Why learning about pain can help – an old study worth revisiting

If you’ve read my blog over the years you’ll see that I love a bit of history. Learning from older studies, and older opinions, can help us position our current thoughts in a larger context. Older studies can also highlight concepts that haven’t grabbed the attention nearly as much as more recent studies but still have value.

Today’s post is about a studied published in 2004. It’s one I’ve often used to illustrate how influential our expectations or beliefs are when it comes to pain intensity and pain aversiveness/unpleasantness.

Take 31 healthy undergraduate students (50% were women in this case). Split them into two groups, and offer them a small incentive (a large bar of chocolate and a soft drink – OK I’m in!). Hold a set of objects to the back of their necks and ask them to rate the experience on a set of visual analogue scales ((1) very soft–very hard; (2) not prickling–very prickling; (3) not noticeable–very noticeable; (4) not painful–very painful; (5) not rough– very rough; (6) not damaging–very damaging; (7) not pleasant–very pleasant; (8) very cold–very hot; (9) very simple–very complex.). The objects were:

a feather, a small mirror, a rough brush, a paper handkerchief, a metal bar, a piece of hard plastic, a piece of sand paper, and a gel. The metal bar (aluminium, length 17.5 cm, diameter 3 cm) was cooled down to -25 degrees Celcius. This temperature was chosen because it’s not damaging when held briefly against the skin.

Each person was then individually exposed to the item, and asked to complete the ratings. The only difference between the groups was that participants were told just before the metal bar was applied, “this is very hot” or “this is very cold”.

The findings supported the hypothesis: when people thought the stimulus was hot they rated it as more painful AND more damaging than when they thought it was cold.

What do we make of this? The simple interpretation is that people interpret what happens to them in light of what they think is going on. That meaning influences the experience of pain. And that this interpretation occurs rapidly and without conscious awareness. The authors argued that attentional focus, anxiety and interpretation all influence the experience – however, in this instance, attention to the stimulus was greater in the case of the “cold” stimulus than the hot. Anxiety might influence attention to a stimulus, and “hot” might be more anxiety-provoking than “cold”, enhancing attentional awareness – or not. So the final consideration from this study is that if interpretation is essential in perceptual processing, tissue-damage related meaning might itself influence how pain is perceived.

The authors conclude by saying that their findings “support the hypothesis that higher order psychological processes influence the experience of pain” and go on to say they are “also of clinical importance, as they suggest that correction of dysfunctional interpretations of pain might help to reduce the burden the experience of pain poses on many people.”

Since this paper was published we have seen a proliferation of educational approaches to help people experiencing pain interpret this in a different way. I’m loathe to describe a person’s interpretation as “dysfunctional” because it is their experience – and at the same time I’m also aware that many unhelpful terms are used to describe what might be going on inside a person’s body. Some examples include “wear and tear” for osteoarthritis, “an unstable pelvis”, “your back has gone out”, “your spine is out of alignment” – the list goes on.

Here’s the thing: we can absolutely acknowledge a person’s distress at what they understand is going on, and what it feels like to them. We should, I think, always be compassionate and validate the distress we see in a person. That is real and their experience.

Here’s another thing: when the distress is based on inaccurate or unhelpful information, then I think it’s unethical to leave a person thinking this – even if we’ve offered validation and compassion. Would we leave a person to believe they had cancer when they didn’t? And yet some people would argue that to offer an alternative explanation somehow invalidates the person’s experience. We can both validate the distress a person is feeling AND offer a more workable or useful alternative.

At this point in my blog I want to be absolutely crystal clear – I do not know all the mechanisms involved in pain. Nobody does. And none of our explanations are terribly “True” with a capital T, because we actually don’t know. We do have some workable explanations to dispute or replace some unhelpful or unworkable explanations – eg that what we can see on imaging doesn’t equate with pain; that “issues in the tissues” are poorly correlated to pain; that “wear and tear” is often interpreted by people as “I’m wearing out” when it might be more useful to describe osteoarthritic changes as “age-related changes”. We definitely know that the brain is involved in our pain experience, and we know that various so-called psychological processes influence how much of a nociceptive stimulus is processed. What we don’t know is how – and that’s OK. To a great extent the “how is pain ‘produced'” question remains unanswered. But to leave people with an impression that “if I bend without using my core, I’ll do serious damage”, or “this could leave me in a wheelchair if I’m not very careful” in the name of validating a person’s experience is, I think, the very worst example of paternalism.

Do I espouse any particular way of helping someone make sense of their experience? Yes, glad you asked. My preference is to take the person through their own experiences, to help them “join the dots” of the various factors that might be influencing their pain. If, and when, it’s appropriate I might add in some things we know about pain such as increased anxiety likely increases pain and attention to pain – and this is why, in the middle of the night when there’s not much going on, and a person isn’t sleeping, they might notice their pain really going nuts. I accept that pain is present, and how or why isn’t nearly as important as exploring what this person notices about their own pain. And sometimes that might include some gate control theory, some neuromatrix, some descending inhibition information, and so on. In the service of my clinical reasoning about why this person is presenting in this way at this time, and what might be maintaining this person’s predicament.

