Bias: Is pain all the same?

The topic of how we define pain, and how humans respond to pain has come up for me as I mull over the IASP definition of pain. The current (new) definition is this:

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Six key notes:

• 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.

Now, for me the definition works fine – definitions describe and establish boundaries around what is being defined. Definitions don’t have to include all the uses of the term but instead just have to be distinct and clear, to “express the essential nature of something” as Merriam-Webster puts it.

Alongside this definition are notes about the function of pain – in other words, the notes (but not the definition) attempt to indicate why we experience pain. ‘An adaptive role‘ – in other words, pain serves a purpose in most cases and it may have adverse effects.

The question that leaps out to me now is what is the adaptive purpose of pain? This is the question that vexes many commentators who really don’t like the idea of what one author has called “maldynia“. Maldynia is thought to be “bad pain” that is severe, disabling and long-lived. I’m not fond of the word, but I do think there are pains that are not “adaptive” and these are amongst the ones that puzzle us the most in clinical practice. Things like phantom limb pain, nonspecific low back pain, complex regional pain syndrome and dear old fibromyalgia.

Back to the adaptive purpose of pain. Right now I have a cracked area on my heel. It’s quite a deep crack and it hurts every time I put my foot down. The way I’m using that information (the ‘ouch’) is to notice that yep, the crack is deep and there is tissue damage. And I am doing something about it by looking for urea-based cream and covering it while I work in the garden. I’ve (1) noticed tissue damage; (2) recognised that I need to do something about it; and (3) from experience, know that it will settle down and no longer be painful once the tissues have healed. I’ll also take care in the future to treat my heels so they remain soft as a baby’s bottom.

The metaphor of pain as an alert and action prompt serves quite well for me at the moment. And in most cases this is how we experience pain. Another example: I burned my thumb and finger on a soldering iron recently – you bet that hurt! I let go of the soldering iron PDQ, soaked my thumb and finger in cold water, then covered them until they had healed. The pain I experienced settled down after a day or so (unless I held a hot coffee cup!), and the new skin was a little tender for a couple of weeks. Again – pain served a purpose to alert me to stop doing dumb stuff, to protect the area, and to learn not to grab hold of the wrong end of the soldering iron! The metaphor of pain as an alert, call to action and learning experience again worked pretty well.

Now over the last few years I’ve had shoulder pain, imaging showed a bit of an enlarged bursa, a tiny fragment of calcification. This pain hasn’t settled down, even after I had cortisone injection AND did all the movement stuff including strength (yes – I did strength stuff!). Where oh where is the purpose or function of pain in this instance? Pain is not serving me well – I’ve been alerted, I’ve acted on that alert, nothing has changed and the metaphor breaks down.

But let’s take a look at the notes from IASP again – “Although pain usually serves an adaptive role” – usually. Usually. So there are times when pain does not serve an adaptive role. I think my shoulder pain, my groin pain, and my neck and back pain (yep, good old fibromyalgia) does not serve a function. I can’t think of any utility in having a grumpy body that really gripes about doing everyday movements like getting dressed, standing up from a chair, turning to look our the rear window of my car while I reverse down the driveway or aches in different parts of my body on different days then moves somewhere else at random.

A hidden assumption of the pain definition notes is that the “adaptive role” is reserved for those with a normally functioning nervous system, and where pain is associated with nociceptive activity, or inflammation. What if a nerve itself is damaged? What if the spinal cord is diseased or traumatised? What if there are changes to the way the nervous system processes information (we have that in every other sensory process, and in every other body system)? The experience of pain remains the same – still the same old aching, burning, gnawing, stinging sensations and the “ew”, “I don’t want this”, frustrating, totally unpleasant sensory and emotional experience as defined. The adaptive function, however? Not present.

The thing is, while I focus on persistent pain, most pain by far is not ongoing. I expect my heel crack to heal and the pain to go, and my now-slightly scarred finger and thumb are fine now.

Yes, the epidemiology of persistent pain shows that the prevalence of pain that goes on for more than three months is between 13–50% of adults in the UK. Of those who live with chronic pain, 10.4–14.3% were found to have moderate-to-severe disabling chronic pain (Fayaz, Croft, Langford, Donaldson & Jones, 2016). Similar findings for New Zealand – 16% of NZers live with pain lasting three months or more.

