The complex world of identifying nociplastic pains

Towards the end of 2017, IASP put forward a new mechanistic classification: nociplastic pain. The definition is: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

Note: Patients can have a combination of nociceptive and nociplastic pain”.

This was great news! Prior to this, the term “central sensitisation” was used and abused to describe processes involved in ongoing pain that wasn’t inflammatory or neuropathic. Problem with that term is that it’s apparent in nociceptive mechanisms, as well as both inflammatory and neuropathic…. When the way people used the term was more akin to “well, the pain hasn’t settled down, so ‘something weird’ is going on and it must be in the central nervous system so we’ll adopt this term seeing as Clifford Woolf described it in the spinal cord” (Woolf, 1996, 2007).

In other words, any pain that seemed to radiate, hang around, and no respond to treatment was “centrally sensitised”. Perhaps so. Perhaps not. Suffice to say, people got confused because most of the typical central sensitisation from nociceptive/inflammatory processes subsides over time, but these “centrally sensitised” pains did not.

I, for one, am glad there’s a group in which weird pains that don’t appear to involve typical nociceptive, inflammatory or neuropathic mechanisms can be put.

Problem is: how do we know what fits into this group? We can be pretty certain when it comes to neuropathic pain, because the definition is very clear (though not so clear in the clinic) – “Pain caused by a lesion or disease of the somatosensory nervous system.” The notes go on to say that “neuropathic pain is a description, not a diagnosis” and I’d say the same about nociplastic pains (which is why I use the plural…). I also step out to say that I don’t think ALL nociplastic pains will be found to have the same biological mechanisms, especially given how widely variable neuropathic pains are.

Nevertheless, we need some way to decide which pains are in, and which are out of this group.

This table comes from Kosek et al., (2021) and summarises the findings from a consensus process within an expert group. They make the point that acute pain isn’t helpfully included in this group, and instead it should be used for pains that persist for 3 months or longer. They also point out that regional pain is included while discrete pain is typically not because of the central sensitisation processes involved (note: this is the correct use of the term! Confused? CS is a neurophysiological phenomenon, associated with more than nociplastic pain).

Looking at the above criteria, possible nociplastic pain is present if the person has criteria 1, and criteria 4. Probable nociplastic is present if the person has all the above.

There are some notes, of course: regional means the musculoskeletal pain is deep, regional or in several places or even widespread (not localised to one place), and each condition eg frozen shoulder and OA knee needs to be assessed separately. If there is an identifiable nociceptive source (or neuropathic source) then the pain needs to be more widespread than “usual” for that pathology. Finally, because nociplastic pain unlike neuropathic pain, has no definitive test currently, there is no “definite nociplastic” category – but once there is, this will be added.

What does this mean for us as clinicians?

Firstly it ought to stop people being thought as faking, malingering or otherwise not being believed. That should be a given but unsurprisingly because of legal and health systems and our own frustration at not being able to “fix” people, people with pain get that impression more often than they should. It also ought to stop psychopathologising people who have this kind of pain: we can’t distinguish between people with nociplastic pain and the DSM5 “Somatic Disorder” – so let’s just not add another unhelpful mental health label to what is already a stigmatised situation.

Then it ought to stop clinicians using treatments that simply don’t help – such as opioids for fibromyalgia. It might help clinicians pause before prescribing movement therapies at a level that is too intense for the person, because this only revs the nervous system up even more making the whole process unpleasant. Beginning at the level the person can manage and gradually increasing is crucial to success. And it ought to stop clinicians from administering “explanations” or “education” and expecting that alone to reduce pain. Because while cortical processes are part and parcel of every pain there is, it’s in this group of pains that some people think “top down” by thinking yourself out of pain is a thing. FWIW pain reduction is lovely and part of treatment, but shouldn’t ever be the only outcome (Ballantyne, 2015), and many times in this group of pains, may not even be an outcome.

Finally, it should stimulate helpful discussion about what “whole person” approaches to managing these pains looks like. The authors say “patients with nociplastic pain are likely to respond better to centrally than peripherally targeted therapies” and this does not mean talk therapy alone, or exercise alone, or indeed medications such as gabapentin or nortriptyline alone. To me, it means individualised, tailored, and integrated strategies to moving, managing daily life, restoring sleep, enjoying an intimate relationship, managing mood and memory, and these might best be offered by pain coaches rather than siloed “therapies” of physical, psychological or whatever other stripe there is.

Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of Chronic Pain — The Wrong Metric? New England Journal of Medicine, 373(22), 2098-2099. https://doi.org/10.1056/NEJMp1507136

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Woolf, C. J. (1996). Windup and central sensitization are not equivalent. Pain, 66(2), 105-108.

Woolf, C. J. (2007). Central sensitization: uncovering the relation between pain and plasticity. The Journal of the American Society of Anesthesiologists, 106(4), 864-867.