TL:DR – what a person thinks is going on has a powerful influence on both pain intensity and unpleasantness (oh and beliefs about harm). This matters because some explanations given to people (and some of the rubbish found on the internet) are not helpful at all.

Arntz, A., & Claassens, L. (2004). The meaning of pain influences its experienced intensity. Pain, 109(1-2), 20-25. doi:10.1016/j.pain.2003.12.030

Health anxiety & chronic pain

Yesterday’s post about ‘hypochondria’ and chronic pain created a bit of a storm.  Emotions run high when you have chronic pain and someone somewhere suggests (a) that it’s ‘all in your head’   or (b) you’re just being a ‘hypochondriac’.  There are loads of reasons why both of those comments are inaccurate and unhelpful, but as I said yesterday, there is also a lot of research suggesting that health anxiety might play quite a big part in increasing the distress and disability associated with having persistent pain, and maintaining both.

How would you know if you, or a patient you were seeing, was anxious about his or her health?
You know I’m going to say there is no black and white answer to this one, don’t you?! Anxiety about health varies along a continuum, but there are four main characteristics that you could use to guide your thinking.
(1) Excessive preoccupation with, and fear of developing or having a serious illness
(2) The fear persists despite medical reassurance
(3) It interferes with everyday life
(4) It has been a problem for at least six months

First, the problems with this set of criteria: what is ‘excessive’? This depends on the person’s experiences in the past, and what is happening at the moment. For example, if someone has had a previous heart attack, I’m pretty sure the next time they have chest pain they’re not going to ignore it. Similarly with a breast lump – I’m sure I’d be double-checking each change in my breasts if I’ve had a past lump biopsied. If there is a current flu epidemic (H1N1 pandemic anyone?) I’m sure anyone with a cold or ‘the beginnings of the flu’ will be checking to see whether this is The Flu, and taking it pretty seriously.

A rule of thumb for me would be whether the worrying is taking up time and energy from what the person has to do, or wants to do every day. And it would also be the degree of distress associated worrying – if the person is starting to get panicky, tearful, has physiological arousal symptoms (increased heart rate, nausea, sweating, shallow breathing and so on), then I’d be starting to think this worrying was a problem. I’d also be concerned if the person was catastrophising, and thinking that any and every body symptom was associated with a dread disease, or that maybe the underlying cause was inevitably cancer or something terminal.

But that’s not the only criteria – the next is that the fear persists despite medical reassurance. Some examples from my clinical work recently:

• despite having had imaging (X-ray & MRI) and four surgeons from different parts of New Zealand who confirmed there was no need for surgery, one client continued to believe that there was ‘something wrong’ in his shoulder, possibly cancer, and doctors weren’t telling him.
• after full investigations and x-rays showing well-united ankle fractures (fractured some 5 years ago), another patient wanted more images to confirm that it was ‘safe’ to walk for more than an hour because he worried that the ‘bone had ulcerated and maybe they need to scrape some of the stuff out of it’.

The third criteria is interference – both of the people described above had stopped working, stopped their usual recreational activities (fishing and playing with the grandchildren and mowing lawns), and were miserable.  They spent more time either on the internet or seeking medical opinions than they did doing any of their usual ‘fun’ activities.  Despite the reassurance they’d had from specialists, they stopped life and worried.

And yes, for both of these men, this worry had been present for more than six months – more like six years in fact.

The fine line between being informed and advocating for yourself – and health anxiety

Yesterday someone mentioned that she was worried that by describing health anxiety as ‘excessive worry’ and describing some of those behaviours such as

• not moving much
• seeing doctors who then give them investigations, maybe MRI, CT, X-ray, nerve conduction
• checking their bodies all the time
• palpating various body parts for pain
• examining body parts for colour change, temperature change
• asking other health providers to examine them
• going onto the internet (!) and reading forums, web pages, searching for syndromes that ‘explain’ what is going on

That I might be treading a fine line between being a self-advocate and having health anxiety.

I hope I’m not, but I can see the difficulty!  Here’s my opinion, for what its worth.

To me, the main differences between being a self-advocate and having health anxiety is the degree of distress about the symptoms, and the interference experienced because of the ‘safety behaviours’.

My bottom line?  In the process of searching for the ’cause’ and ‘cure’ – are people living well?