But given I think most of us will hurt ourselves at least once this year (especially with the lockdowns and stress of COVID19 and the economy and elections…), this means that more often than not, our experiences of pain are the acute kind. The ones that do alert us to notice what’s happening in our body, to take some kind of action, and to learn something useful from this experience.

So, while the metaphor of an alarm, alert, “danger signal” or “bear” or “beast” doesn’t hold up for all of our pain experiences, on the whole, it works. And the purpose of metaphor is “a way of conceiving of one thing in terms of another, and its primary function is understanding” (Lakoff and Johnson, 2003). Ultimately, we use metaphors like these to generate a sense of purpose for an experience that is commonplace, and the most common pain we have is a short-term, temporary one. Let’s not let my bias towards persistent pain lead me astray.

Fayaz A., Croft P., Langford R., Donaldson J., Jones G. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6

Lakoff G, Johnson M. Metaphors we live by. Chicago: University of Chicago Press, 2003:36.

Merskey H., Bogduk N., editors. IASP task force on taxonomy, Part III: Pain Terms, A Current List with Definitions and Notes on Usage. IASP Press; Seattle, WA: 1994. pp. 209–214.

The positive power of what we say during treatment

Expectations form one of the important predictors of response to treatment, especially in the case of treatments for pain. A person’s belief or expectation that a treatment will reduce their pain is thought to be part of the response to placebo – and indeed, part of the response to almost any treatment.  Much of the research into expectancies has been carried out in experimental models where healthy people are given a painful stimulus, then provided with some sort of treatment along with a verbal (or written) instruction that is thought to generate a positive belief in the effectiveness of that treatment. The people we see in a clinical setting, however, are in quite a different setting – they experience pain sufficiently disruptive to their sense of well-being that they’ve sought treatment, they may not know what the pain problem is, they may have other health conditions affecting their well-being, and for some, their pain may be chronic or persistent. Do expectations have a clinically-relevant effect on their pain?

Luckily for us, a recent meta-analysis published in Pain (Peerdeman, van Laarhoven, Keij, Vase, Rovers, Peters & Evers, 2016) means the hard work of crunching through the published research has been completed for us! And given 15 955 studies were retrieved in the initial pass through the databases, we can be very relieved indeed (although only 30 met the inclusion criteria…).

What are expectations?

Before I swing into the results, it’s important to take a look at what expectations are and how they might relate to outcomes. According to Kirsch (1995) response expectancies are expectancies of the occurrence of nonvolitional responses (ie responses we’re not aware we make) as a result of certain behaviours, or specific stimuli.  Kirsch points out that nonvolitional responses act as reinforcement for voluntary behaviour, so that by experiencing a nonvolitional response such as relief, joy, reduced anxiety and so on, people are likely to engage in  behaviours associated with that experience again. For example, if someone is feeling worried about their low back pain, just by having a treatment they expect will help and subsequently feeling relieved, they’re likely to return for that treatment again.

How are expectations created?

Some expectations are generated within a culture – we expect, for example, to see a health professional to relieve our ill health. In general, simply by seeing a health profession, in our developed culture, we expect to feel relieved – maybe that someone knows what is going on, can give a name to what we’re experiencing, can take control and give direction to whatever should happen next. This is one reason we might no longer feel that toothache as soon as we step into the Dentist’s waiting room!

Peerdeman and colleagues outline three main interventions known to enhance positive expectations for treatment: verbal suggestion “You’ll feel so much better after I do this…”; conditioning “If I give you this treatment and reduce the painful stimulation I’ve been giving you, when you next receive this treatment you’ll have learned to experience relief” (not that you’d actually SAY this to anyone!); and mental imagery “Imagine all the wonderful things you’ll be able to once this treatment is over”.

I think you’d agree that both verbal suggestion and mental imagery are processes commonly used in our clinics, and probably conditioning occurs without us even being aware that we’re doing this.

How well does it work for people with acute pain?

