Managing sleep problems – a medication-free approach (i)

I’ve recently completed two posts on assessing sleep problems in people experiencing persistent pain, and today I turn my attention to strategies for managing sleep problems – without medication. Why without medication? Because to date there are no medications for insomnia that don’t require a ‘weaning off’ period, during which time people often find their original sleep problems emerge once again… I’m not completely against medications for sleep or pain – but I think they need to be used with care and full disclosure about the effects, side-effects, and the need to eventually withdraw from them.

The approach I’m advocating is a modified form of cognitive behavioural therapy for insomnia (CBTi). CBTi is a form of treatment that is now considered to be first line therapy by both the British Association for Psychopharmacology (Wilson, Nutt, Alford, Argyropoulos, Baldwin, Bateson et al, 2010), and the American College of Physicians (Qaseem, Kansagara, Forciea, Cooke, Denberg et al, 2016). It includes sleep hygiene, cognitive therapy for the thoughts and beliefs associated with sleep, and sleep restriction for those who clinically need it. The modified version I advocate is based on Dr Guy Meadows ACT-based approach and I’ll cover that next week, but I’ll describe the classical CBT approach first.

Basic principles

The basic idea behind a CBT approach to insomnia is that although the initiating event may be out of our control, it’s unlikely to be maintaining the problem – and the factors maintaining the problem are typically the habits people have, and the thoughts and beliefs about their sleep problem.

Sleep is a behaviour that is infinitely malleable, as anyone who has travelled far enough on long-haul flights will know (and parents of small babies as well!). There are cues we use to decide when we should head to bed, and how long we should stay asleep. Bodies in turn respond to these cues and modify automatic processes such as digestion, urine production, and body temperature to ensure we stay asleep for as long as needed. When those cues change – for example, we’re in a new time zone when it’s light at the “wrong” time, and we’re hungry at the “wrong” time, we have trouble staying asleep until the body adjusts. Some people say we can manage a two-hour time zone shift every 24 hours, but in some sensitive people even a one-hour daylight savings change can upset the apple-cart!

If sleep is a habitual behaviour, then we can manipulate the cues to our benefit when sleep is elusive. We learn to associate things like the routine we follow prior to going to bed, light in the room, the “winding down” process we use, and even the timing of our snacks and drinks as a way to signal to the body/mind that we’re sleepy/tired.

There are three basic steps in CBTi: stimulus control (aka sleep hygiene), cognitive therapy, and sleep restriction – with the usual relapse prevention steps an essential part as well.

Sleep hygiene (stimulus control)

The basis of sleep hygiene is to control the stimuli associated with going to sleep so that we clearly indicate to the body/mind that it’s time to get to sleep. That means some basic “rules” around what we do in the time preceding getting into bed, and what we do when in bed trying to sleep.

The golden rule is that the bed is for sleep and sex – not for worrying in, not for watching TV or using the computer or phone or tablet, not for arguing in, not for talking on the phone. If you’re awake in bed for longer than 20 minutes, it’s time to get out of bed until you’re sleepy/tired (more on this in a moment), keeping the lights down low, doing something tedious or boring, then returning to bed to actually sleep.

Simple, commonsense things like keeping the room dark and warm, blocking out the worst of the noise, NOT using a TV or radio or any other noise-making device to go to sleep, ensuring caffeine intake is limited, having a regular bedtime and wake-up time, not taking naps through the day and timing when exercise and relaxation are undertaken are all part of sleep hygiene and most of us are aware of these steps. If they’re not familiar to you, this site is a good one – click.

Cognitive therapy

The cognitive therapy part is about managing the thoughts and attitudes that can exacerbate the sleep problem – things like having a busy mind, worrying about not being able to sleep, believing that it’s crucial to have a certain number of hours of sleep or the next day will be awful, getting that sinking dread as bedtime approaches, following any number of almost (and sometimes actual) obsessive rituals to achieve sleep – and so on…

As usual, with any conventional CBT, dealing with these thoughts involves firstly reality testing – Is it true that you must have a certain number of hours of sleep or the next day will inevitably be terrible? Must the room be absolutely silent or sleep will elude you? Then challenging or disputing those thoughts – “It’s possible I’ll feel tired tomorrow, but I can still function even if I’m not at my best”, “It might take me longer to fall asleep but I’ll get to sleep even though I can hear a clock ticking”.

These simple approaches are reasonably easy to implement – and they are effective. But if sleep is still a problem, and the person isn’t getting more than 4 hours sleep a night, it’s time to bring in the big guns.

Sleep restriction

There are two parts of altering sleep habits that are particularly challenging: getting out of bed after 20 minutes of being awake (especially in the wee hours of the morning!); and using sleep restriction. Neither are easy, yet both are effective.

The idea behind sleep restriction is to reduce the amount of time being in bed while not actually being asleep. Simple huh? So that period from when you first hop into bed and until you actually fall asleep is called sleep latency – and the longer your sleep latency, the less sleep you actually get. You become inefficient at sleeping, and worst, your body/mind learns that it’s OK to be in bed wide awake, and as I mentioned earlier, people begin to associate even going into the bedroom as a negative thing which revs up the autonomic nervous system making it even more difficult to fall asleep.

The nuts and bolts are to work out what time you actually fall asleep, and only go to bed at that time. So if you stay awake until 2.00 or 3.00am, you only go to bed at 2.00am. And you keep your morning wake-up time the same as normal. Yes, this means you end up being only able to sleep for the time between 2.00am and 7.00am! Ouch!

The idea is to extinguish the “habit” of being awake while in bed, reducing the association between being in bed and wide awake, while getting you absolutely tired and sleepy that you fall asleep into a deep sleep quickly. Once this falling asleep part happens regularly (usually for a week or so) then it’s possible to begin a very gradual process of bringing the bedtime back to a more reasonable hour – I usually suggest 15 minute increments, returning to the previous step if falling asleep begins to be difficult.

