Assessment

When it hurts – but it’s important to keep doing


To date, despite years of research and billions of dollars, there is no satisfactory way to reduce pain in all people. In fact, our pain reduction treatments for many forms of persistent pain are pretty poor whether we look at pharmaceuticals, surgery, psychological treatments or even exercise. What this means is there are a lot of disillusioned and frustrated people in our communities – yet life carries on, and people do keep doing!

In an effort to understand what might help people who don’t “find a cure”, researchers and clinicians have been looking at mediators. Mediators are factors that explain a relationship between two variables. In the study I’m examining today, the predictor is pain intensity, and the criterion variable is participating in valued life activities (the things we want or need to do). The research question was whether self-efficacy and/or pain acceptance mediated engaging in valued life activities.

Ahlstrand, Vaz, Falkmer, Thyberg and Bjork (2017) used a cross-sectional study to explore relationships between the variables above in a group of people with rheumatoid arthritis (RA), drawn from three rheumatology registers in South East Sweden. Participants were required to have confirmed RA; be between 18 – 80 years; have had RA for four years or more; and have data included in the quality register – a total of 737 people agreed to take part (from a total of 1277 meeting entry criteria).

The researchers used the Swedish versions of Health Assessment Questionnaire (Wolfe, 1989) to establish degree of difficulty in daily activities, as well as the Valued Life Activities scale (Katz, Morris & Yellin, 2006); the Arthritis Self-Efficacy Scale (Lorig, Chastain, Ung, Shoor & Holman, 1989); and the Chronic Pain Acceptance Questionnaire (Wicksell, Olsson & Melin, 2009).
The statistical analyses included Chi-square tests of independence to identify significant differences in categorical factors due to gender, and steps were taken to establish whether there were gender differences for pain acceptance, self-efficacy and valued life activities. Pearson correlations were used to explore the relationships between acceptance, self efficacy and the valued life activities summary score, and then univariate regressions were undertaken to test each individual factor (eg pain, pain acceptance and self efficacy on valued life activities). Then, only the significant contributors in univariate analyses where entered into the hierarchical linear regression models. The tests were to establish whether self-efficacy would predict valued life activities after acceptance and pain scores were considered.

Finally, structural equation modelling was used to examine the contribution and influence of pain, activity engagement and self-efficacy on difficulties performing valued life activities. A note here: The authors used the structure of the ICF model to name the constructs in their structural equation model.

What did they find?

The people who responded to this survey tended to be less active than those who were on the registers but didn’t respond, so we need to keep this in mind when we interpret their results. They found that women reported slightly more pain than men, but there were no differences between men and women on all measures except that men scored more highly on the symptom control subscale of the self-efficacy measure. A point to note here is that, unlike the Pain Self Efficacy Questionaire, this measure includes attempts to reduce or control pain and/or disability, so it’s a slightly different construct from the PSEQ which measures confidence to engage in doing things despite the pain.

In terms of pain, pain acceptance, and arthritis self-efficacy, there were low to moderate associations between these and engaging in valued life activities. In fact, all pain acceptance and self-efficacy constructs measured in this study were associated with performing valued life activities. In other words, when people are confident, and willing to do things and engage in activities despite pain, the more valued activities they actually do. In fact, one of the more striking findings was a negative relationship between activity engagement and performing valued life activities – those with lower activity engagement scores reported great difficult engaging in what was important to them (not especially surprising given that both scales are about doing what’s important and getting on with life).

Now for the really geeky model: structural equation modeling found a rather complex relationship between all the variables – so complex I’m going to include the diagram.

What does it show? Well, there’s a relationship between pain intensity and valued activity engagement – the more pain, the less people do what’s important. BUT this is mediated by “personal factors” (remember the ICF labels). These personal factors are the pain acceptance activity engagement, self-efficacy for pain and self-efficacy for symptoms. Interestingly, pain willingness, the other subscale on the pain acceptance scale, wasn’t correlated.

Or is it surprising? To my mind there are some interesting conceptual issues with this study. Firstly, in a group that is self-selected and represents slightly more disability than those who didn’t respond, it’s not surprising that pain intensity and disability were correlated. This is something we see often pre-treatment in chronic pain settings. It’s also no surprise to me that the Arthritis self-efficacy scales were associated with valued activities, and with activity engagement – the arthritis self-efficacy scales ask “How certain are you that you can decrease your pain quite a bit?”; “How certain are you that you can that you can make a small-to moderate reduction in your arthritis pain by using methods other than taking extra medication?” amongst other questions. These suggest that pain reduction is a primary aim in arthritis management. The Chronic Pain Acceptance Questionnaire, however, is a very different beast. The Activity Engagement scale is about doing things that are valued (similar to the Valued Life Activity scale), while the  Willingness scale is about being willing to live life again despite pain – for example “I am getting on with the business of living no matter what my level of pain is.”; “It’s not necessary for me to control my pain in order to handle my life well.”.

While the authors argue that this study shows the value of self efficacy, stating “Active management promotes a sense of confidence, or self-efficacy, for dealing with pain that is associated with improved participation in daily activities and wellbeing.” I think the Arthritis Self-Efficacy Scale’s focus on controlling pain and other symptoms is incompatible with the constructs implied in the CPAQ. The ACT (Acceptance and Commitment Therapy) approach to pain is, as I’ve mentioned many times, a focus on engaging in valued activities irrespective of pain intensity – a more achievable goal for many than becoming confident to reduce pain as the ASES measures.

To their credit, the authors also indicate that men and women who continue to experience pain despite optimal medical treatment might benefit from strategies to increase their confidence to manage their own symptoms – but that a focus on pain control instead of participation despite pain is probably unhelpful. They go on to say that “by focusing on pain aceptance and activity engagement despite pain, self-management strategies may change the focus from pain control to a more flexible engagement in valued activities.” I couldn’t agree more – and I wish they’d used the Pain Self Efficacy Questionnaire instead of the ASES in this study. Maybe we need more discussion about appropriate measures in rheumatology research.

 

Ahlstrand, I., Vaz, S., Falkmer, T., Thyberg, I., & Björk, M. (2017). Self-efficacy and pain acceptance as mediators of the relationship between pain and performance of valued life activities in women and men with rheumatoid arthritis. Clinical Rehabilitation, 31(6), 824-834. doi:10.1177/0269215516646166

Katz PP, Morris A and Yelin EH. (2006). Prevalence and predictors of disability in valued life activities among individuals with rheumatoid arthritis. Annals of Rheumatology Diseases. 65: 763–769.

Lorig K, Chastain RL, Ung E, Shoor S and Holman HR. (1989). Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis & Rheumatism, 32(1): 37–44.

Wicksell RK, Olsson GL and Melin L. (2009). The Chronic Pain Acceptance Questionnaire (CPAQ)-further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia. European Journal of Pain, 13: 760–768.

Wolfe F. (1989). A brief clinical health assessment instrument: CLINHAQ. Arthritis & Rheumatism,  32 (suppl): S9

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Do pain management programmes really influence “doing” in daily life?