As I mentioned above, expectations are used in experimental designs where healthy people are poked and zapped to elicit pain, and hopefully our clinical population are not being deliberately poked and zapped! But in clinical samples, thanks to the review by Peerdeman and co, we can see that there are quite some impressive effect sizes from all three forms of expectancy induction – g =  0.67 (95% CI 0.49-0.86). That means a good deal  of support from the pooled results of 27 studies to suggest that intentionally creating the expectation that pain will reduce actually does reduce pain!

And now for chronic pain

Ahhh, well…. here the results are not so good, as we’d expect. Small effects were found on chronic pain, which is not really unexpected – chronic pain has been around longer than acute pain, so multiple reinforcement pathways have developed, along with pervasive and ongoing experiences of failed treatments where either neutral or negative effects have been experienced.

What does this mean for us as clinicians?

Probably it means that we can give people who are about to undergo a painful procedure (finger pricking for diabetes, dressing changes for ulcers, getting a flu jab) a positive expectation that they’ll feel better once it’s over because the strongest effect was obtained for people undergoing a painful procedure who received a positive verbal suggestion that the procedure would help.

Chronic pain? Not quite so wonderful – but from this study I think we should learn that expectations are a powerful force in our treatments, both individually with the person sitting in front of us, but also socioculturally – we have an expectation that treatments will help, and that’s not something to sniff at. Perhaps our next steps are to learn how to generate this without inducing reliance or dependence on US, and on helping the person recognise that they have generated this themselves. Now that’s power to the people!

 

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189.

Peerdeman, K. J., van Laarhoven, A. I. M., Keij, S. M., Vase, L., Rovers, M. M., Peters, M. L., & Evers, A. W. M. (2016). Relieving patients’ pain with expectation interventions: A meta-analysis. Pain, 157(6), 1179-1191.

Getting through it

Some of you may know that I’ve just had surgery, and I’m gently recovering from the comfort of my own home over the next few weeks.  Posts on here will be intermittent but I find myself considering aspects of pain management from a ‘patient’s’ perspective today as it’s about 5 days since surgery and my brain is starting to unfog.

I had good pre-surgical analgesia – couple of paracetamol and midazolam – and excellent post-surgical pain relief, a combination of anti-inflammatories, codiene and paracetamol.  I also had oxygen for about 24 hours, and a drip.  Yummy stuff.  I had wonderful nursing staff who checked regularly that my pain relief was adequate – and yet despite all of this, I had several hours of feeling really horrid.  And yet I coped.  I’m trying to use my self as a subject here, to work out what I did to get by – so for what it’s worth, this is what I think I did.

1. I reminded myself that this pain is probably gas not tissue pain.  As a result, although it felt awful it wasn’t like I was worried that stitches were popped or anything.
2. I breathed.  I breathed out a LOT, and relaxed each time.  And you know what? It worked!  Each time I found myself tensing up I breathed out and relaxed AGAIN.
3. I sipped water.  Not sure why, not sure how, but it helped!
4. I noticed parts of my body that weren’t hurting and tried to really FEEL them.  The pressure of the sheets on my legs, the textures under my fingertips, the difference between warmth and cool on my arms where the sheets were and weren’t.  My toes.  Letting go muscle tension where I could.  Feeling the sensation of air entering my lungs and escaping as I breathed out.
5. Strange, but I compared this pain with the pain I’d had the surgery for – and it wasn’t a patch on what I’d been coping with!  OK that pain was a day or two at a time, but it was pretty intense – this pain was not nearly as intense and I knew it was going to go, and why it was there.
6. I talked myself through each moment, rather than looking ahead or trying to predict what might be.  I tried to stay as much in the present as I could.  And just breathed.

I had read through my pre-surgery printed material.  Lots of information on altered bowel habits, on the amount of lifting I was allowed to do (nothing more than 2 kg!! and NO vacuuming or pushing grocery trolleys!), on the need to rest after surgery, and strangely, suggestions that I might feel saddened or grieve for losing that bit of me (and the potential to have babies).

Nothing at all on how to use pain relief after I was discharged from surgery.  Nothing on nonpharmacologic coping strategies – like the ones I used most often.  Nothing on anxiety, hypervigilance, breathing, positive coping statements, mindfulness, relaxation – zilch.