Health anxiety persists because of four main factors:

1. Selective attention – attending to a biased selection of information. Instead of hearing ‘we found degenerative changes on your x-ray that are quite normal and there’s no need to operate, but I don’t know the exact cause of your pain”, the person with health anxiety might hear ‘your x-rays are normal so your pain is in your head’.
2. Safety seeking behaviours – avoidance, reassurance seeking, checking.  By avoiding certain movements or activities, the person doesn’t test out whether his or her dire predictions are true.  By seeking reassurance, this temporarily alleviates distress, but because of selective attention and hypervigilance to body symptoms, worries sneak in.  This can lead to checking – and like the spider phobic who gets really worried when a spider disappears from view, checking but finding nothing means nothing is there – yet!
3. Physiological arousal – as a result of feeling anxious about the meaning of sensations, it’s common for people to experience increased sympathetic nervous system arousal. This means that in addition to finding that ‘strange bump on my leg’, or ‘the colour change over my elbow’, the person can also experience nausea, sweating, heart racing and shallow breathing. Sometimes this can progress to a full-blown panic attack, which can feel at the time like something terrible is going to happen! Then these symptoms can be misinterpreted as confirmation that there is something seriously wrong and the person was right to be worried. Which in turn leads to more anxiety … and so on…
4. Mood – finally, low mood and anxiety can lead to negative brooding or ‘ruminating’ where thoughts go around and around in never-ending cycles of ‘what if’ and ‘then this will happen’ and ‘what does this mean?’  Ruminating can often disrupt sleep, certainly reduces the ability to concentrate on what is happening here and now, and most importantly, it interferes with taking action.

I’m sure you can see the difference between being informed and advocating for good information and open, honest communication between a patient and a clinician, and the negative effects of being anxious about health.

Tomorrow I’ll start to explore some ways to work with people who are really worried about their health – and it’s not so different from what we do when we work with people who are less bothered by their health.  It does mean listening, being genuinely concerned, being empathic, and asking questions so you can understand the meanings the person is placing on his or her symptoms.  It also involves you as a clinician not judging or dismissing the person’s health concerns – what you need to do is ‘walk a mile in the person’s moccasins’, really understand what the person thinks is going on.  More tomorrow on this!

Safety behaviours – do they maintain kinesiophobia?

Let me start by saying this post is conjecture, but based both on observing patients, and after reading an interesting paper on ‘subtle avoidance and safety behaviours relevant to social anxiety’.

First some definitions: I hope you’re all familiar with the term ‘kinesiophobia’, or ‘fear of movement’ – it’s the fear and avoidance of movements that an individual believes will hurt or harm them.

Safety behaviours: are strategies that may be used to reduce the anxiety of carrying out a behaviour – and are usually ‘logically’ linked to the underlying belief about the movement.  For example, using ‘safe lifting techniques’ can be a safety behaviour in someone who is fearful of bending; taking a deep breath in and breathing out prior to doing a movement may also be a safety behaviour, as can moving very slowly while carrying out the movement.

The reason safety behaviours are important in the treatment of phobia is that they are ‘subtle forms of avoidance that are employed during feared movements’, and as such the prevent the ‘unambiguous disconfirmation of unrealistic beliefs about danger’  (note that I’ve inserted the words ‘movements’ and ‘danger’ in these quotes that I’ve drawn from the paper by Cuming, Rapee, Kemp, Abbott, Peters and Gaston, 2009).

Let’s unpack that sentence: in a phobia, a person holds an unconfirmed and (usually) unrealistic belief that some sort of disaster will occur if they encounter the feared stimulus.  In kinesiophobia, this belief can be complicated by the degree of meaning that people hold about experiencing pain – not only are individuals probably correct in their belief that if they move they may experience pain, but from childhood we have been trained to avoid experiencing pain because it is equal to harm or damage.  The problem for people with chronic pain who also have kinesiophobia is that the movements may exacerbate pain but the pain they experience no longer represents harm or damage.  But it doesn’t feel like this!

As a result, people with high levels of fear and avoidance will avoid movements that they believe will cause pain in the belief that some sort of harm will befall them – the harm may be their belief that some sort of damage will occur in their bodies (their backs will ‘fall apart’ or ‘go out’), or it may be much more subtle, perhaps a belief that ‘I can’t cope if the pain increases’, or ‘I will have an awful day and I won’t sleep if my pain goes up’.

As in social phobia, safety behaviours in kinesiophobia prevent the person from experiencing or verifying that the feared outcome will not occur.  The person may instead believe that the awful thing hasn’t occurred because they have used a protective safety behaviour – so they still believe that the movement will cause harm (think of ‘safe lifting’ techniques supposedly reducing the risk of back ‘injury’); or safety behaviours may actually increase the likelihood of experiencing the negative outcome – by tensing and moving very carefully, the person may increase muscle tension and inefficient movement patterns, thereby increasing pain after the movement is complete.  By carrying out safety behaviours, the person never confronts his or her fear that something horrible will inevitably occur – either increased pain that they ‘can’t cope with’, or ‘damage’.

The paper I read that triggered my pondering today suggests that subtle avoidance and safety behaviours are prevalent in individuals with social anxiety.  The subtle behaviours allow the person to remain in a feared social situation – but only if they carry out these ‘special’ behaviours, for example speaking very slowly or quietly, mentally rehearsing what to say, holding onto a utensil very tightly causing it to shake and so on.  The problem is, these behaviours may make the negative outcome more likely (people will get frustrated listening to someone who speaks very slowly or hesitantly!), and they therefore maintain the fear that ‘people will ignore me and I’ll make a fool of myself’.

Can you see the similarities between these behaviours and maybe what we ask patients to do while getting people to carry out movements?

Maybe we ask people to review their footing and posture before they do a manual handling task – suggesting, in effect, that if they do the task ‘this way’ they will be ‘safe’.

