Chronic pain

lining up

Things don’t always go smoothly


You know, making changes in life is never one of those beautiful uprising graphs like this:

progress It’s far more likely to be like this:

Untitled-1

There are days when life looks fantastic, then you hit a flat spot and it all goes pear-shaped.

While overall you’re definitely making progress, it doesn’t always feel like that especially during a set-back. And this is normal and predictable – but we nearly always fail to plan for it, so the set-back can pounce like a Tigger.

The thing is, though, that as clinicians we can forget this when we’re working with people living with pain. We’re so keen to see people make positive changes that we can forget just how hard it can be when change needs to happen right throughout the daily habits and lifestyle of the person. And so when someone begins to slow down in their pace of change, perhaps even fall back a bit, we can be somewhat unhelpful.

If set-backs are a normal part of making progress, why don’t we help people prepare for it? Forewarned is forearmed, or so they say (not sure who “they” is, but “they” are wise).

Preparing for set-backs

What constitutes a set-back? Different things for different people, I think. So for me, a set-back is a time when changes you’ve recently instituted get harder to do. The reasons changes might get harder could be because of a pain flare-up, or having less pain than usual. They could happen when life gets especially busy. Or the weather has turned colder (or hotter). Or because it’s holidays, or family members are unwell, or a new puppy gets added to the family. Set-backs can happen when anything disrupts the routine, and when the high of deciding to make a change begins to ebb.

Although set-backs are common, they don’t have to put people off their stride, but they DO need some planning. And it’s important NOT to use pain intensity as the guide to whether a person has handled a set-back well – remember that pain intensity can and does fluctuate for many, many reasons, and it’s not the pain that we’re as concerned about as the ability to handle it without losing track of making changes. Painful flare-ups can be a trigger for a set-back, but so can times when pain settles! In fact, in my experience it’s those times when things are going well, pain is settled and all seems to be ticking along when BAM! people forget to use the skills they’ve been developing and begin to head back down to the familiar but unhelpful ways of coping.

I think it’s really helpful to list all the various things that can get in the way of carrying on with changes.

Then it’s useful to list some ways to get around those factors – for example, if I know that cold weather is going to make it hard for me to get out of bed to go dancing first thing in the morning, I know I can programme the air conditioning so that the room is warm, I can lay my dance clothes out the night before (or practice in my PJ’s!), I can make sure my bedroom is warm in the morning, and I can set an alarm 5 minutes before my practice time to remind me. I can also have the music all ready to go in my player, and I’ve planned what I’m going to practice – in this way I’ve managed to work around the obstacles I know I will encounter. And I add to this by setting a ridiculously low amount that is my bottom line – five minutes! – and then I reward myself by eyeing myself in the mirror after my practice and saying “You’re a dancer!” And yes, I got this off the wonderful Nadira Jamal, Bellydance teacher extraordinaire.

setback planningWhen people do have a set-back, it’s still not too late to do something positive about it. In fact, I think there are two things to do.

1. Go through the factors leading up to the set-back. Identify all the opportunities where different choices could have been made. It’s the “seemingly innocent decisions” that gradually lead towards slipping up that really erode change.

So it might be that it’s been a really busy week, so I’ve thought that it’s OK to do half my exercises during the week, and because it’s been great to see a good friend, I’ve gone out with her rather than do my relaxation. And when I’ve been with the friend, we’ve gone to the pub and I had a drink or two. I’ve decided to get up and dance for a while. I’ve been enjoying myself and haven’t noticed the time. I have another drink and carry on dancing. My friend and I head home about midnight and I’ve got a busy day ahead tomorrow – ooops! I’m so sore I can’t move!

Does that sound familiar?

Where could I have made different choices? Sometimes it’s about avoiding a negative emotion, or about being in a positive mood and being carried away. Sometimes it’s because I might have been feeling a bit flat and down and so I’ve decided it’s OK not to do something – and ended up having to do things at the last minute. Whatever it is, it’s worthwhile taking some time to work back to the earliest point at which I could have made a different decision, and avoided wandering down the path of least resistance.

2. Use a “Can Cope” plan for dealing with the fallout once it’s happened. This is a short set of actions that are already written down before the inevitable happens, so people don’t have to do the thinking when they’re feeling least like it. I always start with “Stop. Breathe out. Breathe in. Breathe out. Breathe in. Say something nice to yourself”

The subsequent steps are designed to move from immediate and short-term actions to avoid a complete cr@p out – like doing a stretch or two, going to have a drink of water, taking a few minutes out to say something calming, maybe changing the task to something different for a few minutes, going to talk to someone (or phone them), maybe even taking lunch early. Longer term actions might include taking some medication (as a last resort), changing position, having the names of a few people to get support from, doing a relaxation, and so on.

The “Can Cope” plan can be written down on a small card about the size of a business card (they used to be called visiting cards). Then it can be kept in the wallet and pulled out when needed.

The thing with all of these approaches is that they need to be done BEFORE they’re needed. It’s incredibly hard to think straight when life has gone pear-shaped, so do the thinking before it happens. Make every action very specific – if the person is going to phone someone, list their name and phone number on the form. If they’re going to do some stretches, write them down. If it’s a coping statement, write it down!

And therapists, remember to let the person you’re working with come up with their own plans for how they might get around these things. Remember, people have incredible resourcefulness if WE just get out of the way and stop rescuing before it’s needed. I think the best way is to let the person know you have confidence in their ability to get through. Don’t step in to rescue – it doesn’t teach anyone anything, and it shows that really you don’t think the person is capable of managing by themselves. Unless you want to see a person and be their therapist forever, stand back and let it happen – then work with the person to analyse what went wrong and what they could do differently. Every set-back is a chance to learn!

 

Sunday alone time

Developing a shared plan


Last week I introduced you to one way I use to develop a shared understanding of the many factors influencing how and why a person seeks help for their pain.  The person and I work together to understand his or her perspective. I use a range of open-ended questions and reflective listening to guide our discovery of how his/her pain affects life and emotions.

Some points to note:

  • I don’t try to give explanations at this point – explanations will influence what the person says to me, and may inadvertently shape or change what he or she says without necessarily changing his or her beliefs.
  • I’m not trying to make any diagnoses either. A diagnosis is just a short-hand way of lumping a bunch of symptoms together. Great for research, and great for when we have a clear treatment, but a diagnosis tells us nothing about how the problem is affecting this person at this time. And in pain we’re always looking at the person and his or her experience, because even if we successfully get rid of the pain, the person will have learned something through the experience and this will influence the person in the future.
  • I’m informed by what we know about pain from research, so I’m constantly probing and looking for the relationships between factors we know will affect the person. Note that I’m not looking for tissue-level influences, but rather I’m investigating at a “person” level. This means I’m looking at psychological and sociological processes. I’m not ignoring those tissue-level factors, but I’m placing those off to one side for the moment. There are a couple of reasons for this: the first is that I’m probably not going to directly influence tissue-level factors. I don’t lay hands on people. I don’t give drugs. The second is that the person isn’t likely to be aware of those factors. They know much of their own experience (not all – but we’ll come to that), and experience and perception are the most potent drivers of what a person believes and therefore does.
  • I try wherever possible to flesh out my interview with additional information. This might be from questionnaires, or observing, or clinical notes from other people. And yes, I incorporate this information with the full knowledge of the person – in fact, they’re part of the process of integrating this information.