Disability and coping are two of the most important targets in persistent pain management, along with distress and pain intensity (the latter perhaps being the most difficult to influence). A question, however, is whether existing measures of disability truly capture the activities or occupations that people most value. For example, if house cleaning is just not my thing, even if my functioning improved over the course of a programme, would I choose to spend that new capability on vacuum-cleaning or out there in the garden?!

The Westhaven-Yale Multidimensional Pain Inventory (MPI)(Kerns, Turk & Rudy, 1985)  is a true workhorse of pain management measurement: It’s a measure that provides, via the subscales, an estimate of the complex inter-relationships involved in pain-related disability and distress. Three profiles of coping approach have been derived from the MPI indicating “Adaptive Coping” – the person is likely to continue to improve and engage in living well if they carry on as they are; “Interpersonally Distressed” – the person is experiencing difficulties with relationships and is feeling unsupported by others around them; and “Dysfunctional” – the person is struggling with their pain, and both disability and distress can feel overwhelming.

But the disability components of the MPI don’t really indicate the kinds of activities that people might be passionate about – or those that are relevant to their lives. The items are about general activities people “typically” do – in a North American setting. I know they’ve been validated in many different populations but they still represent a general idea of activity and function rather than the unique and idiosyncratic occupations that people do. (What's the difference? An occupation is the unique way I perform the important tasks of my day - the way I dash around the house while simultaneously cleaning my teeth, getting the dogs outside, making sure the curtains are opened and the appliances off just before I head out the door! We could call this "getting ready for work" but the way I do it, and the way you do it is probably very different!)

Why is that important? Well, because people value different occupations differently, and because values drive motivation, a broad measure of disability may not capture the true value of a pain management programme. And this is why the Canadian Occupational Performance Measure (COPM) (Law, Baptiste, McColl, Opzoomer, Polatajko & Pollock, 1990) is often used by occupational therapists to establish exactly what it is a person wants to be able to do. Goal Attainment Scaling is another option.

The study

In this study by Persson, Eklund, Lexell & Rivano-Fischer (2017), the aims were to assess longterm changes in MPI profiles over the course of a year; to look at associations between “Adaptive Coper” profiles at follow-up and improvements in occupational performance; and to look at factors at baseline that might be used to predict changes over time. Participants were, as usual, attending a tertiary pain management centre at a University hospital. They took part in a 21 day programme (oh the luxury of time!), and were seen by a team working together (oh the luxury of a co-located team!) including a psychologist, physician, physiotherapist, occupational therapist and social worker (oh for interprofessional teamwork!). The measures taken at pre and post were the MPI, COPM, and background demographic details.

Now here’s where the analysis gets pretty technical: dropout rates and pre-treatment differences amongst the MPI profiles were analysed using Matt-Whitney U, Kruskal-Wallis, chi-squared and independent t-test. Cross-tabs were used to describe the distribution of the MPI profiles. McNemar’s test was used to assess changes over time on each of the four profiles, and ultimately the participants were grouped into four profiles: never AC (Adaptive coper); losing AC; gaining AC, and stable AC, and these groupings were used to analyse associations between changes in MPI profile and changes on COPM from baseline to follow-up. And this, folks, is why occupational therapists NEED to learn statistical analyses! Because they went on to use univariate and multivariate logistic regressions to see whether demographic factors would predict these profiles at follow-up, incorporating satisfaction and performance scores on COPM.

What did they find?

More participants started the programme with a profile of dsyfunctional or interpersonally distressed than adaptive coper – and at both discharge and follow-up the adaptive coping group increased to be the largest subgroup. 20% of the participants ended up in the “gaining AC” group, 11% the “stable AC” group, 6% formed the “losing AC” group, and 63% were never in the adaptive coping group at all. Not so terrific in terms of broad outcome measures, but pretty consistent with other programmes around the world.

On the more individualised outcome measure of the COPM, people in the never AC group showed least clinically relevant improvement, both the stable AC and gaining AC groups showed more improvement on occupational performance and satisfaction with performance than the never AC group, while the stable AC group improved more than the losing AC group in terms of occupational performance changes.

Long-term changes showed those who started as AC were more likely to stay that way over time, and baseline scores for occupational performance were significantly associated with being AC at follow-up – in other words, people who felt OK about what they could do in terms of occupation, tended to become more capable and less disabled over time as measured by the MPI. More importantly, those people who had higher baseline scores on occupational satisfaction were 1.3 times more likely to shift to the AC group over time. “Clinically relevant improvements on performance and satisfaction with performance at 1-year follow-up, in occupations prioritized by the participants, were associated with having an AC profile at follow-up.” (p. 6).

Confidence in doing important occupations breeds confidence in other parts of living with persistent pain.

What does this all mean anyway?

Well, importantly, people who shifted from one of the other profiles to adaptive coping over a year showed clinically relevant improvements in occupational performance and satisfaction with performance – the authors suggest these findings show improvements on and satisfaction with “doing and performing” important occupations. Not being classified into adaptive coping at any time was associated with least improvement in occupational performance and satisfaction. There is an association between “doing/performing” and “coping/adapting” that hasn’t really been studied. Perhaps starting with things people enjoy instead of beating them over the head with things they’ve never been interested in could improve pain management outcomes. Pain management programmes DO influence doing in real life – if real life doing is used as therapy!

The authors also point out that “30–47% of participants who did not show an AC profile at follow-up still showed clinically relevant improvements on occupational performance and on
satisfaction with occupational performance.” (p. 8) This suggests that the MPI coping profiles only represent one part of the outcomes that are important to individuals: occupation being the individualised daily doings that people value very highly, and pointing to the need to explore individualised outcome measurement in more studies. Given that patient-centred pain management is based on individual goals, using only generic measures is likely to give misleading outcomes about treatment efficacy.

 

Kerns IVRD,TurkDC, Rudy TE. (1985) West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 23:345–56

Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. (1990). The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy. 57(2), pp82–7.

Persson, E., Eklund, M., Lexell, J., & Rivano-Fischer, M. (2017). Psychosocial coping profiles after pain rehabilitation: Associations with occupational performance and patient characteristics. Disability and Rehabilitation: An International, Multidisciplinary Journal, 39(3), 251-260.

The gap in managing pain


If you’ve read my blog for any period of time you’ll know that I like practical research, and research that helps clinicians do what they do with humanity, compassion and evidence. One really enormous gap in the field is rarely mentioned: how do clinicians pull their assessment findings together and use them for clinical reasoning? Especially if you’re part of an interprofessional team (or work in a biopsychosocial framework). The silence in the pain literature is deafening!

There are any number of articles on what can be included in an initial assessment, most of them based on the idea that if factor X is an important predictor, it oughta be assessed. So we have a proliferation of assessments across (mainly) the biopsychological spectrum, with a teeny tiny bit of social (family relationships) thrown in, if you’re lucky. There are numerous papers proposing treatments for aspects of pain – anything from medications, to movement treatments, to cognitive treatments (yes, pain education), and behavioural treatments – but after reading them it almost feels like authors think anyone with pain that’s going on longer than we’d hope “should” have That Treatment, and then of course the person will be just fine.