Maybe we encourage patients to breathe in a special way, or pre-plan their movements or ‘wait until you’re warmed up’ before doing movements.

Maybe we get them to do special stretches or breathing exercises at certain times of the day, maybe even ask them to rate their pain and if they report any increase in pain, we reduce the demands on them, or try to identify ‘what has caused the pain’ so we can modify the way they do the activity.

Some patients use medication as a way to avoid experiencing fluctuations in pain – experiencing relief almost immediately after swallowing a tablet and way before it can have had a pharmacologic action.  Some patients use splints or hotties or rubs.

What are we reinforcing in our patients when we encourage them to notice their pain, report on their pain, medicate their pain – maybe we’re actually reinforcing their fear that something awful will happen if they experience a fluctuation in their pain?  Or maybe we are fearful of seeing someone experiencing pain?

The authors of this paper describe the development of a self-report measure of safety behaviours – maybe it’s time we started to develop something similar for people experiencing kinesiophobia.  Of course, in social phobia, and indeed in most phobia, the fear is out of proportion to the threat, the avoidance interferes with daily life, and most phobia are recognised as being ‘unrealistic’ .  I wonder if we can say the same about pain-related fear and avoidance – or do we have mixed feelings about how OK it is for people to experience pain?

I think our job is to help people reduce their level of suffering, to minimise the interference that pain has on their lives, and to encourage full participation in life.  I’m not so sure that we always do this when we encourage people to avoid experiencing pain by medicating or avoiding movements or carrying out movements in special ways.  What do you think?

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Cuming, S., Rapee, R., Kemp, N., Abbott, M., Peters, L., & Gaston, J. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties Journal of Anxiety Disorders DOI: 10.1016/j.janxdis.2009.05.002

Pain-related anxiety and avoidance: a practical application of theory and research to clinical practice

In 1995 I started work at the Burwood Pain Management Centre.  It wasn’t my first foray into pain management, but it was the first time I had worked in a fully integrated interdiscipinary team environment.  It was also significant because of the use of the words ‘fear-avoidance’, ‘guarding’ and ‘anticipatory anxiety’.

What the team had observed was that there were a specific group of patients who were not just worried about experiencing pain, but were also showing the signs of increased physiological arousal, avoidance of specific activities, and firm beliefs about harm, reinjury, or doing further damage.

At the time we used an operant conditioning model (based on Fordyce, 1971 & 1976), along with graded reactivation using a physical conditioning model, to help these people learn to be more functional.  We had some successes – but a number of less successful responses too.

Towards the end of the 1990’s, a new model started to emerge.  It was the ‘fear-avoidance’ model proposed firstly by Lethem et al (Lethem et al. 1983), then elaborated on by Vlaeyen and colleagues (1999, 2000).

This model proposed that people demonstrating avoidance of activities may be developing a ‘phobic’ response to their situation: based on catastrophic interpretations of their pain, beliefs that their body will be dangerously harmed by movements, increased physiological arousal in response to these beliefs, avoidance of situations the same as or similar to those that provoke their beliefs, and subsequent reward of this avoidance by negative reinforcement (ie, by avoiding a negative experience, they increase the avoidance behaviour).

An introduction to case formulation

One definition of case formulation is ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors.

There are many different frameworks for case formulation, but several key elements are usually present:

1. a description of the presenting issues;
2. the factors that act to create vulnerability or precipitate the problems developing;
3. factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally,
4. factors that can help the person cope or act as resources.

To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (ie what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognisable features that are present.

Distress and wellbeing – two sides of the same coin?

Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?
Alexa Hubera, Anna Lisa Sumana, Giovanni Biasib, Giancarlo Carlia

This is an interesting article on the concepts of wellbeing and distress. Distress is often considered a key element in whether someone has ‘good quality of life’ (see my post from a day or so ago), but in this article, the relationship between psychological distress and well-being was explored, and the predictors of both in patients with chronic nonmalignant pain are identified.

Why would we be bothered about distress and how is it measured? Distress is not a particularly well-defined concept, but is often referred to in the same breath as ‘eustress’ and ‘distress’ (see this entry in Wikipedia for an exploration of several theories relevant to stress and coping). If its used in this way, it often refers to suffering (which is about negative judgements of a situation or event), and is distinct from depression. Using Loeser’s onion rings model of pain, it’s the emotional judgement of pain that negatively impact on the individual.

In this article, however, the authors refer to two traditions and the impact these traditions have on our ideas about wellbeing. To quote ‘[the] hedonic approach focuses on happiness, while the eudaimonic approach defines well-being in terms of the degree to which a person is fully functioning, which may or may not be accompanied by feeling good.’
This reminds me of the traditional WHO definition of health – which is not simply the absence of disease!

One of the reasons I was drawn to this study was the statement by the authors that ‘To date, few studies on well-being in patients suffering from chronic pain have been published’. (Of course I’d argue that experiencing chronic pain may be mandatory, but ‘suffering’ is optional!) This is precisely the point I’ve been trying to make for some time in that most of our knowledge about people experiencing chronic pain is drawn from people who are seeking treatment. People who live well despite having chronic pain are not studied often and hence we know relatively little about them.