What do I end up with?

A spaghetti junction! A diagram that looks a lot like this:

formulationThis diagram is a pretty simple one, when you think of all the factors that could be involved – and in this case, I’ve made it much clearer than my usual scribble!

At this point I have a series of hypotheses to explain why Gerald is in this state. Together with Gerald, we’ve established that there could be some fear of pain, and in particular, fear that Gerald won’t be able to cope if his pain goes up and doesn’t settle. Gerald has also identified that he can feel helpless at these times, because he doesn’t know what else to do to manage his pain. He believes he’s getting unfit, and that’s adding to his feelings of frustration. He doesn’t want to go out with his mates because he’s irritable. He tries not to let his wife know how he’s feeling to protect her, but this adds to him feeling isolated. He doesn’t want to go back to work, not because he’s not motivated, but because he’s afraid he’ll let them down and this will add to his guilt. He doesn’t think his case manager understands this.

I could ask Gerald to list his main concerns and use these as a guide for my treatment outcomes, but I’ve recently started using a different approach. I’ll ask Gerald what he would be doing differently if his pain wasn’t such a problem to him.

Bronnie: Let’s imagine for a minute, what would you be doing differently if your pain wasn’t such a problem?

Gerald: Well, I’d be back at work, for one thing.

Bronnie: OK, and would you think you’d be back at work full time, or ease your way back in?

Gerald: Well, I think it would be sensible to ease myself back in because it’s been a while and I’m out of shape. Better to know I can do it than have a go and fail.

Bronnie: Great idea. What else would you be doing differently if your pain wasn’t such a problem?

Gerald: I’d take my wife out for dinner, it’s been hard on her while I’m so laid up and grumpy.

Bronnie: What’s your main concern about going out to dinner with your wife right now?

Gerald: I can’t sit long enough to enjoy a meal out. It all seems so hard, to get into a car, and drive to a restaurant, and sit there for three courses. I’m just too sore to do it.

Bronnie: So going to a restaurant and sitting to get there and while you’re there is going to increase your pain?

Gerald: Yeah. Is it worth it? What if it doesn’t settle? I can’t sleep and then the next day I’m shattered. I don’t think it’s worth it.

Bronnie: OK. Is there anything else you’d be doing if your pain wasn’t such a problem for you?

Gerald: I’d be going out and seeing my mates, going fishing and 4 wheel driving. I miss that. There’s no way I could do that right now.

Bronnie: What’s your main concern about going fishing, and seeing your mates at the moment?

Gerald: I’d be ready to go home before they’d even started. They’d get fed up with me slowing them down. And casting is really hard on my neck.

Bronnie: So to sum up then, it seems like there are some things you’d love to be doing, but reasons you think it would be better not to be doing them right now. If we go through them, you’d love to go back to work, but you’d like to do it gradually so you can get in shape again, and so you know you’ll succeed. You’d love to take your wife out for dinner, but the whole dinner thing feels too hard, and you’re worried that your pain will get out of hand and you won’t be able to sleep. And you’d really love to get back out with your mates again, and go fishing, but right now you think your mates would get fed up with you because you’d want to leave too early, and you wouldn’t be able to cast without setting your pain off. Does that sound about right?

Gerald: Yeah.

Bronnie: I think there are some things we could begin to work on so you feel more confident you can handle it when your pain levels go up and down. And I think we could work on some physical things that could help you feel a bit fitter, more able to do things for longer. And finally, I think it would be great if we could help you and your wife connect a bit more, perhaps not yet at a sit-down restaurant, but perhaps there are other ways this could happen. What are your thoughts? Is there anything you’d especially like to look at?

What I’ve tried to do here is identify the underlying reasons Gerald isn’t doing things. While pain appears to be the problem, it’s not the pain it self but the fear of possible effects of pain that haven’t even happened yet that are really stopping him from doing things. And this is adding to the misery of having neck pain.

By giving Gerald the chance to tell me his dreams, we’re going beyond “I need to get rid of my pain” and into the reasons for living in the first place. People don’t just live to get rid of pain, they live to have lives full of meaning, let’s not ever forget that.

kayaks

After your assessment – then what?


Pain management is replete with assessment measures. There is even a handbook dedicated to pain assessment. I’m sure that every clinician has their favourite assessment tools and process. But there seems to be a gap in terms of how to use the findings from all this assessment: how to put it all together to make some sort of sense.

Chronic pain and disability is a multifactorial problem. There are contributions from biological processes, from psychological mechanisms, and from the social environments in which we live. I think only die-hard types would argue that thinking about pain from a purely biological perspective in any but the most simple presentations makes any sense at all. But how do you put the information together to arrive at a reasonable set of hypotheses about what is going on? I think it helps to have some sort of framework, because this simplifies the way information can be presented. I also think it’s useful to work from the patient’s perspective first, before integrating any contributing factors that don’t feature in the patient’s narrative.

I usually sit down with a large piece of paper or a whiteboard, and a pen, and begin assembling a kind of story.

Bronnie: “You’ve said that it’s hard to know when your pain is going to bother you, and you’re not sure how to make sense of it. Let’s see what we do know already. Tell me your theory of why your pain is still going on.”

Gerald: “Okay… Well one doctor said it was because I’d had a car accident and I’d strained my neck muscles when I got shunted from behind. I know I started to get sore the day after that accident.”

Bronnie: “Let’s put down “got shunted from behind – neck strain”.

smashGerald: “Yep, that’s how it happened.”

Bronnie: “And has anyone else given you an explanation that makes sense?”

Gerald: “Well, this one guy said that because my head got knocked around I might have had a concussion, and that might be why I have these headaches.”

Bronnie: “Does that make sense to you? Should I put that down?”

Gerald: “Yes, put that down, because I’ve had headaches ever since, and I know I really got a shake-up.”

Bronnie: “So, we have a shunt from behind, and a concussion. Is there anything else to explain why you’ve been having such trouble?”

Gerald: “Well one doctor said I was, what did he call it, kinesiophobic. That means I’m afraid to move. Well of course I’m afraid to move – it hurts! But it’s not like I’m a mental case.”

Bronnie: “What do you think he meant by that term?”