The process is reasonably difficult – not because it’s hard to stay awake (after all, the person has been practicing it for some time!) but because of the mind chatter. It’s truly tough when your mind starts having a go at you, suggesting you can’t sleep, or you’ll be so incredibly tired you won’t cope, or you’ll be cranky and that it’s dangerous and how on earth  will you go at work without any sleep? And this is where having access to a really good clinician can be helpful, although there are apps that provide a pretty good alternative if a human isn’t available.

For a detailed examination of the literature on sleep restriction therapy, Kyle, Aquino, Miller, Henry, Crawford, Espie & Spielman (2015) provide a really good systematic analysis of how sleep restriction is employed in research trials.  For a plain language version of CBTi, this is a good description – click

As I mentioned above, I’ll be going through a slightly different version of CBTi – an Acceptance and Commitment Therapy approach to insomnia that is also gaining popularity and an evidence base. Come right on back next week for that exciting episode!

 

Kyle, S. D., Aquino, M. R. J., Miller, C. B., Henry, A. L., Crawford, M. R., Espie, C. A., & Spielman, A. J. (2015). Towards standardisation and improved understanding of sleep restriction therapy for insomnia disorder: A systematic examination of cbt-i trial content. Sleep Medicine Reviews, 23, 83-88.

Manber, R., Simpson, N. S., & Bootzin, R. R. (2015). A step towards stepped care: Delivery of cbt-i with reduced clinician time. Sleep Medicine Reviews, 19, 3-5.

Qaseem, A., Kansagara, D., Forciea, M., Cooke, M., Denberg, T. D., & for the Clinical Guidelines Committee of the American College of, P. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine, 165(2), 125-133. doi:10.7326/M15-2175

Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., . . . Wade, A. (2010). British association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. Journal of Psychopharmacology, 24(11), 1577-1601. doi:10.1177/0269881110379307

Non-drug approaches for people with fibromyalgia

No-one wants to be told their pain is “in your head”. But given our increasingly sophisticated understanding of pain neurobiology, there’s plenty of reason to agree that thinking, feeling and doing things differently makes life far more rewarding and rich than feeling helpless, fatigued and sore. Some proponents of purely biomedical interventions argue that if only the “source of the nociception” was found, the nerve “zapped” or anaesthetised, then all this psychosocial claptrap could be safely ignored because people “return to normal”. I think this belief shows ignorance and perhaps even arrogance because people process and attribute meaning to everything that happens to them.

I originally entitled this post as “psychological” approaches for people with fibromyalgia, but I’ve changed it after reflecting that we actually do not know which of the various parts of non-drug therapy are most useful for people. There are some core components in self-management approaches, these include explanations (or reconceptualising pain), graded return to life’s activities or occupations, exercise (again, graded), and often some work around thoughts/beliefs/emotions that might get in the way of returning to activities, and some practical problem-solving and goal-setting to help people work out how they’re going to “get on with it”.

While the assumptions are cognitive behavioural in origin – that is, people can take control of what is happening around them, and respond differently even if the pain doesn’t change – most of what happens involves doing things differently in order to bring more of what the person values back into their life, rather than having life dominated by pain.

I’ve written before about ACT, Acceptance and Commitment Therapy, and I find it quite appealing. The ACT approach involves developing skills to be fully present, work towards living a life aligned with your personal values, being mindful of what is (rather than worry about what was, or what might be), being committed to taking action even if the process isn’t always happy-happy, joy-joy. I like it, and in my research it seems to fit quite nicely with what people naturally do. In ACT the coping strategies used don’t fall into “good” or “bad” dichotomies, instead they’re evaluated according to how well they’re working in light of each individual’s values. I like the respectful attitude towards people’s personal values and beliefs, and the flexibility of using “what works” and experiential therapy rather than sitting in a clinic room talking.

The question is whether ACT is any better or worse than any other psychological treatment – such as “traditional” cognitive behavioural therapy.

The jury is out. Frankly I am not sure it’s as much about the particular model or type of therapy used as it is about the way in which it’s introduced to the person. There are CBT clinicians who seem to be able to come alongside a person, help them work out for themselves whether their thinking is helpful or not, and help them shift their perspective nicely. Then there are CBT clinicians who leave people feeling as if they have “stinking thinking” or “maladaptive thoughts”, who “have” to change their way of life, who “must” do therapy “homework” – and blame the patient for failing to do “homework” or being “noncompliant”.  I can, of course, say the same about ACT clinicians and indeed any other form of clinician!

Where does this leave us?

Well, I’m not sure that much has changed in the 20 or so years I’ve been working in this field. What has happened is stronger evidence to show that thoughts, beliefs, emotions and behaviour are linked, and directly influence our experience of pain. People still need to understand, or make sense, of what’s happening to them, get more active and have more of what they want in their lives rather than feeling controlled by pain.

How we achieve this probably depends as much on the person who has pain as the clinician.

We also know that fruitlessly seeking pain reduction leads to demoralisation, frustration and increasing disability.

While I’ve put “fibromyalgia” as the type of chronic pain two of the papers I’ve cited refer to, really I’m not convinced that the problems people experience from their pain differs terribly much depending on the diagnosis. The effect of pain that goes on is the same – a diminishing sense of self identity, increased sense of helplessness and overall difficulty doing and being well. Addressing these effects is far more worthwhile in people’s lives than trying to control, avoid or abolish pain – because some pains just don’t go away.