So, getting down to the nuts and bolts of this study: 69 women recruited from a University Hospital Rheumatology centre. The majority of them met criteria for fibromyalgia, while the remainder had widespread pain, and many of them also experienced other conditions associated with central sensitisation syndrome (e.g. psoriasis, irritable bowel syndrome, headache, fatigue).
They all completed a raft of measures, but the ones I want to focus on are those assessing distress:
The Symptom Check List-90 (SCL-90) measures psychiatric symptoms and psychological distress and has been used often in this type of research.
The State–Trait Anxiety Inventory Form Y (STAI-Y) consists of two scales measuring state (STAT-Y1) and trait anxiety (STAT-Y2), respectively. It’s been used in many studies of anxiety in different patient and community groups.

The Multidimensional Affect and Pain Survey (MAPS)was used to measure pain-related emotional suffering and well-being. It consists of 101 descriptors within 30 clusters, grouped into three scales.
1. The Somatosensory Pain scale measures somatosensory pain sensations, and its results weren’t considered in this study.
2. The Emotional Pain scale (EP) measures pain-related emotional suffering within eight areas: Physical Illness, Depressed Mood, Self-Blame, Anger, Anxiety, Fear, Apathy, and Fatigue.
3. The Well-Being scale (WB) measures aspects of wellbeing in five clusters. The first two clusters—Mentally Engaged (e.g.,“interested”) and Physically Active (e.g., “vigorous”)— measure healthy activities and follow the eudaimonic tradition (which defines well-being in terms of functioning, not happiness).
The third and fourth clusters—Affiliative Feelings (e.g.,“sympathetic”) and Positive Affect (e.g., “happy”)—measure happy thoughts and really within the hedonic tradition. The fifth cluster, Treatable Illness, measures to what extent the patient believes that his/her illness is “curable” or “manageable” and represents a separate dimension of well-being.

(Just a comment – I’m not sure of the relationship between this measure and measures of acceptance such as those being studied by McCracken and others).
The other variables included in this study were ‘general epidemiological–anamnestic questionnaire, six measures of physical symptoms (tender point count, pain area, pain intensity, fatigue, stiffness, and physical disability).

Now for some statistics – not particularly challenging ones, so don’t panic!
Pearson correlation coefficients were used to assess the relationships between measures of well-being and psychological distress, applying Bonferroni adjusted α levels.

These showed only three physical symptoms—pain intensity (VAS), number of positive tender points, and physical disability (FIQ)— showed meaningful correlations with psychological distress and/or well-being.

A hierarchical multiple regression analysis was carried out to separately predict each of the six measures of well-being (WB-4 and each of the five WB clusters) and three measures of psychological distress (MAPS EP, STAI-Y2, and SCL-90 GSI).  ‘Predictors were entered in the following order in five steps: (a) age; (b) pain duration (i.e., time passed since the onset of pain symptoms); (c) pain intensity; (d) number of positive tender points; and (e) physical disability.‘ Just so you know, several of these were mathematically transformed to make the stats assumptions work (which may affect the rigour of the results), but at least they told you about it!

Ok, results.
Well, almost half the participants reached the cut-off score for trait anxiety, and many of them also reached the score for high distress.  They sound fairly like the people that get referred to Burwood Pain Management Centre.

In terms of psychological distress, higher age and more physical disability emerged as the two most important predictors of psychological distress, each making unique contributions.

‘Both Pearson correlations (and multiple regression demonstrated that wellbeing (as measured by WB-4) was significantly predicted from low physical disability alone, and was independent of age, pain duration, pain intensity, and tender point count.’

What does this actually mean?
The results really show that the relationship between psychological distress and pain-related symptoms, may be mediated by the patient’s limitations in the capacity to perform daily household chores (ie disability).

We know that disability is influenced by a whole range of factors including the responses of significant others – and the cognitive interpretation of the meaning of those limitations, such as the disparity between what the person believes is expected of them as compared with what they believe they are capable of.  It’s not simply about pain intensity.

Wellbeing, on the other hand, decreased with higher disability but, in contrast to psychological distress, was independent of age, pain intensity, and tender point count.

Now the finding that well-being was independent of pain intensity is an important result of this study.

Yesterday I quoted from Katz where it was assumed that if pain intensity alone was reduced, ‘quality of life’ would improve. I wouldn’t want to equate ‘quality of life’ with ‘wellbeing’ – but the dimensions are similar, and suggest that it’s simply not enough to reduce pain without simultaneously addressing other issues that are important to the individual.

As the authors state ‘Our findings suggest that, in patients with chronic musculoskeletal pain, well-being is related to aspects of physical disability that are not directly linked with pain. The results are in line with the literature demonstrating that the negative impact of chronic pain on physical functioning and work status is moderated by cognitive and psychosocial factors, such as pain catastrophizing and pain-related fear of movement.’