Except that – there are just as many people with persistent pain today as there were 20 years ago, perhaps more (given the global burden of disease shows that low back pain is The Most Common problem associated with years lived with disability). In other words, all our treatments across all our specialties don’t seem to be having the impact that the research papers suggest they ought to. What gives?

I think it’s time to take a leaf from some of the better-conducted pharmacological studies. Yes, I said that! What I mean is that given our treatments especially for low back pain seem to have broadly the same or similar effects, maybe we need to look beyond the grouped analyses where individual differences are lost within the grouped data, and head to some of the sub-analyses proposed and used by Moore, Derry, Eccleston & Kalso (2013). In this paper, they advocate using responder analysis – who, exactly, gets a good result?

At the same time, I think we need to get much better at assembling, integrating and using the multitude of assessments people complete for us when we start treating them. Several points here: yes, we all carry out assessment but how well do we put them together to “tell the story” or generate a set of hypotheses to explain the crucial questions:

Why is this person presenting in this way at this time? And what can be done to reduce distress and disability?

I think case formulations may take us a step towards better use of our assessments, better clinical reasoning, better teamwork, and, most of all, better collaboration with the person we hope to help.

Case formulations are not new in psychology. They’re really a cornerstone of clinical psychological reasoning – assembling the information gathered during assessment into some sort of explanatory framework that will help the therapist generate possibly hypotheses about predisposing factors, what precipitated the problem, what perpetuates the problem, and any protective factors. Psychologists are no less prone to arguing about whether this approach works than anyone else – except they do some cool studies looking at whether they’re consistent when generating their formulations, and sadly, formulations are not super-consistent with each other (Ridley, Jeffrey & Robertson, 2017).

BUT here’s why I think it might be a useful approach, especially for people with complex problems associated with their pain:

  1. Case formulations slow our clinical reasoning down. “Huh?” you say, “Why would that be good?” Well because rapid clinical judgements on the basis of incomplete information tend to lead us towards some important cognitive biases – anchoring on the first possible idea, discounting information that doesn’t fit with that idea, we notice weird stuff more than the commonplace, we fill in information based on stereotypes, generalities and past histories, and we don’t shift from our first conclusion very easily. By taking time to assemble our information, we can delay drawing a conclusion until we have more information.
  2. By completing a consistent set of assessments (instead of choosing an ad hoc set based on “the subjective”) we reduce the tendency to look for confirmation of our initial hunch. I know this isn’t usual practice in some professions because that “subjective” history is used to guide assessments which are then used to determine a diagnosis – but the risk is that we’ll look for assessments that confirm our suspicions, meanwhile being blinded to possible alternative explanations (or hypotheses or diagnoses).
  3. Working together with the expert on their own situation (ie the person seeking help!) we build collaboration, a shared understanding of the person’s situation, and we can develop an effective working relationship without any hint of “one-up, one-down” that I can see appeals to “experts” who like to point out the “problems” with, for example, posture, gait, motor control and so on – all which may have little to do with the patient’s pain, and a whole lot more to do with creating a “listen to me because I Know Things” situation.
  4. Other team members can contribute their assessments, creating a common understanding of the various factors associated with the person’s situation. Common goals can be developed, common language about what might be going on, common treatment aims and enhanced understanding of what each profession contributes can happen when a formulation includes all the wonderful information collected across the team.
  5. If one of the treatments doesn’t work (ie the hypothesis doesn’t hold up to testing) there are other options to draw on – we’re not stuck within our own clinical repertoire, we can think across disciplines and across individual clinical models and become far more confident about knowing when to refer on, and how we can support our colleagues.

But, you know, I looked in the pain journals, searched far and wide – and I found few examples of case formulation for persistent pain. The best paper I’ve found so far is from a textbook – so not readily accessible. It’s Linton & Nicholas (2008) “After assessment, then what? Integrating findings for successful case formulation and treatment tailoring”. Where is the rest of the research?!!

Linton, S. J., & Nicholas, M. K. (2008). After assessment, then what? Integrating findings for successful case formulation and treatment tailoring. Clinical Pain Management Second Edition: Practice and Procedures, 4, 1095.

Moore, A., Derry, S., Eccleston, C., & Kalso, E. (2013). Expect analgesic failure; pursue analgesic success. BMJ: British Medical Journal (Online), 346.

Ridley, C. R., Jeffrey, C. E. and Roberson, R. B. (2017), Case Mis-Conceptualization in Psychological Treatment: An Enduring Clinical Problem. J. Clin. Psychol., 73: 359–375. doi:10.1002/jclp.22354

Targeting the people who need it most


A couple of things came to mind today as I thought about this post: the first was an article in the local newspaper about a man complaining that the government is “promoting disability” because he couldn’t get surgery for a disc prolapse – and the pain was affecting his ability to work. The second was how to direct the right treatment at the right person at the right time – and how we can be derailed by either wholesale over-servicing “everyone needs treatment X”, or by overburdening people with assessment just to give a fairly basic treatment.

Now with the first man, I don’t know his clinical situation – what I do know is that there are many people every day who must learn to live with their pain because there simply is not an effective treatment of any kind, and that amongst these people are those go on to live wonderful lives despite their pain. I wonder if this man has ever been offered comprehensive self management for while he waits for his surgery. Whether the government could spread some funding away from surgery as the primary option for such pain problems – and instead provide better funding for the wider range of approaches offered through the interdisciplinary pain management centres (approaches which include injection procedures, physiotherapy, psychology, occupational therapy and medications). When there is an effective treatment (and this is arguable in the case of disc prolapse – in fact, it’s difficult to know whether even MRI imaging can give a clear indication of who might respond best to what treatment (Steffens, Hancock, Pereira et al, 2016), we should be able to give it, provided it fits within our country’s health budget. Ahh – that’s the problem, isn’t it… expensive treatments mean fewer people can get basic treatment. And with lumbar disc prolapse, the evidence for surgery is less favourable than many people recognise (Deyo & Mirza, 2016) – they state:

“Patients with severe or progressive neurologic deficits require a referral for surgery. Elective surgery is an option for patients with congruent clinical and MRI findings and a condition that does not improve within 6 weeks. The major benefit of surgery is relief of sciatica that is faster than relief with conservative treatment, but results of early surgical and prolonged conservative treatment tend to be similar at 1 year of follow-up. Patients and physicians should share in decision making.”

So here we have a person with lots of pain, experiencing a great deal of distress, and reducing his work because of pain and disability. My question now (and not for this person in particular) is whether being distressed is equivalent to needing psychological help. How would we know?

There’s been a tendency in pain management to bring in psychologists to help people in this kind of situation. Sometimes people being referred for such help feel aggrieved: “My problem isn’t psychological!” they say, and they’re quite correct. But having a problem that isn’t psychological doesn’t mean some psychological help can’t be useful – unless by doing so, we deny people who have serious psychological health problems from being seen. And in New Zealand there are incredible shortages in mental health service delivery – in Christchurch alone we’ve had an increase in use of mental health services of more than 60% over the past six years since the massive 2010/2011 earthquakes (The Press).