Gerald: “I think it was a way he could say that it wasn’t his fault I wasn’t getting any better. That I need to pull myself together and start doing things.”

Bronnie: “What would you like me to put down on this diagram then? What do you think, are you afraid to move?”

Gerald: “Yes, I don’t want to hurt, so I don’t move. Every time I do move, I get a headache and feel awful.”

Bronnie: “I’ll add that in, then. It makes sense that if you hurt when you move, you stop moving. What we call it doesn’t really matter.”

Untitled-1Bronnie: “What’s it been like for you, not moving very much? How do you feel in yourself?”

Gerald: “It’s horrible. My life has closed in on me, and I’m not doing very much at all. I feel pretty down some days, but mostly I feel frustrated.”

Bronnie: “We could say then that being afraid to move has meant you’ve stopped doing a lot of things. And as a result you’re feeling down and frustrated.”

Gerald: “You can say that again.”

Bronnie: “And what about the people around you? What’s it been like at home?”

Gerald: “The kids couldn’t care less. They’re just grumpy because I’m not taking them to places like a taxi driver. I’m not driving because I really don’t want to get back into that car, even though it’s been fixed.”

Bronnie: “And what about your partner? How are things with her?”

Gerald: “I think she’s really concerned about me, but doesn’t know what to do. Sometimes I know she’s really angry with me, like it was my fault I got hit, other times she’s really supportive, and wants me to get some treatment to fix it so I can get back to normal again.”

familyBronnie: “And what’s been happening with work?”

Gerald: “Well, I can’t go back yet because I don’t want to drive. And I keep getting these headaches, so I don’t think I could even think about going back. My boss, he’s been ringing me to see if there’s anything he can do – he’s a good sort, and I want to go back, but what can I do when I’m like this?”

Bronnie: “And how are you doing for income at the moment?”

Gerald: “I’m on compensation, but my case manager keeps pressuring me to go back to work. She doesn’t seem to realise that I can’t do anything, I’d just be a liability. I think she needs to stop hassling me until I’ve got things sorted out a bit more. If only I could get rid of these headaches, and move my neck a bit more, but I can’t even look down to pick things up even if I could carry them.”

fomrulationBronnie: “To sum up, it looks to me like right now you’re feeling pretty stuck. There are lots of different explanations for your headaches and neck pain, but no matter what we call it, you’ve stopped doing things and as a result you’re feeling fed up and down. And your family aren’t really helping though they’re doing their best. Your employer is keeping in touch and that’s great but you don’t think you’re reliable enough to go back to work, even though your case manager keeps pushing for you to try. How does that sound?”

Gerald: “Pretty right to me.”

At this point, Gerald and I have developed rapport, and a shared understanding of his perspective on his pain. You’ll note that I haven’t started “educating” him, or trying to change his understanding. I haven’t done this because I want to be certain I’ve started to understand where he’s coming from. People don’t develop weird beliefs for no reason – these beliefs usually begin from a misunderstanding, or perhaps faulty logic that hasn’t accounted for some of the factors, and they usually make sense once you take the time to listen to the person.

I will also often add some questions about treatments he’s tried, and what he’s learned from them. I’ll usually ask about his family and colleagues beliefs about pain and what he should or shouldn’t be doing. I’ll ask about other times he’s had pain and what he’s done to recover, and what he might have learned about his resourcefulness and coping from these times (or his vulnerabilities and challenges).

I will usually then ask him what his main concern is, and what he thinks the “next best step” might be. The answers to these questions will often help guide the first therapeutic steps we take. I also incorporate his responses to a set of questionnaires I usually administer before seeing him. These include the Pain Catastrophising Scale, Chronic Pain Acceptance Questionnaire, Chronic Pain Coping Inventory, and Pain Anxiety Symptoms Scale, plus a measure of general function or disability such as the Pain Disability Index, or the Multidimensional Pain Inventory. By reflecting on the findings from these questionnaires, together we can factor those aspects of his understanding into the formulation diagram.

If I’m working within a team, I like to bring the team into the formulation process – but not until after the client/patient and I have developed our understanding first. This makes it much easier to generate a collaborative approach to learning about the many factors influencing the person’s presentation.

I’ll continue with this formulation in next week’s post….

A couple of good readings:

Asmundson, Gordon J., & Hadjistavropolous, Heather D. (2006). Addressing Shared Vulnerability for Comorbid PTSD and Chronic Pain: A Cognitive-Behavioral Perspective. Cognitive and Behavioral Practice, 13(1), 8-16.

Thompson, B. (2012). Abductive reasoning and case formulation in complex cases. In L. Robertson (Ed.), Clinical Reasoning in Occupational Therapy: Controversies in practice (1st ed., pp. 15-30). Oxford: Wiley-Blackwell.

Tompkins, Michael A. (1999). Using a case formulation to manage treatment nonresponse. Journal of Cognitive Psychotherapy, 13(4), 317-330.

Vertue, F.M., & Haig, B. D. (2008). An abductive perspective on clinical reasoning and case formulation. Journal of Clinical Psychology, 64(9), 1046 – 1068. doi: http://dx.doi.org/10.1002/jclp.20504

don't come around no more

On pain…and suffering


Two words that often go together: Pain, Suffering.  Pain we can define according to the IASP definition –

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Read the note below as well).

Suffering? What is that?

My favourite definition comes from Eric Cassell (Emeritus Professor at Cornell University). He makes the point that bodies don’t suffer, only people do, saying that “in all the situations in which suffering comes about the meaning of the occurrence to the person and the person’s perception of the future are crucial” (Cassell, 2011). The point he makes is that while bodies may have nociception, and neuroendocrine responses to emotional stimuli, bodies do not have a sense of the future, and bodies don’t know meanings, only people do.  Illness doesn’t come from disease, it comes from a process that “unfolds over time” as the sickness and how it is lived show the individual character of the person who has them.

So, then, what is suffering? It is the response to a threat to self-integrity.  This means the way we suffer is always personal to what matters most to us.

Cassell’s paper outlines why some of our healthcare efforts result in more suffering than less. He argues that health professionals want to alleviate suffering, but need some sort of measurement tool to detail whether their efforts have met with success. But being better, or worse, is “ultimately defined by the patients themselves”, and when sickness is defined, it should reflect what it means to be well in the patient’s terms (Cassell, 2011, p. 12).

Now here’s where it gets interesting. Because health professionals make assumptions about what it is that is causing the suffering in their patients. And in many cases, the assumption in pain management is that it’s the pain that is causing the suffering. If that were the case, people with low levels of pain wouldn’t seek help, and people with extreme pain would be seeking treatment. Is that the case? Well, not exactly, actually. People seek treatment because their pain is beginning to interfere with what they want to do (Ferriera, Machado, Latimer, Maher, Ferriera & Smeets, 2010). It’s the meaning of the pain that drives people to look for help. So, we have people with arm pain they’ve had for months, but they seek treatment only when there is a change at work because now they can’t keep up.  People with low back pain who only look for help because it’s winter now and they can’t stand on the rugby field to watch their son playing.

