m talking about YOU, occupational therapists! So far I haven’t been able to find a randomised controlled trial of occupational therapy graded exposure for low back pain. I’m sorry about this – it’s possibly a reflection of the difficulty there is in even suggesting that DOING NOTHING (ie not attempting to change the tissues, just helping people return to normal activity) might be an active form of treatment, and one that could work.
I don’t want to denigrate the wonderful work many clinicians do in the field of low back pain, but I suspect much of what seems to work is “meaning response” – well-meaning clinicians who believe in their treatments, patients who believe in their therapists, treatments that appear plausible within the general zeitgeist of “why we have low back pain”, all leading to a ritual in which people feel helped and begin to do things again.
Many of us have read Ben Darlow’s paper on The Enduring Impact of What Clinicians Say to People with Low Back Pain (Darlow, Dowell, Baxter, Mathieson, Perry & Dean, 2013). We have yet to count the cost of well-meaning clinicians feeding misinformed and unhelpful beliefs (and behaviours) to people with acute low back pain. I think the cost will be extremely high.
I just wonder if we might not be able to cut out much of the palaver about low back pain if we went directly to the “feeling helped and begin to do things again” without the misinformation and cost of the rituals involved. While other clinicians can contribute – the process of doing in the context of daily life is where occupational therapy research, experience and models have focused for the discipline’s history. That’s the professional magic of occupational therapy.
Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine, 11(6), 527-534. doi:10.1370/afm.1518
Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S.(in press). Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study. Journal of Geriatric Physical Therapy.
Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.
Machado, G. C., Maher, C. G., Ferreira, P. H., Pinheiro, M. B., Lin, C.-W. C., Day, R. O., . . . Ferreira, M. L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials (Vol. 350).
Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012004/abstract doi:10.1002/14651858.CD012004
van Wijk, R. M. A. W., Geurts, J. W. M., Lousberg, R., Wynne, H. J., Hammink, E., Knape, J. T. A., & Groen, G. J. (2008). Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain. Pain Medicine, 9(2), 212-221.
Easter break – and I’ve gone fishin’
Back next week with more from Healthskills. Don’t forget that you can subscribe to my blog, you can send comments and ask questions, make topic requests and connect with me via Facebook (Bronnie Lennox Thompson), Twitter (@adiemusfree), Tumblr: Miss Miche’s Mother, and LinkedIn: Bronnie Lennox Thompson. Introduce yourself via my “About” page, and enjoy browsing the many posts I’ve put up over the last 8 years.
It’s a new year and 8 years since I began Healthskills. I’m ready to review what people want from me – are you up for it?
When I began there were very few blogs on chronic pain, and I wanted to give good, scientific information on pain management for all those people who can’t access the research as easily as I can. I also wanted to make sure that the content was useful, could help people who were first beginning to work in pain management some of the information they might not have learned in their training (or postgraduate training even!). Things have changed in the past 8 years, there are many more blogs around and a lot more discussion about the practicalities of using modern pain science in the clinic. Is what I write relevant? Is it useful? Does it fill a gap? What would YOU like from me? Now’s your chance! The poll will be open for two weeks only.