People living with persistent pain often do experience depression, anxiety, poor sleep, challenges to relationships and in general, feeling demoralised and frustrated.  In a recent study of those attending a specialist pain management centre, 60% met criteria for “probable depression” while 33.8% met criteria for “severe depression” (Rayner, Hotopf, Petkova, Matcham, Simpson & McCracken, 2016). BUT that’s 40% who don’t – and it’s my belief that providing psychological services to this group is allocating resources away from people who really need it.

So, what do we do? Well one step forward might be to use effective screening tools to establish who has a serious psychological need and who may respond just as well to reactivation and return to usual activities with the support of the less expensive (but no less skilled) occupational therapy and physiotherapy teams. Vaegter, Handberg, & Kent (in press) have just published a study showing that brief psychological screening measures can be useful for ruling out those with psychological conditions. While we would never use just a questionnaire for diagnosis, when combined with clinical assessment and interview, brief forms of questionnaires can be really helpful for establishing risk and areas for further assessment. This study provides some support for using single item questions to identify those who need more in-depth assessment, and those who don’t need this level of attention. I like that! The idea that we can triage those who probably don’t need the whole toolbox hurled at them is a great idea.

Perhaps the New Zealand politicians, as they begin the downhill towards general elections at the end of the year, could be asked to thoughtfully consider rational distribution of healthcare, and a greater emphasis on targeted use of allied health and expensive surgery.

 

Deyo, R. A., & Mirza, S. K. (2016). Herniated Lumbar Intervertebral Disk. New England Journal of Medicine, 374(18), 1763-1772.

Hahne, A. J., Ford, J. J., & McMeeken, J. M. (2010). Conservative management of lumbar disc herniation with associated radiculopathy: A systematic review. Spine, 35(11), E488-504.

Koffel, E., Kroenke, K., Bair, M. J., Leverty, D., Polusny, M. A., & Krebs, E. E. (2016). The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial. Health Psychology, 35(1), 41-49.

Rayner L, Hotopf M, Petkova H, Matcham F, Simpson A, McCracken LM. Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs. Pain. 2016;157(7):1472-1479. doi:10.1097/j.pain.0000000000000542

Steffens, D., Hancock, M.J., Pereira, L.S. et al.(2016) Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review. European Spine Journal 25: 1170. doi:10.1007/s00586-015-4195-4

Vaegter, H. B. P., Handberg, G. M. D., & Kent, P. P. Brief psychological screening questions can be useful for ruling out psychological conditions in patients with chronic pain. Clinical Journal of Pain.

What do we do with those questionnaires?


Courtesy of many influences in pain management practice, you’d have to have been hiding under a rock or maybe be some sort of dinosaur not to have noticed the increasing emphasis on using questionnaires to measure factors such as pain catastrophising, depression or avoidance. The problem is I’m not sure we’ve all been certain about what to do with the results. It’s not uncommon for me to hear people saying “Oh but once I see psychosocial factors there, I just refer on”, or “they’re useful when the person’s not responding to my treatment, but otherwise…”, “we use them for outcome measures, but they’re not much use for my treatment planning”.

I think many clinicians think psychosocial questionnaires are all very well – but “intuition”  will do “…and what difference would it make to my treatment anyway?”

Today I thought I’d deconstruct the Pain Catastrophising Scale and show what it really means in clinical practice.

The Pain Catastrophising Scale is a well-known and very useful measure of an individual’s tendency to “think the worst” when they’re considering their pain. Catastrophising is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al., 2001). The questionnaire was first developed by Sullivan, Bishop and Pivik in 1995, and the full copy including an extensive manual is available here. Keep returning to that page because updates are made frequently, providing more information about the utility of the measure.

The questionnaire itself is a 13-item measure using a 0 – 4 Likert-type scale from 0 = “not at all” to 4 = “all the time”. Respondents are instructed to “indicate the degree to which you have these thoughts and feelings when you are experiencing pain”.

There are three subscales measuring three major dimensions of catastrophising: rumination “I can’t stop thinking about how much it hurts”; magnification “I worry that something serious may happen”; and helplessness “It’s awful and I feel that it overwhelms me”.

To score the instrument, simply sum all the responses to all 13 items, but to get a better idea of how to help a person, the subscale calculations involve the following:

Rumination: sum items 8,9,10, and 11

Magnification: sum items 6,7, and 13

Helplessness: sum items 1,2,3,4,5, and 12

There’s not a lot of point in having numbers without knowing what they mean, so the manual provides means and standard deviations relating to a population individuals with injury leading to lost time from work in Nova Scotia, Canada.

thingClinicians are typically interested in whether the person sitting in front of them is likely to have trouble managing their pain, so the manual also provides “cut off”scores for what could be described as “clinically relevant” levels of catastrophising. A total score of 30 or more is thought to represent the 75th percentile of scores obtained by individuals with chronic pain.

The “so what” question

Cutting to the chase, the question is “so what”? What difference will getting this information from someone make to my clinical reasoning?

Leaving aside the enormous body of literature showing a relationship between high levels of catastrophising and generally poor responses to traditional treatments that address pain alone (including surgery for major joint replacement, recovery from multiple orthopaedic trauma, low back pain, shoulder pain etc), I think it’s helpful to dig down into what the three subscales tell us about the person we’re working with. It’s once we understand these tendencies that we can begin to work out how our approach with someone who has high levels of rumination might differ from what we’ll do when working with someone who has high levels of helplessness.

As an aside and being upfront, I think it’s important to remember that a questionnaire score will only tell you what a person wants you to know. Questionnaires are NOT X-rays of the mind! They’re just convenient ways to ask the same questions more than once, to collect the answers and compare what this person says with the responses from a whole lot of other people, and they allow us to organise information in a way that we might not think to do otherwise.  I also think it’s really important NOT to label a person as “a catastrophiser” as if this is a choice the person has made. People will have all sorts of reasons for tending to think the way they do, and judging someone is unprofessional and unethical.

Rumination

Rumination is that thing we do when a thought just won’t get out of our mind. You know the one – the ear worm, the endless round and round, especially at night, when we can’t get our mind off the things we’re worrying about. If a person has trouble with being able to drag his or her attention away, there are some useful things we can suggest. One theory about rumination is that it’s there as a sort of problem solving strategy, but one that has gone haywire.

Mindfulness can help so that people can notice their thoughts but not get hooked up into them. I like to use this both as a thought strategy, but also as a way of scanning the body and just noticing not only where the pain is experienced, but also where it is not.

“Fifteen minutes of worry” can also help – setting aside one specific time of the day (I like 7.00pm – 7.15pm) where you have to write down everything you’re worried about for a whole fifteen minutes without stopping. By also telling yourself throughout the day “I’m not worrying about this until tonight” and afterwards saying “I’ve already worried about this so I don’t need to right now”, worrying and ruminating can be contained. By being present with the thoughts during that 15 minutes, the threat value of the thought content is also reduced.