Women, partner violence and pain

As the potential for greater repression of women’s autonomy grows (Afghanistan, United States, Mexico), along with racist and misogynist statements from business leaders (DGL CEO Simon Henry) it’s timely to look at pain in women. We already know that more women than men present with persistent pain (Blyth, n.d.), while women who are seen for their pain are more often misdiagnosed, offered psychiatric medication or psychological intervention only and have their experiences dismissed as “hysterical, fabricated, or nonexistent” (Samulowitz, et al., 2018). My daughter, when attending Emergency Department was offered a paracetamol and told “there’s no cure for being a woman” when seeking help for an ovarian cyst. Period pain is considered “normal” (Drabble et al., 2021). Pain in women is not a sexy topic.

Intimate partner violence is common among women. 27% of women who have had a partner report violence perpetrated against them. 24% of young women aged between 15 – 19 years report violence. Low-income countries reporting higher levels of intimate partner violence, and while data was not available for the past two years of covid-19 disruption, it’s expected that higher levels of violence are probable (Sardinha et al., 2022).

What about the intersection between partner violence and persistent pain? (BTW violence is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship and includes stalking, psychological aggression such as coercion, as well as physical and sexual violence).

Persistent pain is one of the most commonly reported health consequences of intimate partner violence (Walker, 2022), and women are more likely to be the recipients of partner abuse than men. Yet – open conversations about violence and persistent pain in women, recognising the signs and symptoms of partner violence in people seeking help for persistent pain, and adequate approaches to treatment are rare. Women may not disclose their situation for fear of being stigmatised, labelled unfairly, or having their pain – and their situation – trivialised.

Walker and colleagues (2022) carried out a systematic review of studies exploring the types of pain women experienced in association with partner violence, the severity of that pain, and the impact of pain on the person. They found that while pelvic pain was common amongst women who had been sexually abused, women also reported chest pain, back pain, neck pain, arthritis, and stiffness in joint or muscles, more frequent headaches, and more back pain – furthermore, women who had experienced partner violence reports higher pain severity, with 75% of women indicating moderate to severe pain, and the longer a women had been in an abusive relationship, the more likely they were to report higher intensity pain.

Interestingly, disability from persistent pain wasn’t measured often – only two studies from 12 included in the final review – but women with persistent pain from partner violence reported higher pain-related disability. They also reported worse impact on their mental health – more PTSD, anxiety and depression, with depression being one of the key mediator between a history of partner violence and ongoing pain.

The authors of this study (Walker et al., 2022) point out that it’s likely that women who have sustained partner violence and experience persistent pain are “not being adequately identified and responded to in clinical settings” – and that the fear of not being believed and the stigma of being on the receiving end of partner violence likely limits how many women openly discuss their situation.

Isn’t it time to get women’s pain prioritised? To get political about systems and processes that fail women? Isn’t it time to shift the narrative around women’s menstrual pain? To acknowledge that women are not mini men?

Finally, when we consider pain rehabilitation, we need to not only recognise that women have different priorities and goals for their lives than men, we also need to understand that doing rehabilitation is more complex for women than men – women report more difficulty prioritising their own rehabilitation over other responsibilities in their life (Côté & Coutu, 2010). Women may not even be referred for rehabilitation as often as men (Stålnacke et al., 2015). It’s time to prioritise understanding the lived experience of women as they pursue help for their persistent pain – and then do something different.

Blyth, F. (n.d.). Chronic pain in Australia: A prevalence study. Retrieved May 12, 2019, from http://www.ncbi.nlm.nih.gov/ pubmed/11166468

Daniel Côté & Marie-France Coutu(2010)A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?,Disability and Rehabilitation,32:2,87-102,DOI: 10.3109/09638280903026572

Drabble, S. J., Long, J., Alele, B., & O’Cathain, A. (2021). Constellations of pain: a qualitative study of the complexity of women’s endometriosis-related pain. British Journal of Pain, 15(3), 345-356.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018. https://doi.org/10.1155/2018/6358624

Sardinha, L., Maheu-Giroux, M., Stöckl, H., Meyer, S. R., & García-Moreno, C. (2022). Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. The Lancet, 399(10327), 803-813.

Stålnacke, B., Haukenes, I., Lehti, A., Wiklund, A., Wiklund, M. et al. (2015)
Is there a gender bias in recommendations for further rehabilitation in primary care of patients
with chronic pain after an interdisciplinary team assessment?.
Journal of Rehabilitation Medicine, 47(4): 365-371
http://dx.doi.org/10.2340/16501977-1936

Walker, N., Beek, K., Chen, H., Shang, J., Stevenson, S., Williams, K., Herzog, H., Ahmed, J., & Cullen, P. (2022). The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review. Trauma Violence Abuse, 23(2), 490-505. https://doi.org/10.1177/1524838020957989

Rehab Fails: What goes wrong in rehab 4

It’s not hard to choose rehab fails, the problem is more about when to stop! I tell a lie, it’s more about how to make changes so these things don’t happen.

