Chronic pain

headlands

“Failed back surgery” syndrome – who or what failed?


It’s a term I thought had died a natural death. Failed back surgery syndrome. I used to hear it in the late 1980’s when people with low back pain often had five or six surgeries to try to “fix” whatever wasn’t working in the back. I hadn’t heard it for a while and I really thought it had gone the way it should have – into that great rubbish bin diagnosis pile in the sky, along with “somatisation” and “functional pain” and trigger points. But, to my astonishment, there it is, now a separate MeSH title when you search through Ovid or Medline.

The question I always ask is “Who or what has failed?”

Is it the patient who dares to carry on saying that they have pain, sometimes even more pain than before surgery?

Is it the surgeon for choosing the wrong surgery, or perhaps for doing surgery at all?

Is it the nervous system, already sensitised, now subject to more sensitisation through the planned trauma of the surgical scalpel?

Is it the system for funding surgery?

In a paper written by Shapiro (2015), the rate of “failed back surgery syndrome” is reported as being between 10 – 40%. It seems to increase when the surgery is complex, and it hasn’t improved despite developing less invasive surgical techniques.  Shapiro goes so far as to define FBSS as  “a multidimensional chronic pain syndrome that has significant myofascial and psychosocial components that are directly related to the high incidence of lumbar surgeries in the United States.” Sorry to say, but it’s not just present in the US.

These are the psychosocial risk factors, as identified by Chan and Peng :

  • significant levels of depression,
  • anxiety,
  • poor coping,
  • somatisation
  • hypochondriasis

To be honest, I think these indications would be risk factors for ANY surgery (and probably ANY invasive procedure, including dry needling). But there’s more than this – preoperative risks such as having had prior surgery (spinal instability seems to become worse with repeated revisions); surgery carried out when imaging results suggest there may be good reason, but there is no corresponding clinical correlation; nonsurgical cases of radiculopathy and neuropathy (eg diabetes, viruses, inflammation, vascular disease). And intra-operative risks such as difficult radiographic imaging, inadequate decompression – this paper uses the term “pain generator” for the potential source of nociception, but you and I know that pain only occurs as an output of the brain within a biopsychosocial system; lots of other surgical issues including bleeding, fragments of tissue, “battered root syndrome” (!) where the nerve root is damaged during discectomy; and finally, there are a load of post-operative issues as well – such as haematoma, pseudoarthritis, fibrosis, irritation of the nerve roots, spinal instability, loss of disc height and the list goes on.

Shapiro suggests that some types of ongoing pain after surgery are misdiagnosed myofascial pain, stirring up or producing trigger points. He does add that central sensitisation in the dorsal horn could also play a part, expanding receptive fields in the spinal cord and amplifying “perception” (once again, think of this as amplifying nociceptive input reaching the brain). He also favours the notion of motor control problems following surgery, again compounding the problems that occur with movement after surgery and feeding back into the ongoing pain experienced by the individual.

Shapiro also goes on to suggest various ways the problems could be ameliorated, primarily through careful imaging and then possible surgical management.  The overall management, however, he argues should be pharmacological, “with the goal of increasing physical activity and community involvement”.  Interestingly, Shapiro says “FBSS patients are often pushed aside and told that their surgeons have little to offer them after their surgeries were unsuccessful. These patients are generally managed by community-based physicians, including primary care physicians, anesthesiologists, physiatrists, and neurologists.”  He goes on to say “Treatment of FBSS demands recognition that it is a chronic pain syndrome. One reason that FBSS is a difficult-to-treat syndrome and a public health problem is that the antecedent back pain did not respond to intervention and was often augmented with additional pain complaints caused by the surgery. The psychosocial burden for individuals is huge, especially if there is job loss or loss of function physically. Many of the immediate postoperative pharmacologic strategies complicate the situation further by altering the patient sensorium, mood, affect, and even libido. Opioid-induced hyperalgesia is probably under-recognized and under-reported.”

What does this mean to me?

It must be terribly distressing to be offered a treatment for low back pain and leg pain that is both invasive and expensive – only to find that it hasn’t helped one bit. And even more distressing to then be advised that “there is nothing more I can do, it’s a risk of having surgery”. Worse, then to be advised that the options for managing this pain are quite limited – and for many people, means repeated surgery, perhaps even to the point of having a spinal cord stimulator implanted (with all the known complications of this kind of intervention). Shapiro describes people being offered facet joint radiofrequency neurotomy, but even he acknowledges that “it does not offer a permanent fix to facet-mediated pain, which should raise concern with regard to overutilisation”.