Luciano, J., Guallar, J., Aguado, J., López-del-Hoyo, Y., Olivan, B., Magallón, R., Alda, M., Serrano-Blanco, A., Gili, M., & Garcia-Campayo, J. (2014). Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomized controlled trial (EFFIGACT study) PAIN®, 155 (4), 693-702 DOI: 10.1016/j.pain.2013.12.029
BERNARDY, K., FUBER, N., KOLLNER, V., & HAUSER, W. (2010). Efficacy of Cognitive-Behavioral Therapies in Fibromyalgia Syndrome — A Systematic Review and Metaanalysis of Randomized Controlled Trials The Journal of Rheumatology, 37 (10), 1991-2005 DOI: 10.3899/jrheum.100104
Williams ACDC,, Eccleston C,, & Morley S (2012). Psychological therapies for the management of chronic pain (excluding headache)in adults. Cochrane Database of Systematic Reviews (11) DOI: 10.1002/14651858.CD007407.pub3

 

NB: I have amended the first paragraph because it may have been viewed as unnecessarily pejorative towards a single type of clinician. The truth is, I point the finger at any clinician from any background or discipline if I think what is being done is harmful, illogical or maintains distress and disability, including my original profession of occupational therapy.  I was being simplistic to suggest a single profession is at fault. It’s not the profession per se, it’s the attitude that I strongly object to.  To those who were upset by my original wording, here’s an invitation: if you’re able to demonstrate HOW you integrate biopsychosocial approaches in your practice, I’ll publish it. That’s the beauty of dialogue, and particularly social media.

How well do people understand their neuropathic pain?

When coming to terms with a chronic pain problem, one of the important steps involves obtaining a diagnosis that fits with both the individual’s personal experience of their pain, and also their knowledge (drawn from what is available in the general population). If the label doesn’t square with their experience, people continue searching until they find something that does.

There has been an enormous wave of excitement about giving people good “pain education”. I’ve always been a bit anxious about the term “education”, because it can so often mean giving an information dump, leaving the person being “educated” with little or no relevant knowledge about their personal concerns – and it’s the individual and unique concerns that influence how a person interprets what is happening, and how they respond. As a result, I prefer “helping people to develop a personal pain formulation” or “reconceptualising” their pain. Putting the pedantics aside, it seems really important for health professionals to not only understand what people with pain already know about their health condition, but also to understand how people interpret what they’re told – if they’re told anything.

In this study, 75 people with neuropathic pain were asked to sort a series of statements about neuropathic pain according to their level of agreement with them. This is known as Q-methodology. The sorted statements are then analysed to identify common features amongst them. Four factors were identified:

1. Neuropathic pain is a nervous system problem, psychology influences the pain experience and acceptance, and being open to psychological interventions – this group of respondents had tried psychological treatments, their pain was on average about 6 – 7 years.
2. Neuropathic pain is nerve damage, psychology is irrelevant in pain experience, neutral about psychological treatments – this group of people had not tried psychological treatments, but had tried surgery and medications.
3. Neuropathic pain is irreparable nerve damage, symptom management is needed, psychological factors play a part in pain perception but psychological treatment is not OK – this group of individuals had pain for an average of 10 years, and they had used breathing, positive thoughts, medications and physical treatments.
4. Neuropathic pain cause should be identified, psychological influences may play a part, and treatment can include both medical and psychological – this group had pain for an average of 1 -2  years, and they had tried a range of medications, physical methods, yoga, meditation and complementary therapies.

The authors point out several limitations of this study – people were not recruited on the basis of an particular characteristics, there could be a number of recruitment biases, and they were all identified via online recruitment processes, therefore it’s hard to generalise. What it does indicate is that there is no coherent biopsychosocial explanation put forward by participants, they appeared to have received very little explanation about their problem, and this affected their readiness for psychological or self management interventions.

Another interesting point is how many of these participants, across all the four factor groups, described experiencing being given psychosomatic explanations of their pain. The authors write :”Across all accounts, participants’ comments indicated that they had received psychosomatic explanations of their pain and had been distressed and offended, consistent with other studies which use open-ended methods to sample patients’ experiences. (p. 353).” The influence of psychological factors was found to be associated more with adjusting to chronic pain, rather than to developing an integrated model of pain. Factor 1 were the only group to endorse the notion of acceptance, or learning to live with pain – and the groups in Factors 3 and 4 were strongly against the idea that pain could be lived with.

I find this study interesting, not so much in what it has discovered, but rather more in terms of the discussion about psychological factors and medical factors – but nothing on social factors. I find myself wondering again whether we have a biopsychological model of pain, rather than a more complex biopsychosocial model.

That being said, I agree with a point made in the conclusion: people with chronic pain value a coherent explanation for their pain, it helps resolve their worry and enables them to approach their pain differently.  The problem facing people with chronic pain is how to access evidence-based and accessible information about neuropathic (or indeed any type of) pain. Often people find out about neuropathic via biomedical models, and they rarely get exposed to the complexity of a biopsychological model, let alone a biopsychosocial one.

We desperately need to understand the best ways to personalise an explanation for an individual with chronic pain. I think a case formulation approach is the most useful, but I’ve found that many clinicians think this takes “too long” and is “too complex”. I wonder about this. A formulation might take a couple of sessions, but it’s a lot less expensive and has lower risk than surgery.

In light of the very limited range of interventions for people with neuropathic pain, perhaps taking the time to respond to the person’s unique questions about their pain would be time and money well spent.

 

People who have chronic pain are often very reluctant to consider the influence of psychological factors on their pain, reflecting their fear that by accepting this, their pain is being dismissed as “not real”, or not legitimate. This means people may not accept (or indeed be referred for) psychological interventions. Treatment approaches based on a cognitive behavioural approach have good evidence to support them, but they don’t do much good if people are not ready for them, or even referred for them.

 

Martin, S., Daniel, C., & Williams, A. (2014). How do people understand their neuropathic pain? A Q-study PAIN®, 155 (2), 349-355 DOI: 10.1016/j.pain.2013.10.021

Worrying about health

You may wonder why I’m writing about health anxiety: how does this fit with pain management? Read on – the connection is pretty clear.