The problem with assuming that having pain is equal to suffering is that there is an expectation that treating the pain intensity will automatically alleviate the suffering.

Let’s think about that for a moment: Jonathan has just had his first episode of angina. He came into hospital for it to be checked out, and has been given a clean bill of health but given tablets to take if the pain returns. He’s advised “this is a bit of a warning”, and told to go on his way but perhaps lose a little weight and do some more exercise. Jonathan hears “next time you have this it could be the Big One”, and because his pain occurs when he’s doing exercise, he doesn’t exercise very often. He takes his angina pills as soon as he begins to feel a little tightness in his chest. And he seems to be having this quite often, especially when he starts thinking about how he nearly had a heart attack. He has no pain – but he is suffering.

Or another example: Frances has had a series of blocks to locate the source of her pain in her lower back. They’ve found it, but the results of the radiofrequency neurotomy are not as good as the blocks were. She has a lot less pain, but she’s afraid that if she moves too much, she might do more damage to her back and this will bring her pain on, so she’s playing it safe and hasn’t returned to her netball. She misses the social atmosphere of netball and, to be honest, she’s feeling down in the dumps, and because she’s not exercising she’s gaining weight. She’s suffering although her pain has been reduced.

I’ll conclude with these thoughts from Cassell (2011). I think this paragraph is profound -

A human being in all its facets interacts simultaneously outwardly into the world and with others, as well as inwardly in emotions, thoughts, and the body, and these are generally consistent and harmoniously accordant. By contrast, suffering variously destroys the coherence, cohesiveness, and consistency of the whole. The person’s experience of this is of no longer being in accord and “whole,” but rather of “being in pieces,” of not being able to “hold themselves together.” It is in this sense that suffering threatens or destroys the integrity or intactness of the person.

He points out that some practitioners think almost two kinds of knowledge exist: medical science about the body and disease, and knowledge of the person. And that these only join together at the bedside.  He says “The problem is not two kinds of knowledge in medicine, the problem is that the goals of practice are almost universally divided – treat the disease and care of the patient focusing on the personal asepcts of the illness – as though these were two separate elements to be brought together. That is not correct. There is only one goal: the well-being of the whole person who is the patient.

And this is The Most Important Thing Ever:

The key to relief of suffering is a focus on function. What do patients have when they have a sense of well-being? They believe they can accomplish their purposes and goals. Put another way, they can do the things they need and want to do to live their lives the way they want to (Cassell, 2011, p. 16).

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause. [italics my own]

Cassell, Eric J. (2011). Suffering, whole person care, and the goals of medicine. In T. A. E. Hutchinson (Ed.), Whole person care: A new paradigm for the 21st century (pp. 9-22). New York, NY: Springer. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=psyc7&AN=2011-24010-002. doi: 10.1007/978-1-4419-9440-0

Ferreira, Manuela L., Machado, Gustavo, Latimer, Jane, Maher, Christopher, Ferreira, Paulo H., & Smeets, Rob J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. doi: http://dx.doi.org/10.1016/j.ejpain.2009.11.005

Rivermouth

Patterns of pain after total knee joint replacement


My orthopaedic colleagues are concerned about how they choose patients who will benefit from surgery, rather than ending up with poor outcomes. It’s interesting to know that knee replacement surgery is revised mostly because of pain rather than infection, dislocation or other surgical problems. Naturally, my colleagues would like to find an easy way to pick who is going to develop chronic post-surgical pain because it would avoid a lot of bother and repeated surgeries.

Pagé, Katz, and colleagues (2015) conducted this study which was nested within a study looking at postoperative gabapentin as a way to reduce the risk of postsurgical pain. People were studied for up to 12 months, which is a good length of time for outcome studies.  They then performed a complex statistical analysis called Growth Mixture Modeling, which is “a longitudinal analysis methodology in which a latent membership to discrete trajectories is estimated” (p. 462), which uses data drawn from baseline and each data point thereafter to generate groupings of individuals based on patterns identified in the data. I’m not sufficiently comfortable with my ability to describe the statistics so I’ll refer you to the article itself, but suffice to say, the researchers were able to identify four groups, and range of movement at the knee joint between the groups was no different – so it’s not the surgery that makes the difference, but “something else”.

They found four groups: (1) People with high baseline pain, but which decreased quickly after surgery, then decreased again at 12 months after surgery. This is the kind of outcome orthopaedic surgeons and patients want to see!

(2) People with low baseline pain that continued to reduce over time. Again, a group the orthopods like.

(3) People with high baseline pain but gradually reducing over time, higher immediately post-surgery than groups (1) or (2), but generally a good outcome for everyone involved. Possibly a group that needs a bit more TLC immediately after surgery than groups (1) and (2).

(4) People with moderate levels of pain before surgery and also after, but the pain not changing much even 12 months later. Not the kind of outcome that surgeons, or people having surgery want!

What factors were associated with this not-so-good outcome?

The first thing to note is that there was no difference in terms of age or gender – and this is unusual because often it is women and older women at that who have more difficulty recovering from knee replacement surgery.  People in group (4) were slower to move in presurgical functional tests, had greater anxiety (as measured on the Hospital Anxiety and Depression Scale), and had higher scores on the Pain Disability Index.

The authors consider that patients in group (4) had similar levels of acute postoperative pain to the other groups, but didn’t report any change in their score from before surgery to the first two measurement points at 4 days and 6 weeks postop. In fact, this group of people had the same level of pain intensity or thereabouts for the next 12 months. They suggest that treatments for this group of people should be given at this 4 days to six weeks stage to try to minimise their transfer from acute postop pain to chronic postsurgical pain, and they suggest these should target “prehabilitation” and “total-body physical conditioning”.

I have some questions that still remain unanswered:

  • Why did this group of people have the same level of pain intensity as the other groups, but lower functional abilities before surgery?
  • Could general anxiety as measured by the HADS and either health anxiety or catastrophising be associated (probably yes)?
  • If a person is generally anxious, does this mean he or she is more likely to be cautious while mobilising? is this group of people at greater risk of falling/doing less/participating less in rehabilitation postop (probably yes)?
  • Why did the study authors not include pain catastrophising as a measure? Would they have changed their recommendations for prehabilitation if they’d included it as a predictor?