What astonishes me, but probably shouldn’t, is that interdisciplinary pain management approaches continue to be seen as costly, yet there is ample research showing these programmes achieve clinical and cost-effective improvements in patient function.  I’ll let you draw your own conclusions from the following paragraph snipped from Shapiro’s paper:

The cost for this individually tailored 20-day outpatient program, including physical therapy, occupational therapy, and psychological support, is approximately $15,000 (Pain SolutionsNetwork, personal communication, 2013). This is similar to the cost for a single-level laminectomy not requiring a hospital stay and is substantially less costly than the direct costs for lumbar fusion when hospital, hardware, surgeon, and anesthesia costs are added up. [and I’d go even further to add that the 30% risk of a poor outcome is even more expensive…]

I think the health system has failed the people who undergo surgery for low back pain. With a failure rate quoted by Shapiro as approximately 30%, and an increase in epidural injections and facet joint injections of over 250% without any similar improvement in health status, something is going wrong. Very wrong.

Allied health professionals can and do provide cost-effective interdisciplinary pain management for people living with so-called “failed” back surgery syndrome. I think it’s time for allied health professionals to begin agitating, and perhaps even advertising direct to people who have pain – we can help. Our treatments don’t have the risks of invasive procedures. We are focused on helping you DO despite your pain. And what we do can hardly make your pain worse – unlike some of the very sad stories I’ve read.

 

 

Chan C, Peng P. (2011). Failed back surgery syndrome. Pain Medicine 12:577–606.

Shapiro, C.M. (2014). The failed back surgery syndrome: Pitfalls surrounding evaluation and treatment. Physical Medicine & Rehabilitation Clinics of North America, 25(2), 319-340.

Rhodin, A. (2014). A case of severe low back pain after surgery. Journal of Pain & Palliative Care Pharmacotherapy, 28(2), 167-168; discussion 168-169.

tanglewood

Central sensitisation – can a questionnaire help find out who is, and who isn’t?


My orthopaedic colleagues have been asking for a way to identify which surgical candidate is unlikely to have a good outcome after major joint surgery. They know that between 10 – 50% of people undergoing surgery will have chronic pain.  5 – 10% of those people experiencing pain that’s rated >5/10 on a numeric rating scale where 0 = no pain, and 10 = most severe pain you can imagine ( Kehlet, Jensen, & Woolf, 2006). The people with severe pain are the kind of people who hear “well the surgery I did went well…” and can be left wondering why they ever decided to go ahead with their surgery.

Two main factors seem to be important in postsurgical chronic pain: the presence of central sensitisation (usually indicated by reporting chronic pain in at least two other areas of the body) and catastrophising. I’ve discussed catastrophising a great deal here and here .

What I haven’t talked about is central sensitisation. Now, the idea that people can experience chronic pain associated with changes in the way the nervous system responds to stimuli isn’t new, but the neurobiology of it is still slowly being unravelled.  I’m not going to get into definitions or whether having changes in the nervous system equates with “chronic pain” (because pain is an experience and the neurobiology is just the scaffolding that seems present, the two are not equivalent). I want to talk about the measurement of this “sensitisation” and whether a pen and paper tool might be one way of screening people who are at greatest risk of developing problems if they proceed with surgery.

First of all, what symptoms come under this broad heading of “response to an abnormally sensitised nervous system”? Well, Yunus (2007) proposed that because there are similarities between several so-called “medically unexplained symptoms” such as fibromyalgia, chronic fatigue, irritable bowel disorder and so on, perhaps there is a common aetiology for them. Based on evidence that central sensitisation involves enhanced processing of many sensory experiences, Yunus proposed the term “central sensitivity syndrome” – basically a disorder of the nociceptive system. Obviously it’s pretty complicated, but various researchers have proposed that “dysregulation in both ascending and descending central nervous system pathways as a result of physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system, as a result of physical trauma or viral infection… including a dysfunction of the stress system, including the hypothalamic–pituitary–adrenal axis (Mayer, Neblett, Cohen, Howard, Choi et al, 2012, p. 277)”. (what are “pain impulses”?!)

By proposing this mechanism, various researchers have been able to pull together a number of symptoms that people experience, and their premise is that the more symptoms individuals endorse, the more likely it is that they have an underlying central sensitisation disorder.

The authors completed a literature review to identify symptoms and comorbidities associated with fibromyalgia and the other disorders they believe indicate a sensitised central nervous system. they then develop a self-report instrument and asked people with these problems to complete it, and compared their results with a group of people who wouldn’t usually be thought to have any sensitisation problems (students and staff at a University – we could argue this, but let’s not!).

What they found, after much statistical analysis, is a four factor measure:

Factor 1 – Physical Symptoms (30.9%)
Factor 2 – Emotional Distress (7.2%)
Factor 3 – Headache/Jaw Symptoms (10.1%)
Factor 4 – Urological Symptoms (5.2%)

Test-retest reliability was established, and because the questionnaire could discriminate between those who reported widespread pain (aka fibromyalgia) and those who had no pain, it’s thought to have discriminant validity as well. (BTW a copy of this measure is included in the appendix of the Mayer, Neblett, Cohen, Howard, Choi, Williams et al (2012) paper – go get it!)