Magnification

This is the tendency to think of the worst possible thing rather than the most likely outcome, and it’s common! Magnification can really increase the distress and “freeze” response to a situation. If a person is thinking of all the worst possible outcomes it’s really hard for them to focus on what is actually happening in the here and now. There’s some adaptive features to magnification – if I’ve prepared for the worst, and it doesn’t happen, then I’m in a good situation to go on, but in some people this process becomes so overwhelming that their ability to plan is stopped in its tracks.

Once again, mindfulness can be really useful here, particularly paying attention to what is actually happening in the here and now, rather than what might happen or what has happened. Mindful attention to breathing, body and thoughts can help reduce the “freeze” response, and allow some space for problem solving.

Of course, accurate information presented in nonthreatening terms and in ways the person can process is important to de-threaten the experience of pain. This is at the heart of “explain pain” approaches – and it’s useful. What’s important, however, is to directly address the main concern of the person – and it may not be the pain itself, but the beliefs about what pain will mean in terms of being a good parent, holding down a job, maintaining intimacy, being responsible and reliable. It’s crucial to find out what the person is really concerned about – and then ensure your “reassurance” is really reassuring.

Helplessness

Helplessness is that feeling of “there’s nothing I can do to avoid this awful outcome so I won’t do anything”. It’s a precursor to feelings of depression and certainly part of feeling overwhelmed and out of control.

When a person is feeling helpless it’s important to help them regain a sense of self efficacy, or confidence that they CAN do something to help themselves, to exert some sort of control over their situation. It might be tempting to aim for focusing on pain intensity and helping them gain control over pain intensity, but because it’s often so variable and influenced by numerous factors, it might be more useful to help the person achieve some small goals that are definitely achievable. I often begin with breathing because it’s a foundation for mindfulness, relaxation and has a direct influence over physiological arousal.

You might also begin with some exercise or daily activities that are well within the capabilities of the person you’re seeing. I like walking as a first step (no pun intended) because it doesn’t require any equipment, it’s something we all do, and it can be readily titrated to add difficulty. It’s also something that can be generalised into so many different environments. In a physiotherapy situation I’d like to see PTs consider exercises as their medium for helping a person experience a sense of achievement, of control, rather than a means to an end (ie to “fix” some sort of deficit).

To conclude
Questionnaires don’t add value until they’re USED. I think it’s unethical to administer a questionnaire without knowing what it means, without using the results, and without integrating the results into clinical reasoning. The problem is that so many questionnaires are based on psychological models and these haven’t been integrated into physiotherapy or occupational therapy clinical reasoning models. Maybe it’s time to work out how do this?

Sullivan M J L, Bishop S, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychol Assess 1995, 7: 524-532.

Main, C. J., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24(2), 205-217. doi:doi:10.1016/j.berh.2009.12.012

Sturgeon, J. A., Zautra, A. J., & Arewasikporn, A. (2014). A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain. PAIN®, 155(2), 292-298. doi:http://dx.doi.org/10.1016/j.pain.2013.10.007

Ambiguity and uncertainty


Humans vary in how comfortable we are with uncertainty or ambiguity: Tolerance of ambiguity is a construct discussed in cognitive and experimental research literature, and refers to the willingness to prefer black and white situations, where “there is an aversive reaction to ambiguous situations because the lack of information makes it difficult to assess risk and correctly make a decision. These situations are perceived as a threat and source of discomfort. Reactions to the perceived threat are stress, avoidance, delay, suppression, or denial” (Furnham & Marks, 2013, p. 718).  Tolerance to uncertainty is often discussed in relation to response to stress and emotions associated with being in an ambiguous situation, or it may refer to a future-oriented trait where an individual is responding to an ambiguous situation in the present. Suffice to say, for some individuals the need to be certain and clear means they find it very difficult to be in situations where multiple outcomes are possible and where information is messy. As a result, they find ways to counter the unease, ranging from avoiding making a decision to authoritatively dictating what “should” be done (or not done).

How does this affect us in a clinical setting? Well, both parties in this setting can have varying degrees of comfort with ambiguity.

Our clients may find it difficult to deal with not knowing their diagnosis, the cause of their painful experience, the time-frame of its resolution, and managing the myriad uncertainties that occur when routines are disrupted by the unexpected. For example, workers from the UK were interviewed about their unemployment as a result of low back pain. Uncertainty (both physical and financial) was given as one of the major themes from interviews of their experience of unemployment (Patel, Greasley, Watson, 2007).  Annika Lillrank, in a study from 2003, found that resolving diagnostic uncertainty was a critical point in the trajectory of those living with low back pain (Lillrank, 2003).

But it’s not just clients who find it hard to deal with uncertainty – clinicians do too. Slade, Molloy and Keating (2011) found that physiotherapists believe patients want a clear diagnosis but feel challenged when they’re faced with diagnostic uncertainty. What then happens is a temptation to be critical of the patients if they fail to improve, to seek support from other more senior colleagues, and end up feeling unprepared by their training to deal with this common situation. The response to uncertainty, at least in this study, was for clinicians to “educate” care-seekers about their injury/diagnosis despite diagnostic uncertainty (my italics), and a strong desire to see rapid improvements, and tend to attribute lack of progress to the client when either the client doesn’t want “education” or fails to improve (Slade, Molloy & Keating, 2003).

Physiotherapists are not alone in this tendency: There is a large body of literature discussing so-called “medically unexplained diseases” which, naturally, include chronic pain disorders. For example Bekkelund and Salvesen (2006) found that more referrals were made to neurologists when the clinician felt uncertain about a diagnosis of migraine. GP’s, in a study by Rosser (1996) were more likely to refer to specialists in part because they were uncertain – while specialists, dealing as they do with a narrower range of symptoms and body systems, deal with less diagnostic uncertainty. Surprisingly, despite the difference in degree of uncertainty, GP’s order fewer tests and procedures yet often produce identical outcomes!

How do we manage uncertainty and ambiguity?

Some of us will want to apply subtypes, groupings, algorithms – means of controlling the degree of uncertainty and ambiguity in our clinical practice. Some of the findings from various tests (eg palpation or tender point examination) are used as reasons for following a certain clinical rule of thumb. In physiotherapy, medicine and to a certain extent my own field of occupational therapy, there is a tendency to “see nails because all I have is a hammer” in an attempt to fit a client into a certain clinical rule or process. We see endless publications identifying “subtypes” and various ways to cut down the uncertainty within our field, particularly with respect to low back pain where we really are dealing with uncertainty.

Some of these subgroupings may appear effective – I remember the enthusiasm for leg length discrepancies, muscle “imbalance”, and more recently neutral spine and core stability – because for some people these approaches were helpful! Over time, the enthusiasm has waned.

Others of us apply what we could call an eclectic approach – a bit of this, a bit of that, something I like to do, something that I just learned – and yes, even some of these approaches seem to work.

My concern is twofold. (1) What is the clinical reasoning behind adopting either a rule-governed algorithm or subtyping approach or an eclectic approach? Why use X instead of Y? And are we reasoning after the fact to justify our approach? (2) What do we do if it doesn’t work? Where does that leave us? As Slade, Molloy & Keating (2003), do we begin blaming the patient when our hammer fails to find a nail?