The things I do remember that helped (aside from the six points above).  The warmth of the surgeon’s hand on mine as I was prepped for surgery and slipped into anaesthesia-land.  The warmth of the blanket that they placed over me as I was wheeled back to my room.  That chilled water.  The nurse stopping beside me and looking in my eyes a moment before asking me how I felt, and waiting while I replied – all the time in the world just for me.   The feeling of clean smooth sheets.  A warm flannel to wash my face and hands with – bliss!  One of the nurses saying ‘you don’t have to feel pain, there is pain relief there for you’.  And another saying ‘there is plenty of time, you don’t have to rush’.

Well, you know me, I’ll find an article to ponder over if I can, so here’s one that I thought made some interesting points about post-operative pain.

This study is a qualitative study of women’s experiences after cardiac surgery – some points to note right off.  Firstly, more women than men complain of post-operative pain than men – curious but not unexpected.  More women than men complain of pain at all ages from puberty until menopause.  Secondly, pain experiences depended on what women’s expectations of pain after cardiac surgery were.   Thirdly, early discharge requires increased patient participation in pain management.  It’s that one that I think could be much more emphasised!

The findings indicated that women described four aspects of the pain experience – location, quality, consequences and cognitive aspects – the latter dealing with ‘expected pain’, ‘unexpected pain’ and ‘devaluation’.  Cognitive aspects were the women’s judgements about having the pain, and included thoughts that the wound pain was ‘expected’ or ‘something to be endured’, whereas ‘pain in the neck, shoulders and back was described as more worrying than that from the surgical wounds’.  This in part because it hadn’t been expected to be so intense.  Notably, women downplayed their pain apart from acknowledging the interruption pain had on their everyday activities.

I was curious to read that self management included receiving instruction on how to use medication – and that women wanted more individualized information on pain management, rather than just the standard prescription for paracetamol with codeine ‘as required’ and advice to use analgesics at regular times, especially about when ‘as required’ meant, and side effects of codiene.  Few women actually used pain medication in the way it was prescribed (ie time contingent paracetamol with codiene used possibly twice a day).  The views of the women about pain relief was that it was a mixed blessing – nice to know it was there, but not that happy about having to use it partly because of fear of side effects.  Instead of taking medication, women instead adjusted their level of activity – ending up by doing less rather than taking adequate pain relief.

As I reflect on my experience – this time around I had few instructions on pain relief on discharge.  I did have a list of medications and was advised to get the prescription filled, but there were few specific instructions, nothing written and nothing suggesting that time contingent analgesia was preferable to prn.  This was in contrast to when I had my tonsillectomy – then it was made very clear to have time contingent medication and I had some very clear instructions on what to expect.  I wonder if this is because it is well-known that tonsillectomy as an adult is extraordinarily painful, while abdominal surgery has less of this reputation.

Looking further into this study by Leegard, Naden and Fagermoen, these women demonstrated that far from receiving patient-centred care and involvement in developing their own self management plan for their pain on discharge, this was largely a biomedical matter and involved providing the women with generic and nonspecific information that didn’t fit with the women’s own beliefs and lifestyle. The information was ‘given to’ rather than a plan being ‘developed with’.

Women complained of increased pain in part because they started to resume household tasks, even though they had been advised not to.  I’m in a similar position: told not to ‘lift anything over 2 kg’ my wee brain is struggling to work out why that particular weight restriction, how far can I push it? What positions can I use ‘safely’?

Complex questions, and ones that I’m surprised haven’t been explored in more depth.  Maybe this represents the biomedical focus that surgery and pain relief have.  Maybe it shows the lack of noise from people being discharged – which again isn’t surprising given that most of us don’t have all that many surgical procedures, and by the time people do complain, the pain is ‘chronic’ and chronic pain is of course a different entity from acute pain – or is it?

Leegaard, M., Nåden, D., & Fagermoen, M. (2008). Postoperative pain and self-management: women’s experiences after cardiac surgery Journal of Advanced Nursing, 63 (5), 476-485 DOI: 10.1111/j.1365-2648.2008.04727.x

More pain sites over time = greater risk of work disability

It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

1. In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving.  In chronic pain management, we ask people to do things despite pain.
2. In acute management, we encourage a ‘start low and go slow’ approach to increasing activity.  We do the same in chronic pain management.
3. In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal.  In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside.  In chronic pain management, we are relatively sure that pain will persist.    So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly.  It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often.  I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem.  If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey?  If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back.  I do write most days during the week, and I do love comments.  If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to.  I’m looking forward to hearing from you!