They add ‘Results are consistent with the view that pain behavior, rather than pain per se, should be the target of treatment’. Not news to many of us, but perhaps to those clinicians with a somewhat simplistic (or perhaps simply a biomedical) viewpoint, it may be surprising.

I’m also keen to support their contention that psychological wellbeing should be measured as an outcome quite distinct from a reduction in psychological distress. It’s a new concept for health care – to think that along with ways to reduce distress, clinicians could also consider ways to enhance wellbeing – and that this can occur in the absence of a focus on pain reduction.

It makes me think that the emerging field of positive psychology is something that pain management clinicians could well start to view more seriously. My post from the other day on counting blessings comes to mind. And for those of us working in the field for the long term – it might make our work just a little lighter and more fun!

HUBER, A., SUMAN, A., BIASI, G., CARLI, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?. Journal of Psychosomatic Research, 64(2), 169-175. DOI: 10.1016/j.jpsychores.2007.09.005

Exposure therapy – not so fast buddy!

From what I’ve posted so far this week, you might think that I would propose exposure therapy be something for all therapists to use with people, but no! I think it’s something that only some people will adopt, and it’s only useful for some people. Although all of us can incorporate some aspects of it in our practice, I don’t think everyone is suited to actually doing this type of work.

Some of my colleagues (and probably my kids too!!) would say that I’m ideally suited to doing this type of therapy – I don’t have any qualms about asking someone to do something that may (read usually…!) increase their distress and often their pain. Just hand me a whip and I’ll use it (no, not really!).
But if you are not like this, and do feel a little worried about possibly causing harm, or at least increasing someone’s pain, then don’t feel you have to do it. The reason for this is simple: if you inadvertently suggest, through nonverbal or verbal means, that they do have a good reason to fear doing the activity, then you may well inadvertently reinforce their anxiety.

It’s true that we as health providers are often as fear-avoidant as the people we work with! What I mean is, we tend to be ‘nicer’ and less assertive in our requirements than when we allow people with pain to set goals for themselves and others. Vlaeyen & Linton (2006), and others have identified that treatment providers who have fear-avoidant beliefs themselves are more likely to suggest passive treatments than those who are not. Some years ago it Hazard (1996) found that people who are given no activity restrictions when they return to work actually return to work more quickly than those who are provided with selected activities.

I’ve observed too, that once the exposure process is underway, progress quickly gains pace. So the first few steps on the hierarchy are quite slow, but provided that the person is generalising their skill, they start to set their own goals and these are often quite a lot higher up the hierarchy than I would have put the target!

So, bringing together some of the factors identified in the Craske, et al. (2008) article I referred to yesterday, here are some thoughts about ways to make exposure therapy effective.

1. Practicing exposure in different contexts, with and without ‘warning’, and maintaining this exposure over time
2. Encouraging tolerance to experiencing anxiety – it’s OK to not feel entirely comfortable with a movement that has been uncomfortable in the past, it’s just not OK to avoid it!
3. Practicing in different situations with or without feedback and encouragement – it seems that too much verbal feedback can ‘seduce’ the person into believing that they have their fear conquered, but this can be a temporary effect that can disappear quite quickly. It seems to be more effective to have a delay between sessions during which the person practices alone than to have multiple practices with support.
4. Avoid the use of ‘safety behaviours’ – especially ‘special’ movements such as a special ‘safe lifting’ technique, but also the presence of another person (especially you!), or special preparations such as counting or breathing or using equipment. Although you may start with this, in the end it’s important that the person learns to do the movement without any props or rituals.
5. Generalising the exposure into the ‘real’ world needs to happen throughout and after the therapy. Integrating the new learning into life is the aim of therapy, but needs to be structured to actually occur. A plan to make this learning happen should be developed and monitored, as well as a ‘relapse’ plan.

I hope you’ve enjoyed this tour through exposure therapy and the pain-related anxiety and avoidance model. I’ll keep you posted on progress with my client – today he made it into the hydrotherapy pool, so here’s hoping he’ll be well on his way to returning to a normal level of activity in the next few months.

Learning to ‘feel the fear and do it anyway’

If ever there was an over-used quote from a pop-psychology book the ‘feel the fear’ quote has to be a prime contender! However, in exposure therapy for kinesiophobia, this is exactly what we are doing. If we don’t activate the feeling of anxiety just a teeny tiny bit, then we are not going to achieve an awful lot!

So, the steps from yesterday are to identify a range of activities that the person doesn’t feel they can do (and therefore avoids doing), get the person to rank them in order from ‘least bothersome’ to ‘most bothersome’ (or whatever scale you want to call it – some people call it the ‘yukkiness’ scale!).

Then it’s time to find out exactly what the person really fears about the movement. To do this, I ask the person ‘what goes through your mind when you think of yourself doing this movement?’ – it can be an image, a phrase, or some sort of prediction. It’s this prediction, or hypothesis, that is being tested in our ‘behavioural experiments’.