It’s that last question that I’m interested in – pain catastrophising is associated with poorer outcomes in many different domains including orthopaedic trauma , orthopaedic surgery (Edwards, Haythornthwaite, Smith, Klick & Katz, 2009; Forsythe, Dunbar, Hennigar, Sullivan & Gross, 2008 Homes, Williamson, Hogg, Arnold & O’Donnell, 2013 Witvrouw, Pattyn, Almqvist, Crombez, Accoe et al 2009); and pain coping (Keefe, Shelby, Somers, 2010; Campbell & Edwards, 2009.

Treating people who have high levels of pain catastrophising isn’t easy but there are a number of options that might be useful. Amongst these are pain neurobiology “education” (Therapeutic Neuroscience Education or TNE) (Louw, Diener, Butler & Puentedura, 2013), mindfulness as a strategy for dealing with anxiety and pain , graded exposure to movement using a phobia paradigm rather than a graded activity one (ie addressing the thinking rather than simply physical fitness), providing people with enhanced postop recovery pathways using a combined psychological and physical rehabilitation approach.

My concern is that by ignoring the information we have about catastrophising, and focusing instead on the reduced function alone without considering why this group are less confident and move with more difficulty, one of the relevant issues won’t be addressed. While it’s easier to just use physiotherapy and exercise to mitigate disability, it doesn’t address the underlying anxiety or catastrophising that influences the amount of attention paid to pain, the meaning pain holds for people who catastrophise, and it doesn’t teach skills to deal effectively with the anxiety or catastrophising. Unless the physiotherapists carrying out exercise programmes are well-versed in psychological approaches to reduce catastrophising, I fear this recommendation may not be as helpful as it could.

 

Brander VA, Stulberg SD, Adams AD, Harden RN, Bruehl S, Stanos SP, Houle T. (2003) Predicting total knee replacement pain: a prospective, observational study. Clinical Orthopedic and Related Research, 416:27–36.

Campbell, C. M., & Edwards, R. R. (2009). Mind-body interactions in pain: the neurophysiology of anxious and catastrophic pain-related thoughts. Translational Research: The Journal Of Laboratory and Clinical Medicine, 153(3), 97-101.

Edwards, R. R., Haythornthwaite, J. A., Smith, M. T., Klick, B., & Katz, J. N. (2009). Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Research & Management, 14(4), 307-311.

Forsythe, M. E., Dunbar, M. J., Hennigar, A. W., Sullivan, M. J., & Gross, M. (2008). Prospective relation between catastrophizing and residual pain following knee arthroplasty: two-year follow-up. Pain Research & Management, 13(4), 335-341.

Holmes, Alex, Williamson, Owen, Hogg, Malcolm, Arnold, Carolyn, & O’Donnell, Meagan L. (2013). Determinants of Chronic Pain 3 Years after Moderate or Serious Injury. Pain Medicine, 14(3), 336-344. doi: 10.1111/pme.12034

Keefe, Francis J., Shelby, Rebecca A., & Somers, Tamara J. (2010). Catastrophizing and pain coping: Moving forward. Pain, 149(2), 165-166. doi: http://dx.doi.org/10.1016/j.pain.2010.02.030

Louw, Adriaan, Diener, Ina, Butler, David S, & Puentedura, Emilio J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy theory and practice, 29(3), 175-194.

Pagé, M., Katz, J., Romero Escobar, E., Lutzky-Cohen, N., Curtis, K., Fuss, S., & Clarke, H. (2015). Distinguishing problematic from nonproblematic postsurgical pain PAIN, 156 (3), 460-468 DOI: 10.1097/01.j.pain.0000460327.10515.2d

Witvrouw, E., Pattyn, E., Almqvist, K. F., Crombez, G., Accoe, C., Cambier, D., . . . Witvrouw, Erik. (2009). Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study. Knee Surgery, Sports Traumatology, Arthroscopy, 17(10), 1189-1194. doi: dx.doi.org/10.1007/s00167-009-0817-x

DSC_7885

Who are you? The effect of pain on self


My client, let’s call him Al, is a plumber. Or was a plumber. He sees himself as a hard-working, reliable guy who takes pride in doing a job once, doing it well, and not stopping until the job is finished. He’s worked for most of his adult life in his own plumbing business, something he’s very proud of. He’s supported his partner while she’s been at home caring for their two now adolescent boys. In his spare time he goes fishing, loves the outdoors and likes to wander the hills whenever he can.

Al isn’t very happy. He’s been told that his back pain, which he’s had for six months now, is not likely to go away. He’s been having treatments from physiotherapy, had a return to work programme developed by an occupational therapist, tried medications and injections but nothing has taken his pain away. He’s slowly stopped seeing his mates, isn’t sleeping well, hasn’t been out fishing in months, and he’s even had trouble keeping from shouting at his boys.

Al doesn’t sound all that different from many of the men I’ve seen in pain management. Some people call him “unmotivated” because he’s stopped thinking about goals for the future, and does his exercises in a half-hearted sort of way. He doesn’t always attend his appointments. It’s hard to know whether he’s actually doing his home exercise programme. A far cry from the “hard-working, reliable” man who runs his own business.

What’s going on? We could say he’s depressed, and maybe he is. But more importantly, why is he depressed? He doesn’t describe his pain as anything more than a 5/10 where 10 is the most extreme pain he can imagine. He’s still getting an income from his worker’s compensation, he’s still in a loving relationship and in their own home. But he’s not a happy man.

We’ve all met an Al, I’m sure. Superficially he looks fine, but a throwaway comment nails it: “I’m just not myself any more, I want things to be normal”.

Self-concept

All of us have an idea of who we are. A self-concept is a set of representations about who we are, what we do, how we do it, and why we do it. We all have several self-concepts – the “actual” self, the “ideal” self (who we would like to be), the “ought” self (the person others think we should be), the “feared” self (the person we really don’t want to be) and so on (Higgins, 1999; Markus & Nurius, 1986). Our sense of self is based on a collection of memories, a pattern of behaviours that we’ve developed and continue to develop as we aim to be the person we want to be.  Our sense of self guides our choices and the way we do things.

What happens when we can’t do things the way we think we “should”, or the way our sense of self would guide us to? Let’s think about this for a minute.

Al is used to getting up early in the morning, usually about 6.00, so he can get out to the site he’s working on that day and begin work by about 7.30. He prides himself on being at work, ready to go, before his apprentice gets there. He’s always organised, got his gear ready and in the truck with a cup of tea all sorted so he can plan his day.

Since he developed his back pain, Al’s had trouble getting out of bed before 8.00. He’s always tired. He’s not sleeping. He’s the last one in the house to get up, and he can’t even get to the work site until 9.00 because his body is sore and he can’t seem to wake up. He’s getting picked up by his apprentice who keeps giving him grief over not having his gear ready in time. He’s not the man he used to be, in fact, he’s become the man he swore he’d never be, a compensation bludger. He doesn’t like who he’s become. He feels lazy and useless.