Kamaleri, Y., Natvig, B., Ihlebaek, C., & Bruusgaard, D. (2009). Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study European Journal of Pain, 13 (4), 426-430 DOI: 10.1016/j.ejpain.2008.05.009

Context and sociocultural factors

I posted yesterday about how little social and cultural factors seem to be included in assessing and managing pain, and I had hoped to find some papers to discuss today. Events conspired and I have failed in that endeavour, so this post is, unusually for me, almost entirely my opinion.

So, sticking my neck out, why do I think the sociocultural context needs to be included when someone presents with their pain problem?

Well, the first thing that springs to mind is how has that person has found their way to a treatment facility – how did they get referred and by whom? To present for treatment means that at some point, this person has decided the pain they are experiencing is undesirable, and something needs to be done about it (whether that ‘something’ is diagnosis, elimination or confirmation of its impact). This decision to seek help seems to be based largely on whether it’s ‘normal’ or ‘expected’ in the culture in which the person lives.

Let me give you an example: and yes, it’s perhaps a little outrageous, and yes, it does relate to acute pain!
In one group in New Zealand society, body piercing and suspension is one way to generate a ‘natural high’. The individual and his or her supporters (usually members of the same social group) congregate and encourage each other through the process of suspending the body from large hooks inserted through the skin of the back. As the process continues, some of the participants begin to swing their bodies from the hooks, and I’ve watched one participant swing and run across a stage to gain more momentum. Although the physical trauma is clear and pain is experienced as the hooks are initially inserted, over the 10 – 20 minutes of the process, these individuals start to feel euphoric and describe the feeling as ‘bringing me closer to a spiritual plane’, ‘overcoming my physical self’, ‘getting in touch with the inner self’.

The practice of body piercing is ancient, and an accepted part of many cultures including Sri Lanka where it forms a part of a ritual to the Hindu god Murugan, and the Phillipines where ritual re-enactments of the crucifixion, complete with nails piercing the hands are performed on Good Friday. Tattooing is also an accepted part of many cultures including New Zealand Maori and the Pacific Islands.

For many of us, the thought of submitting to painful procedures as a recreational activity is just not something we would ever do. However, we may participate in weekend sports – netball, rugby, skiing, running, weight-training…and sustain pain with the ‘support’ of our friends!

So it’s not surprising that if our willingness to experience acute pain can be influenced by social and cultural factors, treatment seeking for persistent pain can also be influenced.

Two common pain problems come to mind: the headache and the backache. Headaches are usually managed with simple analgesia and a quiet night or a walk. Backaches – well for many of us (around half of those that have an episode of back pain in a year (Walker, Muller & Grant, 2004) we will seek health care from a GP or chiropracter or similar. If we don’t initially attend, our families and friends or employers will suggest we do if our function is affected. Who we see will be influenced by our culture – in New Zealand, it’ll be a GP or physiotherapist or chiropracter; in rural China, it will more likely be a practitioner of traditional chinese medicine, or an acupuncturist.

The impact of even our acute pain on our lives will depend on our social context – our work, whether we live alone, the responsibilities for household tasks or caring for family members. And most especially, our pain behaviours will be influenced by others around us – our nearest and dearest strongly shape the kinds of things we do when we are sore (e.g. Smith, Keefe, Caldwell, Romano & Baucom, 2004).

And these are the things that we may well miss assessing if we don’t meet the person’s family (how many people attend a pain assessment alone, without any family present?), or talk to their colleagues. What’s more, we don’t typically include these people in management either – despite our knowledge that people changing behaviour really need to have the support of those who see them every day, especially in the period immediately after a pain management programme. In New Zealand anyway, ACC claimants receiving compensation for an accident rarely have encouragement or funding to enable their family members to also be included in intervention – even when roles have changed significantly, or the relationship is under strain. The ‘claimant’ is the person with the problem – even when we know that people live within a family, community, social, sporting, church system.