By exposing the person to the opportunity to test their belief that something ‘horrible’ or ‘awful’ will happen if they carry out the movement, several things happen:

1. their anxiety level increases initially
2. they get the opportunity to see that their feared consequence either doesn’t happen, or if it does, it is something they can tolerate
3. their elevated anxiety subsides (we simply can’t maintain high levels of anxiety for very long)

It’s important to work out exactly what the person is concerned about.

• Is it that they think some damage will occur? – how will they tell it has?
• Is it that they think their pain will inevitably increase – and more importantly, that this will be ‘horrible’? – what does ‘horrible’ look like or mean?
• Is it that they can see themselves falling, being looked at, being laughed at? – what does this mean to them, or about them?

We can then run through several different ways of addressing their underlying beliefs.

• We can using cognitive therapy to work with their automatic thought, and evaluate the probability that the negative event will happen.

• We can use cognitive therapy to probe more deeply to find out what it means for this event to happen, and perhaps uncover a more significant belief or attitude that can be worked on in therapy.

• We can also find out what the worst possible consequence could be, and why it might be so awful. Or what the most likely consequence could be, and whether they could cope with that.

Having done this, we can then start to ask the person if they’re prepared to see what happens if they try one of the movements that bothers them. This is the ‘behavioural’ part of this process and it’s critical to include this as well as the cognitive aspects indicated above.

Reassuring the person that we are certain that they can handle the situation (that they have the skills not to freak out!), or that we are clear that the harm they think will happen won’t occur gives the person a sense of your confidence in their skills. I always make sure that they do have skills to reduce their physiological arousal – usually using diaphragmatic breathing, and calming self statements – before starting this process. I also make sure that we start low enough on the hierarchy so that their anxiety is only just increased so they don’t refuse altogether.

The activities in the PHODA are daily activities that almost everyone has to do in life. For this reason it’s usually not too hard to get the person to agree that the activity is something they think is important to learn to do. If the person starts to balk, it may be because the activity isn’t that important to them, or that they really lack confidence that they can do it successfully. If this is happening, it’s time to return to exploring importance, and increasing confidence using motivational interviewing strategies. Moving down the hierarchy gives the message to the person that they don’t have the skills to cope, and that they have every right to be afraid, and that you’re not confident that it will be OK.

Then the process is reasonably straightforward.
Demonstrate the movement using efficient biomechanics. Note that I’m not suggesting ‘safe’ movements, or ‘proper’ movements – because this suggests that if and only if the person uses the right technique they will be safe. This is a form of safety behaviour that reduces the anxiety that we really want to have present. What safety behaviours do is act as a sort of lucky charm, and when the lucky charm isn’t present, the avoidance that has maintained the fear returns. Nothing is actually learned!

Then ask the person to rate how much concern they have right now about doing the movement.
Continue with asking the person to then rate how strongly they believe that their hypothesis will come true if they do the movement.

Then it’s their turn to do it. I move quite swiftly into this phase, because it’s the anticipation of doing the movement that generates the anxiety. The longer you delay, the more anxiety, the less likely they are to be able to settle their anxiety level down after the movement.

Once they’ve carried the movement out using efficient biomechanics, it’s time to ask them to re-rate their concern about doing the movement, then re-rate the probability that their feared consequence will occur if they do it again. Most times the rating has reduced, but sometimes it hasn’t gone down by much.

If their rating of the probability hasn’t changed, you can ask ‘how often do you think you need to do this to change your rating?’ You can use logic (How many times have you seen people actually fall over when they bend forward? How many times have you fallen over when you bend forward?) or you use other cognitive strategies to help them re-evaluate their belief, then re-test using the behavioural experiment again. You can also ask the person to develop a new experiment that might be a better test of their belief (to make it more likely that their feared outcome occurs).

For a really good article reviewing models of inhibitory learning in exposure therapy, Craske et al. (2008) have written ‘Optimizing inhibitory learning during exposure therapy’ for Behaviour Research and Therapy. Worth a read, even if you’re inclined to go glassy-eyed at loads of psychological stuff. But if you’re reading this, you’re probably quite happy to read psychological stuff, so head on over to it!

More tomorrow on exposure therapy – so y’all come back now!

CRASKE, M., KIRCANSKI, K., ZELIKOWSKY, M., MYSTKOWSKI, J., CHOWDHURY, N., BAKER, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. DOI: 10.1016/j.brat.2007.10.003

Fear/anxiety, pain and movement…

The best way to start this week’s series of posts is by quoting Simmonds, Moseley & Vlaeyen (2008) who said: ‘Chronic pain and its often associated movement dysfunction are pervasive, intriguing and complex problems … conceptualisation of pain and movement dysfunction has increased our understanding of both…that conceptualisation remains incomplete until it also includes the mind.’

For many years, ‘reactivation’ has been the watchword for chronic pain management ‘functional’ programmes. This was predicated upon the belief that people with chronic pain became ‘deactivated’ or lost physical conditioning due to low levels of activity, and that if they were encouraged to get fitter they would return to normal function. An alternative option was to use the behavioural school of therapy, where positive health behaviour (to normalise activity level) was reinforced, mainly through therapist encouragement and self-monitoring, and by doing this the individual would return to normal function.