Health anxiety (or hypochondriasis) is thought to be fairly common in the community, maybe 5% lifetime prevalence. It involves being extraordinarily worried about the meaning of body symptoms, over-interpreting the significance of ambiguous body sensations.  As you can probably imagine, people who experience health anxiety turn up in many different guises in the health system. It’s distressing to the person, not just because they’re afraid they have some dire disease, but also because the interactions between people with the problem, and healthcare providers, can be strained.  Health providers can think people with health anxiety are “just wanting attention”, that they need a firm hand and should be turned away so that people with “real” problems can then be seen.

Health providers generally like to give explanations to people seeking help, and try to demonstrate that “there’s nothing wrong”.  This means in the early stages at least, people with health anxiety get a lot of investigations and imaging to try to either establish there’s nothing wrong, or to find out what IS wrong. The problem is, in this group of people, giving reassurance by way of a clear MRI or blood test just doesn’t work. In fact, a bit like the spider phobic who covers the spider up with an upturned glass, clear imaging reduces anxiety for a very brief time and then the anxiety goes up. Spider phobics might cover the spider up with a glass, but they keep on coming back just to check it’s still there. And woe betide if it disappears – where oh where has it gone?!

If giving reassurance via imaging doesn’t work, what does? Well, explanations don’t always cut it either – logic doesn’t really play a part in anxiety of any kind. I mean, if you’re afraid of speaking in public, you KNOW the crowd is not going to kill you, but does your mind know that? In New Zealand spiders are not, by and large, poisonous, but my goodness, a big spider will make my heart go pit-a-pat!This response to reassurance or explanation means I’m just a little skeptical about thinking that “pain education” on its own is enough to get people doing things again.

The study that triggered this post is a really large CBT trial in the UK in which patients attending general hospital clinics were screened for health anxiety using a 14-item questionnaire (Health Anxiety Inventory).  28 991 patients were screened and 444 were identified as having  excessive health anxiety. This group were randomised into two groups – one to receive standard care, and the other to receive up to 10 CBT sessions.The outcomes were reduced scores on the HAI as well as some important health use indicators two years later.

The outcome this group obtained were significant reductions in health anxiety for the CBT group, little change in the standard care group. A slight reduction in healthcare use was found between the two groups.

A couple of important points:

1. People with chronic pain are not mentioned in this article, but other research shows elevated health anxiety in those with chronic pain . Health anxiety increases treatment seeking, so that if a person has pain somewhere – maybe chronic noncardiac chest pain, chronic abdominal pain, and even chronic pelvic pain – a health anxious person is likely to look for help for it, while someone who is less anxious may just let it go and get on with life.
2. The clinicians delivering CBT for health anxiety were not specialist clinical psychologists. Instead, they included nurses, graduate research workers, or “other health professionals trained for this intervention.” When cost effectiveness calculations were made, the costs were close to equivalent.  This suggests that allied health clinicians can contribute a great deal, at a reasonable cost, to reducing the distress and over-use of health care resources. I’m not just thinking of the dollar value saved by people not attending for unnecessary treatments, but also the human cost saved, and that by treating this group of people appropriately, other people can access those treatments otherwise absorbed by people with health anxiety.
3. Interestingly, many people were identified as having health anxiety – 5769 scored more than 20 on the HAI. 3935 declined to participate. 1389 were excluded because they didn’t meet the DSM-IV hypochondriasis diagnosis. People don’t like being told they’re anxious about their health. Somehow the message they get is that their problem is not real. Or they think it’s being trivialised.

Go watch someone who is really stressing about their health, it’s no trivial matter. And the more reassurance we give in the form of investigations the longer they stress.  I wonder what would happen if we took the time to listen to what the person is scared about, the meaning they give to their experience, and how this relates to their life, would that investment improve the lives of people with health anxiety?

The link between general health anxiety and treatment seeking for chronic pain (and wanting a “real” diagnosis, “real” treatment, “something to take the pain away”) is pretty close. I wonder what would happen if we ALL got better at responding appropriately to health anxiety?

I wrote about health anxiety in 2010 – here’s a link to one of the posts, or you could use the search function on the blog.

Link

 

Hadjistavropoulos, Heather D., Asmundson, Gordon J. G., LaChapelle, Diane L., & Quine, Allisson. (2002). The role of health anxiety among patients with chronic pain in determining response to therapy. Pain Research & Management, 7(3), 127-133.

Tang, N. K. Y., Salkovskis, P. M., Hodges, A., Soong, E., Hanna, M. H., & Hester, J. (2009). Chronic pain syndrome associated with health anxiety: a qualitative thematic comparison between pain patients with high and low health anxiety. British Journal of Clinical Psychology, 48(Part 1), 1-20. doi: 10.1348/014466508×336167

Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, Dupont S, Finnis S, Green J, McLaren E, Murphy D, Reid S, Smith G, Wang D, Warwick H, Petkova H, & Barrett B (2013). Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet, 383 (9913), 219-225 PMID: 24139977

Pain reduction doesn’t (always) reduce disability

The relationship between pain and disability is a particularly vexing one in primary care. It would be great if it was possible to get rid of pain and be assured that any lingering effects on function would be similarly abolished, but it just doesn’t seem to be quite that simple.

Many different approaches to managing this situation have been suggested. One is to argue that people should be referred for a quick pain reduction injection – for those who have pain that is thought to respond to this approach. Another is to just “reassure” and review often. And still another is to provide a cognitive behavioural approach usually reserved for those referred to a secondary or tertiary treatment centre.

For several reasons I find the first and second options above not particularly satisfying. 

For the avoidance of doubt, I want to make sure readers are aware that I am not agin pain reduction techniques. In fact, they’re a very good thing because, and this is the important point, they allow people to get back doing what is important to them. There are a few “provided that’s” to this because, as I’m going to show, people who have had a bout of pain don’t always “get back doing what is important to them”.