Today’s #rehabfail is all about attempting to carve bits of a person off so each profession gets “their” bit to do with what they will. Oh boy, this is a doozy, and it comes to me off the back of seeing the return of the age-old argument about whether pain is “all about the bio” or whether the person gets a look-in. Cuz if it’s all bio then we just treat that bio and be done with it, right? It’s a question that also arises when we begin to ask questions about what the person understands about their pain and disability, when they <gasp!> show that they’re frustrated, demoralised, maybe sad or grieving for what they can’t do….

If I had a dollar for every time I’ve heard someone say “oh but I’m stepping out of scope” – usually in response to a suggestion that they incorporate cognitive behavioural principles in their work, or when someone says it might be a good idea to look into psychosocial factors – I would be wealthy and retired. I cannot believe how often therapists with a primarily physical orientation seem to think that asking someone how they’re feeling about their situation, what they understand might be going on, what they prefer, how they’re sleeping, how they’re getting on with their family… ALL these things is “out of scope!”

Seriously folks. Since when did being a human communicating to another human about how they are in the face of pain and disability turn into a “OOooh but I’m not a psychologist” kind of fear? Who else is going to be able to guide someone to a psychologist unless it’s the insightful clinician who is sensitive to when someone is feeling pretty rotten?

Another part of this chasm between “mind” and “body” is the idea that psychosocial factors are only relevant if or when the person “fails” therapy. Who failed, huh? And where did the idea that psychosocial factors are all negative come from? We all have psychosocial factors in our lives: our temperament, memories, assumptions, relationships, goals, routines, job, choices are all psychosocial, and some of them are even pretty positive!

The siloing of professions particularly in musculoskeletal pain rehabilitation is one of the least helpful things I’ve seen in health. The second is to have a “team on paper” where the “team” members do exactly the same things they do when working as a solo practitioner. Serial monotherapy does nothing for people living with pain. What I mean by this is every doing their therapy concurrently but failing to talk to one another, failing to modify what they do to suit the overall needs of the person, failing to have a common understanding of what one another do, and failing to support one another. How confusing is that for the person getting treatment?

Now I am not suggesting that psychologists should become physiotherapists, or occupational therapists become pharmacists, or even a full transprofessional approach (though this is something our NZ health ministry is aiming for over time). I am simply suggesting these things:

1. Know that whole people are seeking help, not a knee or a belly pain or a back. Pains are experienced by people.
2. Be human and listen to (and ask about) human things like: how is your job going? what’s your sleep like at the moment? what do you think is going on with your pain, what is your theory? how are you feeling in yourself at the moment? Open-ended questions about human experiences and habits – and follow up with more open-ended questions, and lots of reflective statements. Do this from day one. For everyone.
3. Take some time to sit in with someone from a different profession. Make friends with them. Go have a coffee with them. See how they work with someone in common. Let them know this isn’t so you can be them, but so you can help your patients/clients understand a bit more about what seeing them might look like.
4. Read about “whole person rehabilitation.” Matt Erb and Arlene Schmid’s book is awesome (and not just because I wrote a chapter in it! So did a heap of people! – click.)
5. Dip your toe into understanding your patient’s life. Ask questions that help you understand how they’ve made the decisions they have. Nobody gets up in the morning to do dumb things that might hurt them: there are logical reasons – to them – for why they do what they do. We just need to get our heads around their reasons to begin to tease out the assumptions they hold (and we hold) that have influenced their choices. Remember we all do this.
6. Never, ever think that you’re treating a back, or a knee, or a headache or a belly pain. You are always working with a person who is experiencing pain in a part of their body, and that pain has enough meaning for them to decide to ask for help. That’s what we’re actually working with.

Here are some readings discussing how we might build teamwork and whole person rehabilitation:

Bashir, U., & Siddiqui, A. S. (2021). Teamwork in chronic pain management and the way forward in low and middle-income countries. Anaesthesia, Pain & Intensive Care, 25(2). https://doi.org/10.35975/apic.v25i2.1477

Cartmill, C., Soklaridis, S., & David Cassidy, J. (2011, Mar). Transdisciplinary teamwork: the experience of clinicians at a functional restoration program. J Occup Rehabil, 21(1), 1-8. https://doi.org/10.1007/s10926-010-9247-3

Cassell, E. 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). Springer. https://doi.org/10.1007/978-1-4419-9440-0

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3), e663. https://doi.org/10.1097/PR9.0000000000000663