The researchers then went on to look at some norms for the measure and found that amongst people with chronic pain, referred to an outpatient multidisciplinary pain centre, those with more diagnosed “central sensitisation syndromes” scored more highly on this measure, and that a score of 40 on the measure was able to discriminate between those who didn’t have sensitisation and those who did (Neblett, Cohen, Choi, Hartzell, Williams, Mayer & Gatchel, 2013).

Well and good. What does it actually mean?

This is where I think this measure can come unstuck. I like the idea of people being asked about their pain and associated symptoms. We often don’t have time in a clinical interview to ask about the enormous range of symptoms people experience, so being able to get people to fill out a pen and paper measure to take stock of the different things people know about themselves is a good thing.

What this measure doesn’t yet do is indicate whether there is any underlying common causal link between these experiences. It’s tautological to list the symptoms people might experience with central sensitisation based on the literature, then ask them to indicate which ones they experience and then conclude “oh yes! this means they have central sensitisation!” All it means is that these people report similar symptoms.

What needs to happen, and is now beginning to occur, are studies examining central nervous system processing and the scores individuals obtain on this measure. That, and establishing whether, by completing this questionnaire, it is possible to predict who is more or less likely to develop things like post-surgical chronic pain. Now that would be a really good measure, and very likely to be used by my orthopaedic colleagues.

In the meantime, whatever this measure indicates, it seems to be able to differentiate between people who are more likely to report “medically unexplained symptoms” and people who don’t. This might be useful as we begin to look at targeting treatment to suit different types of persistent pain. At this point in time, though, I think this measure is more useful in research than clinical practice.

 

Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–1625

Mayer, T.G., Neblett, R., Cohen, H., Howard, K.J., Choi, Y.H., Williams, M.J., . . . Gatchel, R.J. (2012). The development and psychometric validation of the central sensitization inventory. Pain Practice, 12(4), 276-285. doi: 10.1111/j.1533-2500.2011.00493.x

Neblett, R., Cohen, H., Choi, Y., Hartzell, M.M., Williams, M., Mayer, T.G., & Gatchel, R.J. (2013). The central sensitization inventory (csi): Establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. The Journal of Pain, 14(5), 438-445. doi: http://dx.doi.org/10.1016/j.jpain.2012.11.012

Roussel, N.A., Nijs, J., Meeus, M., Mylius, V., Fayt, C., & Oostendorp, R. (2013). Central sensitization and altered central pain processing in chronic low back pain: Fact or myth? Clin J Pain, 29, 625-638. doi: 10.1097/AJP.0b013e31826f9a71

Van Oosterwijck, J., Nijs, J., Meeus, M., & Paul, L. (2013). Evidence for central sensitization in chronic whiplash: A systematic literature review. European Journal of Pain, 17(3), 299-312. doi: 10.1002/j.1532-2149.2012.00193.x

Yunus, M.B. (2007). Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis & Rheumatism, 36(6), 339-356.

BFT poster

My North American Tour!! #Bronnie2015


It’s fast coming up – my wonderful North American tour!! Thanks to some amazing friends who have organised the details, I’m going to be in North America from the end of May to mid-June at the following places:

11 June – one day workshop on graded exposure!
13/14 June
What am I doing?
This is a two-day workshop on integrating biopsychosocial factors into clinical assessment, clinical reasoning and treatment planning. It’s about taking pain management from the clinic into the real world. It’s a time to learn more about the practical aspects of integrating these messy concepts – without breaching your scope of practice!
By the end of the two days you’ll have some tools you can use on Monday, gained confidence and had fun.
Come and join me and the fabulous team who have done all the arranging for these workshops!
silent angel comfort me

What does using a biopsychosocial framework mean in practice?


A good friend of mine told me that during her training (as a physiotherapist), psychosocial factors were “what you blame when your treatment doesn’t work”. It’s something I’ve heard more than once. I’ve also been asked many times “…but are you sure you’re not doing something outside your scope of practice?” when I talk about using cognitive behavioural principles and ACT (Acceptance and Commitment Therapy) and other psychological strategies. And some of you might have seen earlier posts of mine where I ask “How social is your biopsychosocial model?”

Today’s medical students are trained in using a biopsychosocial framework in their undergraduate years. They leave medical school, begin their hospital and advanced training, and I guess I wouldn’t be alone in asking “what happened to the psychosocial?” when we see them working.

So today’s post is a bit of a reflection and a musing on what I think using a BPS approach might mean in pain practice.