The second option of providing reassurance is also less than satisfactory because despite this approach being endorsed in numerous guidelines for managing acute musculoskeletal pain, very few specific recommendations as to how to provide reassurance have been given. Reassurance can be both unsatisfying to the person on the receiving end, and in some cases, increase the likelihood that the person remains fearful of moving and continues to look for more reassurance (Linton, McCracken & Vlaeyen, 2008).

Why doesn’t “taking the pain away” just return the person to the way they were?

Good question, glad you asked it!  While abolishing the pain does, in many cases, return the peripheral nervous system and tissues to normal, this situation doesn’t apply to the central nervous system – and most particularly, those parts of the brain concerned with appraisals and judgements, anxiety and emotion, and memory.  Let me explain.

When we are born, we arrive in the world with a functioning set of reflexes that respond quickly to input that startles the nervous system out of “comfort”. Loud noises, textures against the skin, new tastes – all of these provoke a startle response and we cry in protest. Thankfully most of these responses settle down as the nervous system habituates to those features of the environment that reoccur, but our responses are shaped by how adults around us respond to the same events, and how they respond to our behaviour.  This is the effect of social and cultural influences.  At the same time, we begin to develop preferences – some genetically shaped, others from what we observe and imagine about other people, and some from our own processing of the external and internal world.

It’s these factors that influence our responses to sensations that our brains ultimately determine are harmful or potentially harmful – and our brains let “us” know about this in the form of our experience of pain.
We develop tolerances to experiences as we’re exposed to them over time. Think of the sensation of biting into a

HOT CHILLI PEPPER.

Some of you will be thinking “Ouch! No way I’d do that!”, while others of you will be thinking “Yeah baby! Bring it on!”
The way we appraise, or think about/judge a situation influences our emotional response to it.  This in turn influences what we are prepared to do about it.

Returning to the chilli pepper, even the next day after having had the HOT CHILLI PEPPER, you can remember the experience. (As an aside, this ability to remember what has happened – and then predict what might happen in the future – is what I drew on when I suggested that you think about it. ) You also made some decisions in your mind when I asked you to think of it, based on your appraisal of the sensation, and your emotional response to it.

When we experience pain, even if that pain goes after a while, we judge it and we have feelings about it, and we make decisions about what we will – or won’t – do if that situation arises again.

And this is why reducing pain but failing to also address thoughts and beliefs about what has happened and the possibility of it happening again does not always give the outcome we are hoping for.

The papers by Lamb and colleagues demonstrate that group CBT for low-back pain can be delivered in a cost-effective way in primary care, with good long-term effectiveness.   Isn’t it time this approach was seriously implemented?

Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-eff ectiveness analysis Lancet, 375 (9718), 916-923 : DOI:10.1016/S0140- 6736(09)62164-4

Lamb, S., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E., & Underwood, M. (2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) PAIN DOI: 10.1016/j.pain.2011.11.016

Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.

Education or a cognitive behavioural approach?

There is a reasonable amount of evidence suggesting that self management of chronic pain is only moderately effective.  Some of the factors thought to influence outcomes include the “one size fits all” approach – people with chronic pain may not all equally benefit from the same aspects of a programme; that programmes are usually delivered within a university-based, middle-class, North American setting and that there may be moderating or mediating factors that influence the who and what actually works within a programme.

I was interested to read about an RCT of “education” and “cognitive behavioural approach” conducted by Day, Thorn and Kapoor.   Dr Bev Thorn has written many books and research papers on a structured cognitive behavioural approach for pain that specifically addresses the appraisals people make of their pain.   In this approach, people are taken through a process of firstly identifying their appraisals, then learning how to challenge and restructure their thoughts about pain, while at the same time learning to do activities that they may have avoided for some time.  One feature of a CBT approach is using  “home learning” activities to bridge between sessions and help generalise the learning.

By comparison, an educational approach provides accurate information on aspects of pain and coping strategies, but doesn’t include the “home learning” and doesn’t directly address ways to identify and restructure thinking about pain.

One of the problems with many cognitive behavioural programmes for pain management is that they demand a lot from their participants – and particularly, they require literacy.  There can be, if not carefully structured, a lot of writing.  For people who don’t do writing or pen and paper activities, this can be really off-putting.  The sessions are also somewhat “talky” – again, this can be off-putting for people who prefer action and doing.

In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8.  Both groups received a group-based programme of 10 sessions of 90 minutes.  They both received a workbook and additional reading material.  The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not.

Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced.  Instead it presents thematic analysis from in-depth interviews of the participants.

What this analysis found was that while the CBT group participants initially found it difficult to “get into” the process, they spontaneously identified many of the CBT elements that were meaningful to them such as intermediate beliefs, the ability to “redirect” thinking, and integrating activity management strategies such as pacing and task perseverance.

Fewer of these themes emerged from the education group, although group process factors similar to that identified in the CBT group were found.  Both groups identified that it was good to know they weren’t alone and that they learned from other members in the group.  Both groups also identified that they felt more confident and in control of their situation, that they could “rise above” their pain.

Where the groups also differed was in their engagement in preferred life activities (occupations).  Participants in the CBT group indicated that they were returning to preferred social activities, sports and leisure activities and that they believed they were able to persist with these despite an increase in pain.  This didn’t occur in participants involved in the education group.

What does this tell me?

Well, a couple of really important things.  While we don’t know which parts of the self management programmes do the hard work for people with chronic pain, it seems that a group approach has some unique benefits irrespective of the type of programme offered.  People with chronic pain often feel isolated and very alone, as if they are the only people with their specific problems.  A group approach provides an opportunity to normalise these experiences.

I also take the idea that information alone doesn’t necessarily initiate change – structured goals seem to help, setting an expectation that learning and engaging in activities between sessions may help, the feedback and problem-solving may help too.  It could also be the process of cognitive therapy – learning to identify thoughts and beliefs, and restructure these may be helpful.

We can’t, from this study at least, determine which of these ‘active ingredients’ is doing the trick.  I rather fancy that although the cognitive aspects certainly play a part, it could be these other aspects – setting expectations, supporting change, problem solving – these could actually be the parts that get people started on doing things differently in their own environment.