I’ve long advocated working to generate multiple hypotheses to explain how and why a person is presenting in this way at this time. It’s a case formulation approach where, collaborating with the person and informed by broad assessment across multiple domains that are known to be associated with pain, a set of possible explanations (hypotheses) are generated. Then we systematically test these either through further clinical assessment, or by virtue of providing an intervention and carefully monitoring the outcome. This approach doesn’t resolve uncertainty – but it does allow for some time to de-bias our clinical reasoning, it involves the client in sorting out what might be going on, it means we have more than one way to approach the problem (the one the client identifies, not just our own!), and it means we have some way of holding all this ambiguous and uncertain information in place so we can see what’s going on. I know case formulations are imperfect, and they don’t solve anything in themselves (see Delle-Vergini & Day (2016) for a recent review of case formulation in forensic practice – not too different from ordinary clinical practice in musculoskeletal management IMHO) . What they do is provide a systematic process to follow that can incorporate uncertainty without needing a clinician to jump to conclusions.

I’d love your thoughts on managing uncertainty as a clinician in your daily practice. How do you deal with it? Is there room for uncertainty and ambiguity? What would happen if we could sit with this uncertainty without jumping in to treat for just a little longer? Could mindfulness be useful? What if you’re someone who experiences a great deal of empathy for people who distressed – can you sit with not knowing while in the presence of someone who is hurting?

 

Bekkelund, S., & Salvesen, R. (2006). Is uncertain diagnosis a more frequent reason for referring migraine patients to neurologist than other headache syndromes? European Journal of Neurology, 13(12), 1370-1373. doi:http://dx.doi.org/10.1111/j.1468-1331.2006.01523.x
Delle-Vergini, V., & Day, A. (2016). Case formulation in forensic practice: Challenges and opportunities. The Journal of Forensic Practice, 18(3), null. doi:doi:10.1108/JFP-01-2016-0005
Furnham, A., & Marks, J. (2013). Tolerance of ambiguity: A review of the recent literature. Psychology, Vol.04No.09, 12. doi:10.4236/psych.2013.49102
Lillrank, A. (2003). Back pain and the resolution of diagnostic uncertainty in illness narratives. Social Science & Medicine, 57(6), 1045-1054. doi:http://dx.doi.org/10.1016/S0277-9536%2802%2900479-3
Patel, S., Greasley, K., Watson, P. J. (2007). Barriers to rehabilitation and return to work for unemployed chronic pain patients: A qualitative study. European Journal of Pain: Ejp, 11(8), 831-840.
Rosser, W. W. (1996). Approach to diagnosis by primary care clinicians and specialists: Is there a difference? Journal of Family Practice, 42(2), 139-144.
Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558-569. doi:10.1177/0269215511420179

Did it help? Questions and debate in pain measurement


Pain intensity, quality and location are three important domains to consider in pain measurement. And in our kete*of assessment tools we have many to choose from! A current debate (ongoing debate?) in the august pages of Pain (International Association for the Study of Pain) journal shows that the issue of how best to collate the various facets of our experience of pain is far from decided – or even understood.

The McGill Pain Questionnaire (MPQ) is one of the most venerable old measurement instruments in the pain world.  It is designed to evaluate the qualities of pain – the “what does it feel like” of sensory-discriminative components, evaluative components, and cognitive-affective components. There are 20 categories in the tool, and these examine (or attempt to measure) mechanical qualities, thermal qualities, location and time.  Gracely (2016), in an editorial piece, compares the McGill to a set of paint colour samples – if pain intensity equals shades of grey, then the other qualities are other coloures – blue, green, red – in shades or tints, so we can mix and match to arrive at a unique understanding of what this pain is “like” for another person.

To begin to understand the MPQ, it’s important to understand how it was developed. Melzack recognised that pain intensity measurement, using a dolimeter (yes, there is such a thing – this is not an endorsement, just to prove it’s there), doesn’t equate with the qualities of pain experienced, nor of the impact of previous experiences. At the time, Melzack and Wall were working on their gate control theory of pain, so it’s useful to remember that this had not yet been published, and specificity theory was holding sway – specificity theory arguing that pain is a “specific modality of cutaneous sensation”, while pattern theory held that the experience reflects the nervous systems ability to “select and abstract” relevant information (Main, 2016).  So Melzack adopted a previous list of 44 words, carried out a literature review, and recorded the words used by his patients. Guided by his own three dimensional model of pain, he generate three groups of descriptors to begin to establish a sort of “quality intensity scale”. These were then whittled down to 78 words that have been used since, and by used I mean probably the most used instrument ever! Except for the VAS.

There are arguments against the MPQ – I’m one who doesn’t find it helpful, and this undoubtedly reflects that I work in a New Zealand context, with people who may not have the language repertoire of those that Melzack drew on. The people I work with don’t understand many of the words (‘Lancinating‘ anyone?), and like many pain measures, the importance or relevance of terms used in this measure are based on expert opinion rather than the views of those who are experiencing pain themselves. This means the measure may not actually tap into aspects of the experience of pain that means a lot to people living with it. Main (2016) also points out that interpreting the MPQ is problematic, and perhaps there are alternative measures that might be more useful in clinical practice. Some of the criticisms include the difficulty we have in separating the “perceptual” aspects of pain from the way pain functions in our lives, and the way we communicate it, and the MPQ doesn’t have any way to factor in the social context, or the motivational aspects of both pain and its communication.

In a letter to the editor of Pain, Okkels, Kyle and Bech (2016) propose that there should be three factors in the measurement – symptom burden (they suggest pain intensity), side effects (or medication – but what if there’s no medication available?), and improved quality of life (WHO-5). But as Sullivan and Ballantyne (2016) point out in their reply – surely the point of treatment is to improve patient’s lives – “we want to know if it is possible for the patient’s life to move forward again. However it is also important that we do not usurp patients’ authority to judge whether their life has improved” (p. 1574). What weighting we give to, for example, pain reduction vs improved quality of life? I concur. Even the MPQ with all its history doesn’t quite reflect the “what it means to me to experience this pain”.

Did it help? Answering this critical question is not easy. Pain measurement is needed for furthering our understanding of pain, to ensure clinical management is effective, and to allow us to compare treatment with treatment. But at this point, I don’t know whether our measures reflect relevant aspects of this common human experience.  Is it time to revisit some of these older measures of pain and disability, and critically appraise them in terms of how well they work from the perspectives of the people living with pain? Does this mean taking some time away from high tech measurement and back to conversations with people?

 

(*pronounced “keh-teh” – Maori word for kitbag, and often used to represent knowledge)

Gracely, R. H. (2016). Pain language and evaluation. Pain, 157(7), 1369-1372.

Main, C. J. (2016). Pain assessment in context: A state of the science review of the mcgill pain questionnaire 40 years on. Pain, 157(7), 1387-1399.

Okkels, N., Kyle, P. R., & Bech, P. (2016). Measuring chronic pain. Pain, 157(7), 1574.