BPS is, I think, less of a “model” than a way of thinking. Thinking that is based on a systems approach – every factor affects and is affected by every other factor. In fact, Engel, the originator of this way of viewing human health, was strongly influenced by general systems theory which was developed by Ludwig von Bertalanffy, a biologist who lived between 1901 – 1972. General systems theory was a model describing processes thought to be common in many different fields of knowledge. General systems theory is based on these five beliefs:

(1)  There is a general tendency towards integration in the various sciences, natural and social.

(2)  Such integration seems to be centred in a general theory of systems.

(3)  Such theory may be an important means of aiming at exact theory in the nonphysical fields of science.

(4)  Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.

(5)  This can lead to a much-needed integration in scientific education.

Engel then applied this to a model of the influences on human health. At the time he wrote his seminal article (Engel, 1977), psychiatrists were being challenged by reductionism on the one hand, particularly around approaches to mental health – the distinction between “diseases” where biological causal factors are influential, such as neurological disorders, and “problems of living” such as alcoholism, where the relevance of biology was, at the time, hotly debated; and concern that psychiatrists might lose ground to nonmedical practitioners such as psychologists. It’s an argument that continues today: should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management? (For a very interesting discussion of socio-political debates about this, read Wilson, N., Pope, C., Roberts, L., & Crouch, R. (2014). Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain. Social Science & Medicine, 102(0), 138-145. doi: http://dx.doi.org/10.1016/j.socscimed.2013.11.055)

Back to the story. The broad BPS “model” can’t be tested, and to some, was never intended to be a “scientific” model but rather a discussion tool. A way of shaping a dialogue between the person seeking help, and the clinician wanting to understand what was influencing how and why this person was presenting in this way at this time. I like to think of it as a way to remember that the person seeing you is a person-in-context.

We can argue the toss about exactly which factors belong in which “bit” of a biopsychosocial approach, but broadly speaking, we want to understand biological influences on health. Some of these are genetic (a bit hard to investigate for most of us), some of these are environmental (rickets? Vit D deficiency?), some are other organisms (M. leprae and M. lepromatosis? – Leprosy to you and me). Some are associated with what people do – tripping, jumping off things; while some are associated with what people don’t do – manage diabetes, exercise. The bio part is far more readily assessed and addressed than the other messy bits and pieces, so I won’t deal with that any further.

The psychosocial, on the other hand, is messy. It’s muddled and hard to measure and changes over time and geography and culture.

To me, it means remembering that when two people get together, it’s not just about the words we use, it’s about what we both bring to the setting in terms of experience, habits, expectations, vulnerabilities. It’s about where we meet. It’s about the purpose of meeting. It’s about recognising that everything we say and do is imbued with meaning – but it’s also about not necessarily knowing what we know, or what we don’t know.

So if I’m practicing in a biopsychosocial framework, I’m going to have to know a great deal about myself and my assumptions, my attitudes, habits, how others see me, and even what I don’t know. And the same applies to my knowledge about the person I’m seeing – only because I’m usually the “treatment provider”, I need to shape my conversation so that it’s OK for that person to tell me about this stuff, and this means knowing a bit about how people tick. I especially need to know how to hear what the person coming to me is saying – and not saying.

I see much that is called “psychological” as being about how we communicate and what we know about helping people change behaviour. I’m not “doing psychology” when I teach my child how to tie shoelaces, yet I’m using psychological techniques – modeling, reinforcement, verbal instructions and so on. Likewise when I’m helping someone feel OK about driving their car when they have back pain, I’m using psychological techniques such as verbal instruction, grading the difficulty, encouraging, supporting and so on. To suggest we can’t use psychological techniques to enable normal function is unthinkable.

Using CBT or ACT or motivation interviewing simply means refining my interpersonal skills so that I can optimise the chances that the person feels heard, can understand what I’m on about, and begins to feel OK about taking steps towards the life they want and being themselves. It’s about learning ways of explaining things, learning how to show that I’m listening, learning about the right level of support and challenge that will enhance the chances of success. Most people who live with chronic pain probably don’t need to see a psychologist – they need someone to help them make sense of pain, to show they’re there as they find their way through, and celebrate when they’re doing what’s important in their lives. I think all health professionals should be doing this.

Engel, G.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

Rarotonga

How much do you really need to deal with catastrophising?


Catastrophising is a popular concept in pain management. It’s been associated with poor outcomes in major joint replacement (Riddle, Wade, Jiranek and Kong, 2010); spinal fusion (Abbott, Tyni-Lenne & Hedlund, (2010); in experimental pain modulation (Bartley & Rhudy, 2008); in cancer pain (Bishop & Warr, 2003); and influences interpersonal relationships (Buenaver, Edwards & Haythornthwaite, 2007).