Is it time for a different take on self management? Maybe it’s time to embark on a less educational, more occupation-focused approach that incorporates cognitive restructuring in an active and “doing” way as part of problem solving – what do you think?

Day, M., Thorn, B., & Kapoor, S. (2011). A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education The Journal of Pain DOI: 10.1016/j.jpain.2011.02.354
Miles, C., Pincus, T., Carnes, D., Homer, K., Taylor, S., Bremner, S., Rahman, A., & Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs European Journal of Pain DOI: 10.1016/j.ejpain.2011.01.016

A brief review of cognitive behavioural approaches for pain management

Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems.  While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health.  In fact it has only been in the last few years that research into the process of change in pain management have been conducted.

What defines a cognitive behavioural approach?

• The assumption that people can learn to accept their chronic pain
• That people can broaden their self-concept beyond being “a patient” into being “a person with pain”
• That people can learn or re-explore skills to deal more effectively with their pain (Morley, Biggs & Shapiro)
• Managing or living well despite pain
• Pain behaviour that limits living well becomes the target
• CBT provides the skills to (ultimately) change behaviour
• Provided by any/all members of the interdisciplinary team (common treatment model)

What are the goals of this approach? (NB in no particular order!)

• To reduce pain intensity
• Increase functional activity, including work
• Reduce/rationalise use of health care
• Reduce distress
• Improve quality of life

One of the main aims of this approach is to ultimately help the person with pain become his or her own therapist – to effectively self manage pain.

How do we do this?

The exact combination of strategies and approaches that “do the trick” in this kind of approach is not yet known.  It could even be that the specific techniques that people learn may not, in themselves, be all that important.  Maybe it’s the emphasis throughout treatment that there is hope for a life even if pain is present that helps patients become people again.  Research simply doesn’t tell us this yet.

Certainly, in the years that I’ve been working in pain management, the core elements have changed little, with perhaps, the addition of graded exposure and the mirrorbox and laterality work for certain problems.

How do we begin with this approach?

• Assessing what the person with pain considers to be the main problem (the problem/s that pain “causes”, rather than pain alone)
• Asking why he or she is looking for help right now (what were the triggers? It could be the person, or someone else who has initiated the treatment-seeking)
• Identifying the changes he or she wants to see (how will the person know treatment has been successful?)
• Listing the behavioural difficulties the person is currently having

Some of the ways I do this are to ask the person “what would you be doing now if pain was less of a problem?”

There’s a reason I use that phrase “less of a problem”, because I pretty much don’t refer to pain intensity again.  Pain is likely to be present and to fluctuate throughout treatment and afterwards.  I want to model that it’s the fear of pain, rather than the pain itself that is most disabling.  Even when pain is intense, it’s more helpful to relax and go “with” the pain than be fearful and tense the body to resist it.

A first step is often to introduce a model of pain and how it affects the individual.  This is a personalised model of pain, individualised for this person – but based on what we currently know about pain from research.  Various explanations can be used, but I draw from what the person tells me about their experience of pain to generate their specific model.

Most times, it seems to help people to discuss a current neurobiological model of pain – and this is often where “Explain Pain” or similar descriptions can be really helpful.  Taken at a pace that people can manage, and using their own examples, helps people to quickly grasp information that many medical students only begin to learn in 3rd and 4th year of study.

How does this step help?

Cognitive behavioural theory suggests that people appraise or judge situations very quickly, on the basis of past learning, current arousal state, and future predictions.  Automatic thoughts then generate an emotional response.  This emotional response influences behaviour.  The relationships between these four factors can be bidirectional.

By giving people a more accurate and more realistic view of their pain – as something that can be understood (at least in part), and managed, and isn’t signalling harm – people can be far less distressed by it.  You can think of how your knowledge that a flu jab is a helpful way to prevent getting the flu and how this helps you cope with the sting of the needle, and compare it with how you would interpret and respond to being stuck with a dirty needle wielded by a hoodlum in a dark alley! The thoughts and beliefs we hold about sensations influence emotions and behaviour.

Eliciting an individual’s automatic thoughts about pain, and helping them recognise that the way they view their pain may be accurate-but-unhelpful, is one part of the cognitive behavioural approach to pain management that all members of the team need to reinforce.

The remainder of a cognitive behavioural approach to managing pain is focused on helping people engage with activities they value, and doing so in a way that (1) is manageable for now and (2) recognises the sensitive nervous system can be stirred up quickly by things other than physical activity.  Skills are developed to set goals, manage gradual increases, problem solve ways around obstacles, manage arousal levels, and work with thoughts and beliefs that become stirred up by doing things differently.

What about people who are really, really fearful of moving and avoid things? Take a look at that reference below – it’s a review of the approaches that have been used for people in this situation.  More on it very soon…

Bailey, K. M., Carleton, R., Vlaeyen, J. W., & Asmundson, G. J. (2010). Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review. Cognitive Behaviour Therapy, 39 (1) DOI: 10.1080/16506070902980711

Working inside the envelope – or pushing the boundaries

There is something very satisfying about reading a well-designed and beautifully written research paper. Not only can it produce some helpful answers (and usually pose multiple questions!), but the process that is followed means it’s pretty easy to see how the researchers arrive at their conclusions. This paper by White, Goldsmith, Johnson, Potts, Wolwyn, DeCesare, et al., is just one of those papers.

Why am I writing about research into four treatments for chronic fatigue syndrome?  Well, the treatment options used in this trial are exactly the same treatments used in chronic pain management (cognitive behavioural therapy, graded exercise therapy, adaptive pacing therapy and specialist medical care). And it poses the question: does ‘working inside the envelope’ of energy help people achieve better mood status and better functional status than challenging the assumption that ‘this is as good as it gets’?