Sullivan, M. D., & Ballantyne, J. (2016). Reply. Pain, 157(7), 1574-1575.

 

Pain measurement: Measuring an experience is like holding water


Measurement in pain is complicated. Firstly it’s an experience, so inherently subjective – how do we measure “taste”, for example? Or “joy”? Secondly, there’s so much riding on its measurement: how much pain relief a person gets, whether a treatment has been successful, whether a person is thought sick enough to be excused from working, whether a person even gets treatment at all…

And even more than these, given it’s so important and we have to use surrogate ways to measure the unmeasurable, we have the language of assessment. In physiotherapy practice, what the person says is called “subjective” while the measurements the clinician takes are called “objective” – as if, by them being conducted by a clinician and by using instruments, they’re not biased or “not influenced by personal feelings or opinions in considering and representing facts”. Subjective, in this instance, is defined by Merriam Webster as “ relating to the way a person experiences things in his or her own mind. : based on feelings or opinions rather than facts.”  Of course, we know that variability exists between clinicians even when carrying out seemingly “objective” tests of, for example, range of movement, muscle strength, or interpreting radiological images or even conducting a Timed Up and Go test (take a look here at a very good review of this common functional test – click)

In the latest issue of Pain, Professor Stephen Morley reflects on bias and reliability in pain ratings, reminding us that “measurement of psychological variables is an interaction between the individual, the test material, and the context in which the measure is taken” (Morley, 2016). While there are many ways formal testing can be standardised to reduce the amount of bias, it doesn’t completely remove the variability inherent in a measurement situation.

Morley was providing commentary on a study published in the same journal, a study in which participants were given training and prompts each day when they were asked to rate their pain. Actually, three groups were compared: a group without training, a group with training but no prompts, and a group with training and daily prompts (Smith, Amtmann, Askew, Gewandter et al, 2016). The hypothesis was that people given training would provide more consistent pain ratings than those who weren’t. But no, in another twist to the pain story, the results showed that during the first post-training week, participants with training were less reliable than those who simply gave a rating as usual.

Morley considers two possible explanations for this – the first relates to the whole notion of reliability. Reliability is about identifying how much of the variability is due to the test being a bit inaccurate, vs how much variability is due to the variability of the actual thing being measured, assuming that errors or variability are only random. So perhaps one problem is that pain intensity does vary a great deal from day-to-day.  The second reason is related to the way people make judgements about their own pain intensity. Smith and colleagues identify two main biases (bias = systematic errors) – scale anchoring effects (that by giving people a set word or concept to “anchor” their ratings, the tendency to wander off and report pain based only on emotion or setting or memory might be reduced), and that daily variations in context might also influence pain. Smith and colleagues believed that by providing anchors between least and “worst imaginable pain”, they’d be able to guide people to reflect on these same imagined experiences each day, that these imagined experiences would be pretty stable, and that people could compare what they were actually experiencing at the time with these imagined pain intensities.

But, and it’s a big but, how do people scale and remember pain? And as Morley asks, “What aspect of the imagined pain is reimagined and used as an anchor at the point of rating?” He points out that re-experiencing the somatosensory-intensity aspect of pain is rare (though people can remember the context in which they experienced that pain, and they can give a summative evaluative assessment such as “oh it was horrible”). Smith and colleagues’ study attempted to control for contextual effects by asking people to reflect only on intensity and duration, and only on pain intensity rather than other associated experiences such as fatigue or stress. This, it must be said, is pretty darned impossible, and Morley again points out that “peak-end” phenomenon (which means that our estimate of pain intensity depends a great deal on how long we think an experience might go on, disparities between what we expect and what we actually feel, and differences between each of us) will bias self-report.

Smith et al (2016) carefully review and discuss their findings, and I strongly encourage readers to read the entire paper themselves. This is important stuff – even though this was an approach designed to help improve pain intensity measurement within treatment trials, what it tells us is that our understanding of pain intensity measurement needs more work, and that some of our assumptions about measuring our pain experience using a simple numeric rating scale might be challenged. The study used people living with chronic pain, and their experiences may be different from those with acute pain (eg post-surgical pain). The training did appear to help people correctly rank their pain in terms of least pain, average pain, and worst pain daily ratings.

What can we learn from this study? I think it’s a good reminder to us to think about our assumptions about ANY kind of measurement in pain. Including what we observe, what we do when carrying out pain assessments, and the influences we don’t yet know about on pain intensity ratings.

Morley, S. (2016). Bias and reliability in pain ratings. Pain, 157(5), 993-994.

Smith, S. M., Amtmann, D., Askew, R. L., Gewandter, J. S., Hunsinger, M., Jensen, M. P., . . . Dworkin, R. H. (2016). Pain intensity rating training: Results from an exploratory study of the acttion protecct system. Pain, 157(5), 1056-1064.

Using a new avoidance measure in the clinic


A new measure of avoidance is a pretty good thing. Until now we’ve used self report questionnaires (such as the Tampa Scale for Kinesiophobia, or the Pain Catastrophising Scale), often combined with a measure of disability like the Oswestry Disability Index to determine who might be unnecessarily restricting daily activities out of fear of pain or injury. These are useful instruments, but don’t give us the full picture because many people with back pain don’t see that their avoidance might be because of pain-related fear – after all, it makes sense to not do movements that hurt or could be harmful, right?

Behavioural avoidance tests (BAT) are measures developed to assess observable avoidance behaviour. They’ve been used for many years for things like OCD and phobias for both assessments and treatments. The person is asked to approach a feared stimulus in a standardised environment to generate fear-related behaviours without the biases that arise from self-report (like not wanting to look bad, or being unaware of a fear).

This new measure involves asking a person to carry out 10 repetitions of certain movements designed to provoke avoidance. The link for the full instructions for this test is this: click

Essentially, the person is shown how to carry out the movements (demonstrated by the examiner/clinician), then they are asked to do the same set of movements ten times.  Each set of movements is rated 0 = performs exactly as the clinician does; 1 = movement is performed but the client uses safety behaviours such as holding the breath, taking medication before doing the task, asking for help, or motor behaviours such as keeping the back straight (rotation and bending movements are involved); 2 = the person avoids doing the movement, and if the person performs fewer than 10 repetitions, those that are not completed are also coded 2. The range of scores obtainable are 0 – 60.

How and when would you use this test?

It’s tempting to rush in and use a new test simply because it’s new and groovy, so some caution is required.

My questions are: (1) does it help me (or the person) obtain a deeper understanding of the contributing factors to their problem? (2) Is it more reliable or more valid than other tests? (3) Is it able to be used in a clinical setting? (4) Does it help me generate better hypotheses as to what’s going on for this person? (5) I also ask about cost, time required, scoring and whether special training is required.

This test is very useful for answering question (1). It provides me with a greater opportunity to review the thoughts, beliefs and behaviours of a person in the moment. This means I can very quickly identify even the subtle safety behaviours, and obtain the “what’s going through your mind” of the person. If I record the movements, I can show the person what’s going on. NB This is NOT intended to be a test of biomechanical efficiency, or to identify “flaws” in movement patterns. This is NOT a physical performance test, it’s a test of behaviour and belief. Don’t even try to use it as a traditional performance test, or I will find you and I will kill (oops, wrong story).