I’m often asked: so, what do I do about it? Can it be treated? What does it really mean? Should I (any kind of non-psychologist) try to treat it, or should I leave it to the psychologists?

The short answer is, I think, yes we need to be aware of catastrophising, yes we can do something to help people become less likely to catastrophise, and yes I firmly believe any and all health professionals have a contribution to make to reduce the tendency to catastrophise simply because it can be so influential for distress, function and disability.

What does catastrophising really mean?

Catastrophising is, basically, the tendency to think the worst about a situation. It probably has some adaptive function in that it helps people identify all the things that can go wrong so they can do something to reduce that risk. On the other hand, it’s not such a wonderful thing when it leads to ruminating (brooding), feeling helpless, and to magnify (or emphasise) all the disasters that could happen, when the probability is really quite low (Sullivan, Bishop & Pivik, 1995).

It’s likely that most of us will have, at one time or another, anticipated the worst. Most of the time the worst doesn’t happen, and we go our way, reassured that we’ve planned for, and managed the situation more effectively than if we’d carried out regardless. But for people who tend to catastrophise about their pain, the risk is fairly high that they’ll experience more distress, depression and disability than those who don’t.

I want to point out that identifying that someone tends to catastrophise does not mean their fears should be dismissed out of hand.  The person who tends to catastrophise is likely to disagree with you, feel their concerns are being trivialised, feel rejected and less likely to talk to you about their concerns. Not the way to maintain a therapeutic relationship!

How can you tell if someone’s catastrophising?

The main assessment measure of catastrophising is Sullivan, Bishop & Pivik’s “Pain Catastrophising Scale“.  It’s not the only measure, but it’s one of the most well-known. It’s relatively brief, and has excellent psychometric properties. But if you’re not comfortable using a pen and paper measure, how else can you decide if someone’s tending to think this way?

Some good questions to ask are:

“What do you think is the most likely outcome of this [procedure/painful event]?”

“How are you feeling about this pain?”

“What can you do to help yourself when your pain is like this?”

“How much can you distract yourself from the pain?”

“What do you think this pain means? What’s your theory about this pain?”

If the person answers negatively – for example, they say they can’t even think about an outcome it’s so bad, or they don’t think it’s ever going to get better, or it’s “terrible”, or “awful”; if they say they can’t distract themselves from the pain, they keep thinking about it all the time; and if they think there’s nothing they can do to help themselves, they feel helpless or hopeless; and if they think the pain means something sinister or bad – then you’re likely to have identified someone who is appraising their situation more fearfully than is helpful.

If the person says “Oh but it really is that bad!”

Remember when you were a kid and were terrified of the dark, or bugs, or things under the toilet lid? or when you were really upset and someone said “Calm down!” – remember that flash of anger that the other person was just not aware of how terrified you were? Simply disagreeing or correcting someone is not going to reduce their anxiety.

I find that first of all it’s important to reflect to the person that you understand they are really worried by their pain. Saying something like “It seems that your pain is really bothering you, and you’re really worried about what it means now and might mean in the future. Have I understood you correctly?”

I then find it useful to unpack the specifics of what the person is really worried about. I might ask “When you say the pain is terrible, what does that mean? What do you think might happen?”

What I’m trying to do is reduce the global appraisal the “everything” is “awful”. I want to find out the details, the underlying beliefs that are underneath the fearful appraisal. So, for example, if the answer to the question above is “I feel like I’m going to die, I can’t breathe and it’s frightening” or “I think it’s never going to end, it’s going to be there all the time, forever”, I can begin to gently reality test these beliefs and also provide some skills to help the person get through them.  I firstly reflect what I’ve heard: “It sounds so scary, not to be able to breathe – no wonder you’re feeling afraid” or “I’d be worried too, if I thought my pain was going to be there all the time, forever”.

Then I might begin suggesting we work on ways to handle the emotions associated with this belief (it’s very hard to reality test if the person is very distressed). “I wonder if we could just spend a minute looking at some ways to help you deal with your feelings, so they don’t wind your nervous system up more? Even if it’s frightening, it’s hard to deal with when your body is getting very stressed, so tell me, what do you find works well to help you calm down?” I might either use what the person says, or teach some diaphragmatic breathing and mindfulness.

Then it’s often a good time to work through a nonthreatening explanation of pain. There are so many ways to present this – YouTube videos of Lorimer Moseley “explain pain”, or Mike Stewart “Know Pain”, or the 5 minute pain video by Hunter Integrated Pain Service. Or you can use your own explanations and metaphors that are meaningful to the person. A case formulation can be helpful too.

When should you refer to a psychologist?

I think most people with chronic pain are fine just learning simple skills like breathing, mindfulness and gently approaching movements that they’ve been worried about doing. Even better if this is carried out with a strong eye to what the person can do and wants to be able to do in their everyday life. Success does breed success.