Achieving self-coherence by re-occupying self

One of the neglected aspects of pain management is how to help someone deal with the changes to his or her sense of self. Life becomes chaotic when assumptions we make about the world no longer apply. The main concern of someone who is learning to deal with chronic pain is how to make life and self make sense again, to regain some coherence.  When they successfully solve this problem, it’s like all the various aspects of “self” have been reassembled. This is usually a new “self”, one that incorporates pain and the things that need to be done to accommodate pain while still expressing important aspects of “who” he or she is.

The process of learning to live comfortably with a new self is, I believe, a process of re-occupying self. Making a new self that feels recognisably “me”, doing the things that make “me” feel like myself, including some of “my” usual standards and attitudes and interests.

Yet what do we so often do when we doing pain management? We tell people like Al to “relax” and “pace” (Al learned as a child that you don’t stop until the job is done). We tell him he needs to move in certain ways (as a plumber? under buildings, in roof cavities, hauling gear out of the truck, carrying it over building sites). We suggest he needs to not do some things (work for the whole day without a break), but ask him to do other things (carry out a set of exercises three times a day). We say he needs to be back at work, but he doesn’t feel he’s pulling his weight.

What can we do?

I think we need to take some time to understand Al and what’s important to him. Not just the occupations (activities) but also the way he does them, and why he does them. How do they contribute to his sense of self? And then we need to work with him to give himself “permission” to do things differently – for a while. It’s like putting on a temporary “self”, a “rehabilitation” self. We can revisit this “rehabilitation” self as time goes on, and help him identify important values and occupations so he can begin to feel more like himself. Perhaps help him develop a new self that lets go of the old “normal” but includes some of the most important values expressed differently. I call this flexibly persisting – as Antony Robbins says, “staying committed to your decisions, but staying flexible in your approach”.

BTW – if you’d like to help me share this concept, you can! The idea of re-occupying self emerged from my PhD studies, and I want to present this at the Pain Science in Motion Colloquium in Brussels at the end of March. If you’d like to help me raise the airfare to get there (and back!), go to Give a Little and my page “Live well with pain”. Every little bit counts! I’ve had some wonderful people help me get almost half the money I need – will you help me get the rest? Thank you!!

 

Beekman, Claire E., Axtell, Lois, Noland, Kathy S., & West, Jaime Y. (1985). Self-concept: An outcome of a program for spinal pain. Pain, 22(1), 59-66. doi: http://dx.doi.org/10.1016/0304-3959%2885%2990148-4

Charmaz, K. (2002). The self as habit: The reconstruction of self in chronic illness. Occupational Therapy Journal of Research, 22(Suppl1), 31S-41S. doi: dx.doi.org/10.1177/15394492020220S105

Hellstrom, Christina. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology & Health, 16(1), 111-124. doi: http://dx.doi.org/10.1080/08870440108405493

Higgins, E. Tory. (1999). Self-discrepency: A theory relating self and affect The self in social psychology (pp. 150-181). New York, NY: Psychology Press; US.

Markus, Hazel, & Nurius, Paula. (1986). Possible Selves. American Psychologist, 41(9), 954-969. doi: dx.doi.org/10.1037//0003-066X.41.9.954

biopicBFT

Will you help me get to Brussels?


One of the most important aspects of research is getting the information out where it can be used. One of the ways to do this is by attending conferences – and the one I’m hoping to go to is in Brussels, Belgium, and is specially set up for new PhD researchers interested in pain research. It’s designed to give plenty of opportunity for researchers to meet other researchers, get to ask and answer questions, and learn ways of making a real impact on people’s lives.
There’s only one problem, and that is, as ever, money.
Frankly, I need some help to raise funds to pay for the flights to and from New Zealand and Brussels.
I’ve set up a “Give a little” page where, if you think I’m doing the right thing in pain research, you can donate.
This is the link to Live Well with Pain

It’s a site set up so people can ask for help and others can help. I like it. There are heaps of pages and causes and reasons people need money.

My reasons are simple. I’ve been working part-time for the last couple of years while I’ve been completing my PhD. I didn’t have a scholarship because I’ve always worked, and I love my teaching job (I work at the University of Otago, Christchurch, teaching postgraduate pain papers)

I haven’t been eligible for funding to travel to the Pain in Motion Colloquium from my University because, now that I’ve completed my PhD, I’m not able to access funding available for postgraduate students.

I’m looking for $4000 to pay for airfares and accommodation in Brussels. The conference is at the end of March, and I need to buy tickets by the end of February.

I think I’ve found out some interesting things as a result of my PhD. I’ve listened to people living with pain tell their stories of success. I think health professionals can learn from this research, and I really want to be able to share my findings, and learn from some of the best researchers in the world. I’ve been committed to blogging about research because I think findings need to get out from behind journal covers and into the world of practitioners.

I promise to keep telling you about research findings, and to keep you updated on pain research – and I’d be really grateful if you’d consider giving even just a little.

 

abandoned interior

How to spend money you don’t need to


I’m a shopper. I love to shop with a pocket full of money and buy lovely new things! I don’t even need to spend the money – just knowing I have it there to spend is enough to send me into raptures. Now one thing I have never heard in healthcare is that there’s plenty of money. Not once. I can’t recall a time when I’ve heard “Oh let’s just go and spend”. Instead I hear a lot about “Lean thinking”, and “efficiencies”, and “cost saving” – and “No, we can’t do that because it needs an up-front investment and the payback won’t be for years”.

What if I could show where there are hundreds of thousands of dollars going to waste that are also contributing to poor health outcomes and increased risk of complication?

Well, as it happens, I have just such a case. It’s when a person goes to the Emergency Department during a bout of back pain.

A group of researchers (Schlemmer, Mitchiner, Brown & Wasilevich, in press) examined the records of people attending ED for low back pain over the course of one year, from 2011 – 2012. They looked at the indications for receiving imaging for the preceding 12 months. Over 14,838 events were recorded – and of this group, 51% had no indications for imaging. This group attended ED less often, had fewer hospital stays, had lower rates of healthcare visits and had fewer appointments with specialists. BUT among this group 30% had imaging, 26% had advanced imaging (eg CT or MRI).

Overall, nearly 30% of people presenting to ED with low back pain are likely to have an Xray, and 10% will go on to have advanced imaging.

What this means is that there are a group of people who really don’t need to have imaging, according to our best evidence, but end up having it. We know that most people with back pain are not going to benefit from having X-ray, CT or MRI because these images either don’t show anything useful (no image shows pain) or show something irrelevant that might look interesting but is actually unrelated to back pain. We know this, and there have been numerous treatment guidelines and algorithms and education indicating not to give imaging for low back pain without neurological changes.

Yet this paper shows very clearly that this practice is still going on.