Tomorrow I hope to post on some of the factors to assess when considering the sociocultural and contextual factors in a person’s pain experience. If you’ve enjoyed this post, and want to read more – don’t forget you can subscribe using the RSS feed button at the top of the page, or you can simply bookmark the blog. And I love comments and respond – even if you don’t like what I have to say!

Smith, S. J. A., Keefe, F. J., Caldwell, D. S., Romano, J., & Baucom, D. (2004). Gender differences in patient-spouse interactions: A sequential analysis of behavioral interactions in patients having osteoarthritic knee pain. Pain, 112(1-2), 183-187.

Walker, B. F., Muller, R., & Grant, W. D. (2004). Low back pain in Australian adults. health provider utilization and care seeking. Journal of Manipulative & Physiological Therapeutics, 27(5), 327-335.

Smoking and pain

Something I’ve noticed many times is the number of people experiencing chronic pain who also smoke. It used to be thought that people who smoke perhaps had poorer health behaviours which lead them to be less fit, less careful about eating well, and perhaps to having poorer responses to stressors generally. And I’ve heard it said that people who smoke have ‘addictive personalities’. Well it’s not quite a simple as either explanation – but it’s time to put some of the evidence forward about smoking, nicotine, and pain.

This is not an exhaustive review by any means, just a couple of papers that I thought might help when considering whether to suggest quitting smoking to people who have ongoing pain.
I ought to add that the studies I refer to don’t demonstrate causation – they are correlational studies, which mean that there is an association between smoking and chronic pain, but we don’t know whether the relationship is direct, or perhaps mediated through other things – and I’ve suggested some above.
Despite this, here are some papers that are quite persuasive.

The first is a large national study published in 2006, specifically looking at tobacco smoking and pain in the general population – quite different from our hospital patients, or those directly seeking treatment. Quoting directly from the abstract: Former and current heavy smokers had higher odds for greater numbers of pain locations and for moderate and intense pain than never smokers after adjustment for analgesic medicament use and behavior-related risk factors. Female former heavy smokers had an adjusted odds ratio (OR) of 1.6 (95% confidence interval, CI, 1.2-2.2) and male former heavy smokers had an adjusted OR of 1.4 (CI 1.1-1.8) for higher numbers of pain locations compared to never smoking women and men respectively (female current smokers: OR 1.4, CI 1.0-1.9; male current smokers: OR 1.3, CI 1.1-1.7).

The findings suggest that former and current heavy smokers are more likely to report more pain locations and more intense pain than never smokers.

Well, that’s quite high odds! And sadly, it doesn’t seem to make a lot of difference whether you’ve stopped smoking or continue to smoke – the odds are still high.

A second study worth considering is this one published in 2005, where people consulting a GP for the first time with acute low back pain were followed. Again quoting from the abstract: At 4 weeks and 3 months 76% of the patients had recovered. Mean pain intensity and mean disability scores dropped 58% and 68%, respectively, of initial levels during the 3 months. The proportion with sickness absence was 8% at 4 weeks and 6% at 3 months. Several sociodemographic, clinical, and psychological factors were of prognostic value. Compared with their respective reference categories, age above 45 years (odds ratio 4.4, 95% confidence interval 1.4-14.0), smoking (3.0, 1.1-8.5), two or more neurological signs (4.6, 1.4-14.9), a score of >90 on the psychosocial screening (3.1, 1.0-9.4), and high levels of distress (4.1, 1.3-12.8) were the best prognostic factors of nonrecovery at 3 months.

And a final study worth mentioning is a very recently published one by Ryall and colleagues, studying people attending primary care and physiotherapy for arm pain: Altogether, 313 (83%) of 375 subjects completed follow-up, including 53% with ‘continuing’ and 24% with ‘unremitting’ pain. ‘Continuing’ pain was predicted most strongly by male sex (OR 1.9, 95% CI 1.2-3.2) (this association was restricted largely to the elbow), higher frequency of pain in the past month at baseline (OR 2.5, 95% CI 1.1-5.6), chronic pain at sites outside the arm (ORs 1.6-2.4 for different sites) and current smoking (OR 3.3, 95% CI 1.6-6.6). There were also indications that mental health and fear-avoidance beliefs influenced prognosis. Predictors for the other two adverse outcomes were similar.