But there are a percentage of people who really struggle with catastrophising. If you find that the person you’re working with can’t use breathing to calm down, finds it really difficult to stop brooding (especially if this is going on all night!), or finds it very hard to accept a different way of viewing pain, then it’s time to work together with a psychologist to develop an approach that combines what you do (restoring occupational engagement or function) with cognitive therapy or ACT (Acceptance and Commitment Therapy). I personally find it’s people who have very rigid beliefs about their pain, about how the world works, and who find it difficult to experiment and try new things that need this kind of input.

So – should we think about catastrophising in our clinical work? Definitely yes. It’s too important to omit. Should we help people who tend to think this way? Definitely yes, it’s not necessarily the remit only of a psychologist, and I’d argue that we ALL need to contribute.

 

Abbott, A.D., Tyni-Lenne, R., & Hedlund, R. (2010). The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy, 96(3), 213-221. doi: 10.1016/j.physio.2009.11.013

Bartley, E.J., Rhudy, J.L. (2008). The influence of pain catastrophizing on experimentally induced emotion and emotional modulation of nociception. Journal of Pain, 9(5), 388-396.

Bishop, S.R., & Warr, D. (2003). Coping, catastrophizing and chronic pain in breast cancer. Journal of Behavioral Medicine, 26(3), 265-281.

Buenaver, L.F., Edwards, R.R., & Haythornthwaite, J.A. (2007). Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain. Pain, 127(3), 234-242.

Riddle, D.L., Wade, J.B., Jiranek, W.A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Sullivan, M.J., Bishop, S.R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7(4), 524. doi: dx.doi.org/10.1037//1040-3590.7.4.524

calm still afternoon

Accepting pain – or are we measuring something else?


Acceptance. Ask a person living with chronic pain whether they accept their pain and the answer is highly probably a resounding “No!”. It’s a word that evokes resignation, feeling helpless and giving up. Or at least that’s what many qualitative papers seem to show (Afrell, Biguet, Rudebeck, 2007; Baker, Gallois, Driedger & Santesso, 2011; Budge, Carryer & Boddy, 2012; Clarke & Iphofen, 2007; Lachapelle, Lavoie & Boudreau, 2008; Risdon, Eccleston, Crombez & McCracken, 2003). I remember when hearing a person tell me “Oh I accept my pain” thinking that this was often a clear indication that underneath it all, the person was pretty angry about the unfairness of pain impacting on their life.

Acceptance is defined in Acceptance and Commitment Therapy (ACT) as “a willingness to remain in contact with and to actively experience particular private experiences (Hayes, Jacobson, Follette, Dougher, 1994) (eds): Acceptance and Change: Content and Context in Psychotherapy. Reno, Context Press, 1994), and from this Lance McCracken and colleagues developed the Chronic Pain Acceptance Questionnaire. This measure has two dimensions: willingness to experience pain and engaging in values-directed activity despite pain.  The other way acceptance has been defined draws from self-regulation, and argues that withdrawing from goals that can’t be achieved, in order to turn to goals that can be achieved is a positive way to cope with life – acceptance is defined as disengaging from a goal to get rid of pain and instead, re-engaging in other goals that aren’t affected as much by pain.

Lauwerier, Caes, Van Damme, Goubert and Rosseel (2015) have recently published a paper reviewing the various instruments that purport to measure pain acceptance. In their analysis, a coding scheme was developed consisting of the three main aspects of acceptance that seem to represent the concept: disengaging from controlling pain, pain willingness (in certain circumstances), and engaging in other valued activities. These three concepts were drawn from the literature – and then there were the left-over concepts that were also present in measures of acceptance. These are the interesting ones!

The addition five codes were: controlling pain, pain costs, pain benefits, unclear and no fit.

They identified 18 difference instruments, of which five didn’t specifically measure acceptance of chronic pain or illness and were therefore excluded from the study, leaving 13 measures to review. The one mentioned the most in the studies reviewed was the Chronic Pain Acceptance Questionnaire-2o.

Moving on to the results, what did these researchers find? And of course, why does it matter

Well, most of the instruments were measuring aspects of acceptance – the Brief Pain Coping Inventory, Chronic Pain Acceptance Questionnaire-A and CPAQ-20, and the Pain Solutions Questionnaire. The original CPAQ and the PASOL were the only two measures with moderate (but the highest percentage) of items with all three acceptance features (disengagement from pain control, pain willingness, and engaging in activity other than pain control), and interestingly, most instruments included “engaging in activities other than pain control”, while the other two factors were less well-represented.