Problem was (and still is), a certain proportion of people just don’t engage in this type of programme, often becoming highly distressed, convinced they had been harmed because their pain increased (often with a raft of new symptoms developing also), and without another alternative, these people were either left without any reactivation or referred for ‘talk therapy’.

In the mid-1990’s, research into the model of pain-related anxiety and avoidance (commonly called the ‘fear-avoidance model’) was initiated, and the growing literature into this model since then has confirmed its value in working with people who develop high levels of avoidance.

Essentially, the model describes the two approaches an individual can take when experiencing pain – either avoidance, with subsequent loss of activity and engagement in life roles; or approach, with increasing re-engagement in activities despite short-term fluctuations in pain. Research has confirmed that it is not just the pain that is the problem, it is the fear and avoidance of pain (or to be quite pedantic, it is the anxiety about pain – fear is quite specific (Rachman, 1998), while anxiety is generalised, future-oriented and the ‘source of threat is more elusive without a clear focus’ (Leeuw et al. 2008)).

Further development of the model has identified some of the underlying thinking patterns that may influence the development of avoidance in response to pain – particularly health anxiety and negative affectivity. Health anxiety refers to the tendency to have catastrophic thinking patterns in response to threats of loss of body integrity, while negative affectivity is the tendency to see the glass half empty rather than half full.

For an excellent recent review of the ‘fear-avoidance’ model, Leeuw, Goossens, Linton, Crombez, Boersma & Vlaeyen (2007) have written in the Journal of Behavioural Medicine (30:1), February 2007.

My interest in posting on this model this week is to review the application of one of the treatment options suggested as a result of this model: exposure therapy. I’ve referred to this approach a couple of times before, in CRPS, in a pain management programme , in whether we are afraid to push our patients, and so on.

My interest currently is because I’m working with a young man who presents with extensive deactivation and loss of roles, depression and difficulty coping who identified almost 70 photographs from my set of 99 PHODA photographs as activities he would not do for fear of either increased pain or potential harm.

I was excited to find that the shortened electronic version of PHODA is available for free download, and I reported recently on a cervical spine version of the PHODA that has been published just a short while ago.

I’m also keen to see how I can integrate some of the work that has been carried out on mindfulness as it is applied to anxiety (eg Forsyth & Eifert, 2007) and whether this can be applied when helping people work through a hierarchy of feared activities.

So…an interesting week ahead!
BTW the three favourite (in terms of number of hits at least!) topics on this blog to date are: mindfulness, malingering and the CBT worksheet – so expect more soon!

Leeuw, M., Goossens, M.E., Linton, S.J., Crombez, G., Boersma, K., Vlaeyen, J.W. (2007). The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. Journal of Behavioral Medicine, 30(1), 77-94. DOI: 10.1007/s10865-006-9085-0

Rachman, S. (2004). Fear and courage: A psychological perspective. Sociological Research., 71, 149-176.

Simmonds, M. J., Moseley, G., & Vlaeyen, J. W. Pain, Mind, and Movement: An Expanded, Updated, and Integrated Conceptualization. Clinical Journal of Pain May 2008;24(4):279-280.

Photographs of activities of daily living – cervical spine

Assessing fear in patients with cervical pain: Development and validation of the Pictorial Fear of Activity Scale-Cervical (PFActS-C).
Turk DC, Robinson JP, Sherman JJ, Burwinkle T, Swanson K.

Ever since the PHODA or photographs of activities of daily living was developed, I’ve used pictures to help establish exactly what movements and contexts people are worried about. Pictures say so much more than a set of words!

So it’s great to see that Turk and colleagues have got together to develop a cervical spine version.

This study examines the reliability and development of ‘a set of photographs depicting movements in which four factors that determine biomechanical demands on the neck are systematically varied – Direction of Movement, Arm Position, Weight Bearing, and Extremity of Movement.’

Although the initial findings are quite interesting the authors acknowledge that further work needs to be carried out. I am curious to see whether there are differences between what is reported by people using photographs compared with their ‘real’ performance as assessed in their own home, perhaps by occupational therapists. I’m also curious to see whether, as I’ve found with the PHODA, there are problems transferring the photographs across different countries. Despite the PHODA being reasonably culturally neutral, there are differences in the type of building, items being carried, equipment, surfaces and so on, and these have been commented on by patients. Similarly, I would expect that a set of photographs developed in North America may also reflect cultural bias, and not be quite as useful in a Southern Hemisphere setting.

The process of developing this instrument is also really fascinating, and I wonder whether there are many areas of pain research where photographers and therapists work together!!

Let me know if you have used photographs to assess anxiety and avoidance – I’m interested to see how far this type of assessment and therapy has spread, and whether it has gained popularity amongst people like occupational therapists and physiotherapists, who work to help people generalise their skill and improve function.

TURK, D., ROBINSON, J., SHERMAN, J., BURWINKLE, T., SWANSON, K. (2008). Assessing fear in patients with cervical pain: Development and validation of the Pictorial Fear of Activity Scale-Cervical (PFActS-C). Pain DOI: 10.1016/j.pain.2008.03.001