Curious – some very strong pointers that smoking increases the risk of persistent pain and poorer recovery from acute pain, yet I’m not sure that I’ve ever heard that in public health messages about smoking, and I’ve not yet heard of quitting smoking efforts targeting people with chronic pain. Time for action? I think so.
BTW I don’t know why I get smiley’s through my posts – any geeks out there able to tell me? Can’t see it in the HTML code, but then again, I’m not a technophile…

Grotle, M., Brox, J. I., Veierod, M. B., Glomsrod, B., Lonn, J. H., & Vollestad, N. K. (2005). Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time. Spine, 30(8), 976-982

John, U., Hanke, M., Meyer, C., Volzke, H., Baumeister, S. E., & Alte, D. (2006). Tobacco smoking in relation to pain in a national general population survey. Preventive Medicine, 43(6), 477-481.

Ryall, C., Coggon, D., Peveler, R., Poole, J., & Palmer, K. T. (2007). A prospective cohort study of arm pain in primary care and physiotherapy–prognostic determinants. Rheumatology, 46(3), 508-515.

Mind, body and pain

For lots of therapists, the connection between mind and body is so clear that we forget many people just have no concept of how the two might be connected. So often in the web there are wild statements about pain that it’s tempting to think that no-one’s prepared to get it right or to spend some time (and web pages) discussing it…

So when I found The Psychology of Back Pain by Jonah Lehrer (with some stunning photography by Craig Cutler) I knew I had to link to it here!
Although many of us know this material through and through, it’s great to find someone who writes well and puts the pieces together for nonclinicians…
Jonah also writes this piece about MRI’s, Back Pain and Transparency – linking in to a couple of other people writing also about MRI’s and the myth that MRI can ‘show everything’. Take a look, enjoy – as a clinician, it’s always great to see someone in the media putting what I talk about ‘out there’ to people in the community!

Mulling over balance in the biopsychosocial…

For some years I’ve taught a postgraduate course in pain and pain management – my responsibility is to teach the psychosocial components, while I coordinate the content of both papers.  Recently I had a discussion with a colleague who suggested that the psychosocial component was over-represented, while the biophysical was under-represented.

At the time I didn’t agree, and on reflection I still don’t agree.

For years undergraduates in most health professions have received information on pain that consists almost entirely of biophysical data, coming from a biomedical model.  There is still minimal information at an undergraduate level in medicine, physiotherapy, occupational therapy, nursing or psychology training that covers pain in any shape or form, and what information there is tends to be about neurophysiology, acute pain, and about ‘injury’ or tissue damage.  When psychosocial material is given any time at all, it’s represented as a ‘response’ to pain (ie physical injury), or referred to in the same breath as chronic pain (ie a confounding factor only in individuals who are having trouble coping with persistent pain).

The definition of pain as given by the International Association for the Study of Pain is “… an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” By definition, people who experience pain are feeling it as an emotional event. ‘Psychosocial factors’ are integral to the experience of pain! We can’t experience pain without it being a psychological event…

The problem is, that while most health professionals gain a grounding in anatomy and physiology, and even in tissue pathology, nerve conduction – and healing… not nearly as many are aware of the fundamentals of pain behaviour, the place of psychosocial factors as both integral to the experience of pain and as factors that may complicate recovery (from acute onset of pain right through to coping with persistent pain and ongoing disability).

So in teaching postgraduate pain and pain management, people like me who teach ‘behavioural medicine’ or psychosocial aspects of pain and pain management to health professionals have to start with the basics of the difference between pain and pain behaviour, health and pain anxiety, measurement concepts, the role of the brain and emotions and attention and cognition, not to mention learning and reinforcement and allied concepts!

So if, in teaching at postgraduate level, I am emphasising the psychosocial, I hope that it’s in an effort to redress the imbalance of undergraduate knowledge that is carried over into professional health care.  Roll on the day when undergraduates receive sufficient training in pain as a complex, multidimensional experience that involves the biophysical, psychological and social aspects of being human.   Until then I think I need to spend a good deal of time just covering the basics…