Even more interesting is that many of the items in these instruments were classified as “controlling pain” – in other words, measuring how willing individuals are to carry on with life without trying to control pain. At the same time, many of the instruments also measured “pain costs” – such as “because of my illness, I miss the things I like to do best”.

Then these researchers did some pretty fancy analysis, looking at dimensions contained within all the items from all the measures. What they found was a 2-dimensional solution, with one dimension going from “fully engaged in valued activities” (my description!) to “pain costs”, and the other axis going from “pain willingness” to “controlling pain”.

Conclusions and why this is important

Most of the assessment measures contained some of the concepts thought to be important in pain acceptance, but the aspect most commonly found was engaging in activities other than controlling pain. Items measuring disengaging from trying to control pain, and pain willingness were found less often, while many measures incorporate pain control, and some that reflected pain costs or were unclear. This research seems to show that engagement in activities other than pain control and pain willingness are key features of items measuring acceptance, but at the same time show that not many measures look at both of these concepts together.  Additionally, this research shows that many supposedly “acceptance” instruments actually measure attempts to control pain but then reverse score these items – this can mean that people using these measures interpret them as avoidance measures rather than willingness to experience pain – appealing to quite a different theoretical model (the avoidance or fear-avoidance model) rather than a pain acceptance model.

Why is this research important? Well, acceptance is still a relatively new concept in pain research and clinical practice. While it has been talked about a great deal, and there are numerous studies of acceptance, the instruments developed for such research have not been around very long, and as we can see, don’t always adequately represent the fullness of the theoretical domains. Some aspects are not well-represented or are at risk of being misinterpreted. What works in a research setting may not always be accurately transferred to a clinical setting, especially if clinicians pick up a new measure without reading the theoretical basis for its development.

I also argue on the basis of my research that “disengaging from trying to control pain” doesn’t only need to be represented by items suggesting that people no longer seek treatment. From my findings based on people who live well with chronic pain, treatment is still a feature – but the investment in the outcome of treatment is far less. It’s less important that the pain is removed, treatment is “an option” rather than a necessary part of “returning to normal”.

I also argue that pain willingness is conditional upon the values placed on the activities the individual wants to do. So, if the activity is boring, unpleasant, hard work or doesn’t have rewards to the individual, the person is more than likely to avoid it, but if it’s highly valued then pain becomes a less dominant factor in the decision to do it.

Why should clinicians care? Because acceptance is an exciting and fruitful aspect of living well with pain that we can incorporate into our treatments. Acceptance is about learning to live well, “being with” or “making space” for the presence of pain, so that the other aspects of life are able to be engaged in. That’s important given how few people can have their pain completely reduced.

 

 
Lauwerier, E., Caes, L., Van Damme, S., Goubert, L., Rosseel, Y., & Crombez, G. (2015). Acceptance: What’s in a Name? A Content Analysis of Acceptance Instruments in Individuals With Chronic Pain The Journal of Pain, 16 (4), 306-317 DOI: 10.1016/j.jpain.2015.01.001

Afrell, M., Biguet, G., & Rudebeck, C.E. (2007). Living with a body in pain — between acceptance and denial. Scandinavian Journal of Caring Sciences, 21(3), 291-296.

Baker, S.C., Gallois, C., Driedger, S., & Santesso, N. (2011). Communication accommodation and managing musculoskeletal disorders: Doctors’ and patients’ perspectives. Health Communication, 26(4), 379-388. doi: http://dx.doi.org/10.1080/10410236.2010.551583

Budge, C., Carryer, J., & Boddy, J. (2012). Learning from people with chronic pain: Messages for primary care practitioners. Journal of Primary Health Care, 4(4), 306-312.

Clarke, K.A., & Iphofen, R. (2007). Accepting pain management or seeking pain cure: An exploration of patients’ attitudes to chronic pain. Pain Management Nursing, 8(2), 102-110.

Eccleston C, Crombez G. (2007). Worry and chronic pain: A misdirected problem solving model. Pain, 132(3), 233-236.

Hayes, Jacobson, Follette, Dougher. (eds)(1994).  Acceptance and Change: Content and Context in Psychotherapy. Reno, Context Press.

Lachapelle, D.L., Lavoie, S., & Boudreau, A. (2008). The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia. Pain Research & Management, 13(3), 201-210.

Risdon, A., Eccleston, C., Crombez, G., & McCracken, L. (2003). How can we learn to live with pain?: A q-methodological analysis of the diverse understandings of acceptance of chronic pain. Social Science & Medicine, 56(2), 375-386. doi: dx.doi.org/10.1016/S0277-9536(02)00043-6

walkaway

An allied health response to primary care for musculoskeletal aches and pains


For as long as I can remember, the joke about doctors saying “take two paracetamol and ring me in the morning” has been a pretty accurate reflection of reality – but no more perhaps?