On with the method.  This study examines four different treatments carried out in parallel, it’s an unblinded/masked randomised trial designed to establish the effectiveness of these treatments as well as the adverse events associated with each treatment, and reviews the outcomes up to one year after treatment ended.

Participants were carefully selected to meet the criteria for a diagnosis of chronic fatigue syndrome, and it’s interesting to see that only 28% of the people initially recruited actually met these criteria, and of this group, only 71% or 641 people actually progressed through to treatment.  Thankfully the CONSORT trial profile included in the paper shows very clearly who was ‘in’ and who was ‘out’ – and why!

Clinicians were carefully trained, supervised regularly, and treatments were monitored for adherence to the treatment type, the manual used, and that sufficient number of sessions were carried out.

A number of outcome measures were used – primary outcome measures of fatigue and the SF-36 physical subscale, with secondary outcome measures covering a range of variables including the ‘I think you look better’ clinical global impression scale, the six minute walk test, and the number of chronic fatigue symptoms remaining, along with a couple of others.

So what exactly were they testing in this study?

Adaptive pacing therapy is based on the idea that people with chronic fatigue have a limited amount of energy available, and that this is fairly static with limited potential for improvement.  People are asked to monitor their fatigue, and plan their days according to their energy levels, avoid ‘overdoing’ things, prioritise and therefore achieve what is important, and set the scene for natural recovery, if that occurs.  The strategies include looking at daily activities to identify links between activity and fatigue, becoming aware of ‘early warning signs’ of fatigue, regularly using rest and relaxation and generally attempting to ensure that no single activity exceeded ‘70% of the energy envelope’.  Participants could participate in more activities provided they felt they could and as long as their symptoms didn’t get worse.

Cognitive behavioural therapy is based on the idea that chronic fatigue is reversible, and that fear of activity (cognitions) and avoidance of activity (behaviours) influence physiology and perpetuate the problem.  By changing the appraisals of symptoms and introducing approach behaviour rather than avoidance within ‘behavioural experiments’, participants can test the usefulness of their beliefs and gradually, in a planned way, increase their activity level.  This is delivered within the context of identifying important activities and problem solving through obstacles that could get in the way of engaging in these activities.

Graded exercise therapy is based on the idea that people with chronic fatigue are, at least in part, deconditioned and intolerant of activity.  By gently extending the level of activity, participants can reverse the physiological changes that perpetuate chronic fatigue, and gradually return to participate in everyday activities.  Participants develop a baseline level of activity, then in planned increments of time rather than symptoms, start to increase the amount of time they spent in exercise.  Target heart rates and time exercising were set collaboratively, and most participants started with walking.

Specialist medical care consisted of education about chronic fatigue, prescription of symptom-alleviating medications (mainly for sleep, pain and mood), and general ‘self help’ advice.

What happened?

Well, surprisingly, both the specialist medical care and the adaptive pacing therapy achieved similar results across the outcome domains.  And both CBT and graded exercise therapy achieved similar results over the domains, with CBT improving mood slightly more than GET, and GET improving physical activity slightly more than CBT.  What was incredibly surprising is that both of these therapies were more effective than pacing and specialist medical advice.  And even more surprising was that the rate of adverse events was pretty similar – with CBT having the least number of events than those in adaptive pacing or graded exercise therapy.  None of these adverse events was considered, according to predetermined criteria, to be a ‘serious’ event, and adverse events generally were quite common.

How does this study finding apply to chronic pain management?

I think the underlying hypotheses of the treatments used in this study are pretty much the same as those used in chronic pain management.  The question is – do we help people ‘live within their limits’, or do we help people extend beyond those current restrictions and progress towards doing things they think they can’t?  It’s a question that some clinicians don’t even consider because the focus in chronic pain management has so often been on curing or fixing the pain.  And then there are clinicians like myself who want to help people live well despite still experiencing pain.

But in a large number of support groups, the whole idea of learning to do more seems invalidating.  To want to change from being seriously disabled to living pretty much normal lives means giving up some of the ‘being disabled’ identity.  It can mean no longer being given special consideration, or having the limitations of choosing what to do and when to do it acknowledged by others.

I’m not sure that I give enough time and attention to helping people mourn these losses as we try to push the boundaries.  At the same time as making space for mourning though, I want to give hope that life can be good, and better, than what is current.  Time to push the boundaries – but gently does it.

White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O’Dowd H, Wilks D, McCrone P, Chalder T, Sharpe M, & PACE trial management group (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet, 377 (9768), 823-36 PMID: 21334061

Moodjuice!

I had a nice email from James Hardie from Moodjuice website, an NHS Scotland site developed for both health professionals and individuals to access self help resources.

For patients, the site starts by saying “Emotional problems are often the mind and body’s way of saying that something needs to be changed in our life” – I like that!  I like the way the patient area is based on practical problems like housing, childcare, hobbies and interests, meeting people, relationships and so on.

For professionals, the feature that really appeals to me is the “build your own resource” area.  This enables you to put together the most relevant handouts for the person you’re seeing – a lovely feature! Then you can print the whole lot off, and it’s a pulled-together document that looks a far cry from some of the tatty photocopied things I’ve seen in the past.

The resources in the professional area is designed to be used alongside individualised sessions, so it’s not a “plug and play” kind of site – but it does provide a great range of tools that you can use.

My one tiny criticism? The site doesn’t clearly indicate who developed it – well, it does, but it’s buried in the menu’s right away from the front page. I’d like to see that information on the front page, along with the dates the material has last been updated (just a wee point).

Anyway, here are the pages for the Chronic Pain page

and the Problem Solving Information page

and the Challenging Thoughts page

Enjoy!

Occupational Therapy & the Cognitive Behavioural Approach For Pain Management – ii

In the first post on my commentary of Robinson, Kennedy and Harmon’s review of occupational therapy for chronic pain, I argued that they have misinterpreted the cognitive behavioural approach to pain management, and in particular, that they appear to hold an outmoded view of pain as either biological/organic or psychological, and refute the place of psychosocial models in occupational therapy practice.