The authors point out why changing practice is important: unnecessary imaging increases exposure to radiation, increases the risk of getting surgery (that’s not likely to change the low back pain outcome), and costs a lot – in this case, the authors suggest $600,000 could be saved in the two years in which this study was conducted. That’s a lot of money – it might even pay for a clinician or two!

I’m interested in why this happens.

ED is a busy place. It’s set up for people to be seen urgently, where the focus is on saving lives, where every minute counts. It’s not the place for people with chronic problems, complex problems (particularly complex psychosocial problems), and it’s not the place for taking time to consider the long term implications of any action. People working in ED care enormously about their work, know they’re making a difference – but find it very difficult to deal with the complex chronic health problems of those with chronic pain. Particularly those with chronic pain and associated mental health problems.

It’s not the place to see people with chronic pain. And yet, within the top 100 “frequent attenders” to ED, most will have a mental health problem, and most will have chronic pain.

To me this suggests there are a lot of people in the community who have unmanaged chronic pain. Or poorly managed chronic pain.

It’s not that people shouldn’t get treatment – but it’s the “better, sooner, more convenient” and the “right person, right treatment, right time” that needs to be addressed.

Let’s say we employed four specialist clinicians to work in ED to help people with chronic pain. Four clinicians at roughly $80,000.  That’s $320,000.

If every person with chronic pain flare-up was seen by a clinician, connected with appropriate chronic pain services, and a management plan developed to help that person stay at home instead of venturing into ED, I volunteer that there’d be a saving. Not only a financial saving, but an emotional one – and not just for the person attending ED! But for the staff working there, the ambulance staff assisting, the family members of the person, and his or her primary care team.

Why doesn’t this happen? Well I think it’s mainly because chronic pain isn’t often given as a primary diagnosis, and certainly isn’t recorded on ED admission forms. That makes it invisible. The costs of admissions for chronic pain are therefore hidden. Chronic pain doesn’t get much airtime, and it’s not sexy. Making a change to how ED manages people with chronic pain requires an upfront investment – and every other area in health is crying out for money, usually much more loudly than chronic pain! And there’s the issue of relative power – a medical solution to chronic pain doesn’t exist, it’s mainly managed by allied health. We’re not a vocal group, we have limited political clout, and we’re poorly represented within healthcare management.  Chronic pain management also requires a team, and a team working in a way that is quite different from most teams because it’s interdisciplinary rather than multidisciplinary. Chronic pain management takes time. Results/outcomes are quite small.

But when we’re being exhorted to save money in health, I can’t see why changing practice around unnecessary imaging can’t be an effective first step.

http://www.choosingwisely.org/doctor-patient-lists/imaging-tests-for-lower-back-pain/

Schlemmer, E., Mitchiner, J., Brown, M., & Wasilevich, E. (2014). Imaging during low back pain ED visits: a claims-based descriptive analysis The American Journal of Emergency Medicine DOI: 10.1016/j.ajem.2014.12.060

into the red sunset

What’s in a name? Why getting a diagnosis of chronic pain is important


Sticks and stones my break my bones, but words will never harm me – yeah right! Words have power when we’re looking for treatment, or we’re giving treatments for pain. I’ve written about the staying power of language used to describe back pain here.

But let’s look at a more distinct problem: diagnoses.

Diagnoses are, in the words of Annemarie Jutel, “the classification tools of medicine…” Sociologically, they segment and order bodily states, indicating what is and isn’t normal. “A diagnosis is integral to medicine because it organises illness, identifies treatment options, predicts outcomes and provides an explanatory framework (Jutel, 2009). ”

Diagnoses also give people permission to be ill. Being diagnosed replaces mystery with — well, something else depending on the label.

Getting a diagnosis indicating that chronic pain was not likely to be alleviated was a striking finding from my PhD research, and supported by numerous qualitative studies. What I found, and others too, was that once a person had been told that their pain wasn’t likely to go, that the disease was chronic and couldn’t be cured, it wasn’t long before people began to think about life with pain rather than searching for a cure.

It’s interesting that although I could find a lot of research looking at how doctors let people know they have cancer, or a life-limiting illness, I couldn’t find anything to show how doctors give someone the news that they have chronic pain. Anecdotally I have heard that doctors don’t like to tell people their pain is likely to be there “forever”, but I couldn’t find anything in the journals to explain what it was like to be the doctor in this situation. And yet it must happen – or does it?

Doctors use diagnoses to predict, to organise, to tell them what to do next. Chronic pain, because of its complex and disputed nature (is it illness? is it disease? is it physical? is it mental?) is one of those labels that violates these principles. A diagnosis of chronic pain, in many cases, means the doctor has no more treatment ideas, or at least, a very limited repertoire.

Let’s look at this from the point of view of the person living with chronic pain. For probably four or five years this person will have been looking for answers. Initially he or she will have been given some sort of diagnosis “low back sprain” or “whiplash”. This may have been extended and refined to become “z-joint dysfunction” or “disc bulge”. Maybe this will have been added to with names like “trigger points” or “myofascial pain”. Even “anterior pelvic tilt” or “muscle imbalance”. Perhaps “kinesiophobic”. Findings on imaging will have been negligible – or pointed to with a flourish: “There! There is your problem”.

With each label, a new set of predictions is made. “If you do X exercises, it will come right”. “Here, let me do Y procedure and you take this medication, and you’ll be fine”.

And each time, the person hasn’t responded. The feelings of hope go up with a new diagnosis, then plunge to the depths as the new treatment doesn’t work.

At the back of the person’s mind is the suspicion that this pain isn’t really going to go away. But it’s not until someone “official” makes a diagnosis, confirming the prognosis, that her or she can put away the ideal of “going back to normal” and begin to figure out how to be a person-in-pain rather than a person waiting for a cure. Because until someone official sanctions this suspicion, there still is this sneaking hope that maybe, just maybe, a cure for this pain will be found, if only they get the right diagnosis.

What makes it so hard for doctors to give this diagnosis?

I haven’t identified anything definitive, so this is speculation, but here goes.

Chronic pain is a disputed disorder. It lives between physical disease and mental illness. Often no physical cause can be found, and because of the legacy of Descartes, an assumption is made that therefore it must be “mental” or at the very least “biopsychosocial”. But not biopsychosocial in the way that I understand it, more of “psychosocial-because-I-can’t-find-the-real-problem”.

I also think doctors (and other health professionals) have a hard time admitting they can’t fix something. It’s difficult to say “here’s the boundary of medical science”. This is why so many people spend their lives looking for cures for cancer, spinal cord injury, rheumatoid arthritis, multiple sclerosis etc.

I think it’s emotionally demanding work. To tell someone “you have this chronic pain, you’ll need to learn to live with it” can provoke anger, grief, despair, distress. That’s not easy – especially if you’re a doctor who is a little fearful that he or she might have missed something. “What if there really is something treatable?”