It is more valid than other tests – the authors indicate it is more strongly associated with measures of disability than measures of pain-related fear and avoidance behaviour. This is expected, because it’s possible to be afraid of something but actually do it (public speaking anyone?), and measures of disability don’t consider the cause of that disability (it could be wonky knees, or a dicky ticker!).

It’s easy to do in a clinical setting – A crate of water bottles (~8 kg) and a table (heights ~68 cm) are needed to conduct the BAT-Back. The crate weighed  7.8 kg including six one-litre plastic bottles. One could argue that people might find doing this test in a clinic is less threatening than doing it in real life, and this is quite correct. The setting is contained, there’s a health professional around, the load won’t break and there’s no time pressure, so it’s not ecologically valid for many real world settings – but it’s better than doing a ROM assessment, or just asking the person!

Does it help me generate better hypotheses? Yes it certainly does, provided I take my biomechanical hat off and don’t mix up a BAT with a physical performance assessment. We know that biomechanics are important in some instances, but when it comes to low back pain it doesn’t seem to have as much influence as a person’s thoughts and beliefs – and more importantly, their tendency to just not do certain movements. This test allows me to go through the thoughts that flash through a person’s mind as they do the movement, thus helping me and the person more accurately identify what it is about the movement that’s bothering them. Then we can go on to test their belief and establish whether the consequences are, in fact, worse than the effects of avoidance.

Finally, is it cost-effective? Overall I’d say yes – with a caveat. You need to be very good at spotting safety behaviours, and you need to have a very clear understanding about the purpose of this test, and you may need training to develop these skills and the underlying conceptual understanding of behavioural analysis.

When would I use it? Any time I suspect a person is profoundly disabled as a result of their back pain, but does not present with depression, other tissue changes (limb fracture, wonky knees or ankles etc) that would influence the level of disability. If a person has elevated scores on the TSK or PCS. If they have elevated scores on measures of disability. If I think they may respond to a behavioural approach.

Oh, the authors say very clearly that one of the confounds of this test is when a person has biological factors such as bony changes to the vertebrae, shortened muscles, arthritic knees and so on. So you can put your biomechanical hat on – but remember the overall purpose of this test is to understand what’s going on in the person’s mind when they perform these movements.

Scoring and normative data has not yet been compiled. Perhaps that’s a Masters research project for someone?

Holzapfel, S., Riecke, J., Rief, W., Schneider, J., & Glombiewski, J. A. (in press). Development and validation of the behavioral avoidance test – back pain (bat-back) for patients with chronic low back pain. Clinical Journal of Pain.

 

 

Fibro fog or losing your marbles: the effect of chronic pain on everyday executive functioning


ResearchBlogging.org

There are days when I think I’m losing the plot! When my memory fades, I get distracted by random thin—-ooh! is that a cat?!

We all have brain fades, but people with chronic pain have more of them. Sometimes it’s due to the side effects of medication, and often it’s due to poor sleep, or low mood – but whatever the cause, the problem is that people living with chronic pain can find it very hard to direct their attention to what’s important, or to shift their attention away from one thing and on to another.

In an interesting study I found today, Baker, Gibson, Georgiou-Karistianis, Roth and Giummarra (in press), used a brief screening measure to compare the executive functioning of a group of people with chronic pain with a matched set of painfree individuals. The test is called Behaviour Rating Inventory of Executive Function, Adult version (BRIEF-A) which measures Inhibition, Shift, Emotional Control, Initiate, Self-Monitor, Working Memory, Plan/Organize, Task Monitor, and Organization of Materials.

Executive functioning refers to “higher” cortical functions such as being able to attend to complex situations, make the right decision and evaluate the outcome. It’s the function that helps us deal with everyday situations that have novel features – like when we’re driving, doing the grocery shopping, or cooking a meal. It’s long been known that people living with chronic pain experience difficulty with these things, not just because of fatigue and pain when moving, but because of limitations on how well they can concentrate. Along with the impact on emotions (feeling irritable, anxious and down), and physical functioning (having poorer exercise tolerance, limitations in how often or far loads can be lifted, etc), it seems that cognitive impairment is part of the picture when you’re living with chronic pain.

Some of the mechanisms thought to be involved in this are the “interruptive” nature of pain – the experience demands attention, directing attention away from other things and towards pain and pain-related objects and situations; in addition, there are now known to be structural changes in the brain – not only sensory processing and motor function, but also the dorsolateral prefrontal cortex which is needed for complex cognitive tasks.

One of the challenges in testing executive functions in people living with chronic pain is that usually they perform quite well on standard pen and paper tasks – when the room is quiet, there are no distractions, they’re rested and generally feeling calm. But put them in a busy supermarket or shopping mall, or driving a car in a busy highway, and performance is not such an easy thing!

So, for this study the researchers used the self-report questionnaire to ask people about their everyday experiences which does have some limitations – but the measure has been shown to compare favourably with real world experiences of people with other conditions such as substance abuse, prefrontal cortex lesions, and ADHD.

What did they find?

Well, quite simply they found that 50% of patients showed clinical elevation on Shift, Emotional Control, Initiate, and Working Memory subscales with emotional control and working memory the most elevated subscales.

What does this mean?

It means that chronic pain doesn’t only affect how uncomfortable it might be to move, or sit or stand; and it doesn’t only affect mood and anxiety; and it’s not just a matter of being fogged with medications (although these contribute), instead it shows that there are clear effects of experiencing chronic pain on some important aspects of planning and carrying out complex tasks in the real world.

The real impact of these deficits is not just on daily tasks, but also on how readily people with chronic pain can adopt and integrate all those coping strategies we talk about in pain management programmes. Things like deciding to use activity pacing means – decision making on the fly, regulating emotions to deal with frustration of not getting jobs done, delaying the flush of pleasure of getting things completed, having to break a task down into many parts to work out which is the most important, holding part of a task in working memory to be able to decide what to do next. All of these are complex cortical activities that living with chronic pain can affect.

It means clinicians need to help people learn new techniques slowly, supporting their generalising into daily life by ensuring they’re not overwhelming, and perhaps using tools like smartphone alarms or other environmental cues to help people know when to try using a different technique. It also means clinicians need to think about assessing how well a person can carry out these complex functions at the beginning of therapy – it might change the way coping strategies are learned, and it might mean considering changes to medication (avoiding opiates, but not only these because many pain medications affect cognition), and thinking about managing mood promptly.

The BRIEF-A is not the last word in neuropsych testing, but it may be a helpful screening measure to indicate areas for further testing and for helping people live more fully despite chronic pain.

 

Baker, K., Gibson, S., Georgiou-Karistianis, N., Roth, R., & Giummarra, M. (2015). Everyday Executive Functioning in Chronic Pain The Clinical Journal of Pain DOI: 10.1097/AJP.0000000000000313