Yesterday I distinguished between cognitive behavioural therapy and a cognitive behavioural approach – while the therapy is often primarily concerned with ‘talk’ therapy followed by behavioural changes to improve mood for example, a cognitive behavioural approach is a broader concept that is based upon the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.

In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Today I want to move into two points: how an interdisciplinary team works (with a specific focus on role blurring and duplication of input), and more on the way in which occupational therapists can use so-called ‘psychological’ approaches to help people engage more fully in their lives.  BTW I think maybe other disciplines can use some of this too.

Interdisciplinary and multidisciplinary are two words bandied about a lot when it comes to pain management.  Sometimes they’re used almost interchangeably – but when it comes down to it, there are important differences between the two.

In a multidisciplinary team, each team member retains an independent, usually discipline-specific, approach or model for working with the patient.  Although the team works concurrently with the person, and there may be common goals, multidisciplinary teams do not necessarily need to integrate their treatment, nor have a common over-arching treatment model or approach.  Some poorly coordinated multidisciplinary teams can actually provide serial ‘mono-therapy’ – just the same as seeing several separate clinicians one after the other.

Interdisciplinary teams work differently.  Firstly they hold a common model or understanding of the problem.  In pain management, this means the team accepts the tenets of a cognitive behavioural approach as I outlined in yesterday’s post.  Then the team works with the person/client/participant to develop a combined understanding of the person’s problems or situation, and collaborate to generate shared goals.  While a newly formed team may function somewhat like a multidisciplinary team in some respects, over time each clinician develops a shared understanding of each other’s contributions – and very often can function at a basic level within some of the domains of concern of each other’s discipline.  They continue to provide discipline-specific input, but always with a view to the overall model and the client’s goals.

For example, after 18 years, I have some knowledge of medications and their side effects, so it’s not surprising that I can talk with someone about when to take medications and what the side effects might be.  I might do this because I’m working with the person to help them get up and schedule their day, and help with a better sleep pattern.  It’s also no surprise that the physiotherapist and the clinical psychologist, nurse and social worker can be heard discussing activity management – even asking how the person is going to apply skills in daily activities!

This can at times be somewhat disturbing, especially to new clinicians.  They might ask “How can I be sure these other team members know what to do? What if they do it wrong? Why are they doing what I should be doing? What if things get left out?”

As I’ve learned, two things help to make interdisciplinary teams work well – really good induction and mentoring as the new clinician settles in, and time.  It’s during the latter that communication needs to be open and robust discussion about why various approaches are used, and who might be the best person to have the main focus on a goal.  Role contributions change over time too, as team membership changes.

Does working this way lead to duplication? Yes, to a certain degree.  Provided that team members are consistent in what they say, ensure no goals are omitted, and focus on the case formulation, I’m not so sure that duplication is always a bad thing.  Maybe it’s better described as being consistent, providing back-up to each other, and more importantly, allowing the patient/client choice about who to approach to talk about topics. Most times, in an individualised programme, teams seem to work best with a combination of clinicians who can address psychosocial aspects, functional/physical aspects, and help the person integrate what is learned into his or her life.

A proviso – team members need to be competent in the techniques they use, and they must ensure the goals they can contribute most effectively to are being addressed. As someone pointed out, an occupational therapist or physiotherapist who dabbles in ‘a bit of CBT’ on the side is not likely to be helpful if they then omit something like how to schedule or plan a day, or progress activity levels over time. At the same time, I keep on saying, when is there a better time to elicit automatic thoughts and beliefs than when engaging someone in activity? When better to discuss whether the thoughts are helpful, accurate or helping the person achieve what is important and valued in life? And carried out with competence, working with thoughts, beliefs, emotions and behaviours in this way is both effective and efficient.

Mainly for occupational therapists, I want to turn to how it’s possible to integrate so-called ‘psychological’ approaches into occupation.  Be warned now – this may be continued!

If occupational therapy is about helping people engage more fully in valued occupations, I’d argue that we need to use the most effective tools to do so.  In pain management, a cognitive behavioural approach has consistently been demonstrated as effective – and occupational therapists, while somewhat silent on the publishing front, have been involved in most of the major pain management programmes.

Occupational therapy is not a ‘talk’ therapy – it’s all about doing.  It involves identifying what is important or valued in a person’s life, and helping them engage in those occupations.  While part of this involves talking and planning and ‘educating’, the purpose and outcome is for the person to then be equipped to engage in those activities or occupations themselves.

During planning and ‘educating’, it’s common for the person to raise objections to doing things differently.  These objections are – yes really – automatic thoughts!  In other words, they’re cognitions or beliefs, or maybe even attitudes or rules about how the person thinks things ‘should’ be done.  Robinson, Kennedy and Harmon seem to construe this situation as one in which what the client believes should be accepted without question.  I argue that unless the belief supports the person engaging in occupation, it is a valid target for an occupational therapist to address. While the belief may be part of the person’s ‘lived experience’ to date, it’s amenable to revision and change so he or she can see themselves and their opportunities differently, and re-engage in what is important.

When using a problem-solving process to review how a person has managed a new set of occupations, or way of approaching an occupation, feedback and evaluation is a vital component. It’s at this point too that an occupational therapist can review how helpful thoughts and beliefs are – and help the person look at the situation (and beliefs) in the light of new evidence.  They can then be helped to generate new beliefs and change their behaviour (or engagement in occupation).

I’ve gone over the word limit again today, so yes, there will be more tomorrow on this important topic.  I hope it’s generating food for thought and that what I’m writing serves as encouragement for ‘non-psychologists’ to learn more about how to work with thoughts and beliefs as they work with people.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

“Pain Management. A Handbook of Psychological Treatment Approaches” (1986) edited by A. D. Holzman and D. C. Turk.Pergamon Press