It’s also an invitation to a long-term healthcare relationship. People with chronic pain don’t go away, they’re not palliative care. To some GP’s, people with chronic pain are SO difficult to deal with. They turn up at all hours, they’re distressed, they’re depressed, they’re needy, nothing works. Not the kind of patient a GP really wants to deal with.

Finally, I think it’s very difficult to be a GP who sees people with chronic pain because, seriously, what can you do for them? There are very few places for people with chronic pain to be referred. Few treatments. Nothing is very effective.

It’s like opening Pandora’s box. Once a diagnosis of chronic pain is made, this person will need to take time to look at their life and make changes. That’s terribly challenging work. Not really what a GP’s practice is for. Making life changes is personal, individual, takes time and people often fail and need to repeat the process. This is the nature of chronic disease management – it’s not about medication, it’s about examining and exploring what will help this person feel well.

And what did my research show? That those practitioners who did the “little things” like personalising an exercise plan, like agreeing to stick with the person as he or she finds ways around or with the problem, who phoned or sent a text to see how the person was getting on – these made all the difference.

So, one more piece of the puzzle of helping people live well despite their pain is letting them know they have chronic pain, that it won’t go away completely, and conveying your belief that they have the resources to live well and you’ll be there beside them. If that’s not all about a therapeutic relationship, then I don’t know what is.

 

Engel, George L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. doi: http://dx.doi.org/10.1126/science.847460

Jutel, Annemarie. (2009). Sociology of diagnosis: a preliminary review. Sociology of Health & Illness, 31(2), 278-299.

Ryton Station Valley

Being: or doing?


I’ve posted a couple of times on goal-setting here and here and here.

You might get the message that I spend my time bimbling along without focusing on anything in particular. That’s just so not true! I definitely have things I want to achieve – and I achieve them (mostly – I never did learn German except to decipher my Burda pattern instructions!). It’s just that I think health professionals can use goals to clobber people with, and I don’t think that helps anyone, least of all the person in the middle.

Here are some more good reasons not to focus on goals:

  1. Goals can make all our efforts focused on the goal, and when the goal’s complete the actions stop. Goals can make daily actions things we do as a means to an end rather than something we do because we think they have value. Goals can make those actions temporary, a chore.
  2. Goals are external outcomes we want to achieve. That means achieving them is often out of our control. If I want to get a new job there are things I can do but in the end an employer must want to hire me. There’s nothing I can do to get a particular job if the employer just doesn’t want to employ me.
  3. When a goal takes a long time to reach, we can lose interest and give up. Then all that work is lost.

So, if I don’t just bimble along, randomly doing whatever takes my fancy, and I don’t set goals, what do I do?

I read a fabulous post by Nadira Jamal, The Belly Dance Geek

In it she’s looking at building a daily dance practice. Dancers need to practice, but many amateur dancers do a boom and bust approach to dance practice. “There’s a performance coming up – must practice! must practice!” Then once that performance is over, dance practice stops. Only to begin again once there’s another performance! No wonder some of us never get beyond struggling with hip drops. Nadira’s reasoning is that when we focus on “achieving the goal”, practice is a means to an end, not a means in itself.  Now the reason I want to dance is that it’s part of who I am, an expression of myself. So, you might wonder, why on earth don’t I practice as often as I can?  Well, it seems too hard to fit it in, I get bored, there are other people around, it’s too hot, it’s too cold, I’m still in my pj’s, I’ve had my shower already and don’t want to get all sticky…

People we work with have similarly good reasons for not doing those exercises we’ve recommended.

Instead, Nadira recommends using themes in dance practice. Picking some areas of dance to work on and working on them – selecting from a theme gives more variety for practice, they become a focus but not a prescription, and we choose them. A theme might be arms – and thinking of all the different ways I could improve my arms in dance. Pick a couple of activities, use these as a “menu”, then when you begin to practice, choose the one or ones that appeal that day.

Translating this into pain management, a theme might be “ways to down-regulate my sensitive nervous system”. The are a heap of ways to do this: mindfulness, yoga, walking in the garden, reading a good book, stretching, self-hypnosis. What a range of things I can choose from each day! I can write them all down, then depending on how I’m feeling that day I can choose the one that suits me the most.

I think it’s good to begin the day by reviewing my diary – and that when I plan my actions. I’ve decided, after listening to Nadira, to practice every morning. It’s easy because I just have to get out of bed five minutes earlier than normal. And yes, I’m only doing 5 minutes at the moment. For those who don’t know, I am NOT a morning person. And 5 minutes means I KNOW I can do it, even when I’m feeling sluggish. And it’s tied to getting up – usually I read, so I just finish reading 5 minutes early. I know the things that are likely to derail me from doing the practice, so I have my music ready, stay in my pj’s to do it (a vision that is not a sight for sore eyes), and go straight to the shower after. I’ve chosen themes for practice, and I focus on those.

With a client, I might look at “exercise” and consider all the activities that could be included in “exercise”. Not just the gym, but also gardening, vacuum-cleaning, dancing, walking along the beach, taking Sheba-the-wonderdog for a walk, throwing a stick for her. So flexible I can pick something to do each day.

The key, I think, is looking at why we think someone “should” do whatever it is we want them to do. Why should someone do exercises? Is it to be able to do something else? Yes? Then choose a number of activities that will contribute to doing that thing. Let the person decide exactly what to do each day.

Here’s an example: if we want someone to get fitter because this will help them return to work, list all the ways we (and the person) can think to get a bit of exercise into their day.

  1. Park the car a bit further away from home today, and walk to the park.
  2. Use the stairs instead of the lift.
  3. Take a bike ride around the blog.
  4. Take the dog for a walk.
  5. Walk along the beach with your partner.
  6. Build 5 minute exercise “snacks” throughout the day (I use Pomodoro technique to do this)

While these aren’t earth-shattering in intensity, for someone who is just not that into exercising, this might be a good beginning. And it allows for variety, builds on existing habits (daisy-chaining) Beginning where we are, allowing for variety and interest, and focusing on actions rather than goals gives us pleasure in the doing.

If we can’t say why we think they need to, for example, increase single leg standing balance, then seriously folks, why are we getting them to do it? If we don’t know why someone should sweat it out on a bike at a gym, then why do we think it’s a good thing? Is a spin class just for the thrill of the spin? If so, does the person enjoy it? Yes? Then fine, go for it. No? If it’s to be fit enough for something else – what other ways could that person “get fit enough”?

There is always more than one way to skin a cat, as they say. Don’t get trapped into getting your patients hooked into doing The One Exercise just because you think it’s a good thing. I’m pretty confident that this is the best way to lose people. Let’s instead focus on being, and the doing will happen in a myriad different ways.