A large review and meta-analysis of randomised placebo controlled trials of paracetamol in back pain and osteoarthritis has found that although paracetamol can provide a limited reduction in pain in osteoarthritis but not at a clinically important level, there is an elevated risk (four times) of having abnormal results on liver function tests (Machado, Maher, Ferreira, Pinheiro, Lin et al, 2015). The meaning of this elevated risk on liver function isn’t clear, but what is clear is the very minimal effect of what has been used as a mainstay drug for two of the most common complaints in the world.

Oh what are we to do? Because if the findings about paracetamol are stunning, add to it the clear evidence of harms associated with nonsteroidal anti-inflammatories, and we have a situation where the two most common front-line treatments for musculoskeletal pain are being strongly questioned. What’s a busy GP meant to do?

As a community, I think health professionals working with people who have musculoskeletal pain need to begin a concerted campaign to show the value of nonpharmacological approaches to managing life with aches and pains. We already have this beginning with some of the physiotherapy social media campaigns – see a physio first! But I think we could add “See your allied health team first”.

What would it mean to see an allied health professional first? And what would allied health professionals need to do to make this a valid option?

I think allied health professionals would need to make some changes to how we assess people presenting with pain – I wouldn’t want to ban the biomechanical, but here’s a question: how well do physiotherapists consider the psychosocial in their history taking? Luckily I don’t need to have the answer because Rob Oostendorp, Hans Elvers and colleagues have done the work for me.  In this study, therapists were observed conducting their first assessment with a new patient experiencing chronic neck or back pain. Their interviews were reviewed against the SCEBS (Somatic, Psychological (Cognition, Emotion and Behaviour) and Social dimensions of chronic pain), and given scores for how well the interviews explored these domains. Perhaps unsurprisingly, history taking for the Somatic dimension (how sore, where are you sore, what triggers etc) was excellent, with 98% including this area. BUT, and you’d expect this perhaps, Cognition was 43%, Behaviour was 38%, Emotion was 28%, and Social was 18%. What this means is that despite the clinicians themselves considering their coverage for all but the social domain as being “adequate”, in reality the only aspect that these clinicians covered well was the most basic area – “what does it feel like?”.

Challenging indeed.

Now, what would happen if we then examined what these clinicians do with that information? Because if we’re not so wonderful at collecting useful information across domains, my bet is that we’re even worse at combining this information to make sense of it – in other words, developing useful formulations.

Unfortunately I don’t have any information on how we as allied health clinicians use the information we collect, but if my experience as an educator and the very limited number of papers discussing formulations is anything to go by, I don’t think we’re doing too well. I suspect we tend to collect information then blithely continue doing what we’ve always done in terms of treatments. And I’m sorry I don’t have the evidence to support my hunch – would someone take this on for a project, please?

I think allied health professionals also need to make some changes to how we present what we do to the general public. While most people in the general public know that physiotherapists help people move, osteopaths are gentle and work with their hands, chiropractic looks after backs and necks – I’m not so sure anyone really knows what occupational therapists might offer, and I’m certain there would be some angst if psychologists were recommended as front line clinicians for musculoskeletal problems!

You see, while we’ve been concerned about a biomedical dominance in musculoskeletal pain, we haven’t been as good at helping the general public recognise that aches and pains are fairly common and often not a sign of pathology. We’ve been pretty poor at showing the value of relaxation, mindfulness and down-regulation as useful ways to deal with pain. We haven’t addressed the need to engage in occupations and activities that are fulfilling and enjoyable and enriching. In fact, I venture to say that we have almost wholly bought into the biomedical model when it comes to how to conceptualise musculoskeletal aches and pains. We are as guilty as anyone for considering an ache or pain as a sign that the person needs to be “fixed” or “mended” or “aligned” or “stabilised”.

I think a more radical approach, and one that allied health professionals can really endorse because there is evidence for it, is that living well involves being fully human beings. That means allowing ourselves to engage in what we love to do, to not only be active but also to relax, to be exuberant and to be peaceful. To think of our lives as a whole, rather than an isolated ouchy hip or knee or neck. And to look to our whole lifestyle as key to living well rather than “treating” the bit that happens to be bothering us right now.

Imagine that – an allied health workforce that puts out the message that life and wellbeing are the products of balancing all the wonderful facets of being human.

 

 

Machado, G.C., Maher, C.G., Ferreira, P.H., Pinheiro, M.B., Lin, C.-W.C., Day, R.O., . . . Ferreira, M.L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials (Vol. 350).

Oostendorp, Elvers, Mikolajewska, Laekeman, van Trijffel, Samwel, Duquet (2015). Manual physical therapists’ use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice. The Scientific World Journal, 2015, art. 170463, doi: http://dx.doi.org/10.1155/2015/170463

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