Griffin, H., & Hay-Smith, E. J. C. (2019). Characteristics of a well-functioning chronic pain team: A systematic review. New Zealand Journal of Physiotherapy, 47(1). https://doi.org/https://doi.org/10.15619/NZJP/47.1.02

Maynard, M. T., & Gilson, L. L. (2021). Getting to know you: The importance of familiarity in virtual teams. Organizational Dynamics, 50(1). https://doi.org/10.1016/j.orgdyn.2021.100844

Mallick-Searle, T., Sharma, K., Toal, P., & Gutman, A. (2021). Pain and Function in Chronic Musculoskeletal Pain-Treating the Whole Person. J Multidiscip Healthc, 14, 335-347. https://doi.org/10.2147/JMDH.S288401

What goes wrong in pain rehabilitation (2)

One size does not fit all. Cookie cutter treatments fail to take into account the huge variability each person brings into a clinical encounter, particularly when the person is living with persisting pain. Not really earth shattering news, is it?!

Let me unpack this one.

When we’re treating a person with an acute musculoskeletal injury, let’s say a lateral ankle sprain, I’m going to hazard a guess that most of the recovery occurs without our assistance (don’t shoot the messenger – go read Chen et al, 2019). In essence, we’re creating an environment that supports tissues to do what they do well – get on with healing. Because of this, there’s good reason to follow a basic treatment algorithm that will work for most people. That is, unless or until recovery stops for some reason.

It’s here that algorithms begin to lose utility, because the factors that are implicated in delayed recovery are many and varied – and it’s important to narrow down the particular factors involved for this person with their ankle.

So, IMHO, cookie cutter treatments begin to fall apart when recovery is slower than expected because there are a heap of variables involved. And yet what do I see? “Oh it failed but let’s do the same thing again but harder!” or “the person wasn’t doing their exercises” or “it must be psychosocial factors.”

Well, no, actually, perhaps psychosocial factors are involved, but they were there from the outset (just ignored because the tissue-based factors capture our attention). And no, doing the same thing again but harder leads to the same outcome, only more disappointing. And we have no idea whether the person was, or wasn’t doing their exercises – or whether the prescribed exercises were useful, or whether they even make much of a difference anyway! (again, don’t shoot the messenger, go read Wagemans, et al 2022).

But probably the most heartbreaking thing about using “one size fits all” is that this doesn’t take into account this person’s goals, lifestyle, current priorities, other contextual factors like workplace, family and friendship obligations that are integral to being a person, not just a lateral ankle sprain.

I once worked at a chronic pain centre where every person was assessed by three clinicians: a medical practitioner for diagnosis and medication management; a psychosocial clinician to understand life stressors and the person’s understanding of their pain and their current coping strategies; and a person who assessed how he or she was managing with daily life and functional activities. What I couldn’t understand was how almost every patient was given the same management plan: to try some drugs, see a psychologist, and do a home exercise programme. Come to the centre to see each clinician on a different day of the week. Irrespective of the unique presentation, the same recipe was given. The ingredients might have been a little different when the person was seen for treatment, but without fail, the basic elements were exactly the same.

How is this person-centred care? What if this person was a 4 wheeldrive off-roading enthusiast who loved to go fishing? What if this person was a traveling sales rep with a well-developed meditation practice? What if this person had five kids and couldn’t get to the pain centre for the twice weekly appointments? What if this person was hankering after spending some time with other people who were also living with pain so she could hear that she wasn’t alone, and could pick up tips from people who knew what it was like?

Today I still hear of people being given a copy of “Explain Pain”, get to do the “Protectometer” and then told to go see the physio and psychologist. Nothing about the person’s desire to work out the impact pain has on their daily life, nothing about the understanding the person already has about their own pain fluctuations, and nothing that’s tailored to what this person needs and wants to do.

Seriously folks, pain rehabilitation and management is all about tailored, bespoke, clever therapy based on what the person needs and wants to do, what they already know and bring to their own recovery, and it probably needs to include connection with other people who are in the same situation. Why? Because while “other people” might not give the advice the journal articles recommend, they offer advice from their own experience. And mostly, people with persisting pain need affirmation that they’re resilient, capable, knowledgeable and can work a way through this.

Maybe what we need to do is include people who live with pain in service design (Sandvin Olsson, et al., 2020) – and pain management delivery (Farr, et al., 2021). It seems to work.

Chen, E. , McInnis, K. & Borg-Stein, J. (2019). Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports, 18 (6), 217-223. doi: 10.1249/JSR.0000000000000603.

Farr, M., Brant, H., Patel, R., Linton, M. J., Ambler, N., Vyas, S., Wedge, H., Watkins, S., & Horwood, J. (2021, Dec 11). Experiences of Patient-Led Chronic Pain Peer Support Groups After Pain Management Programs: A Qualitative Study. Pain Med, 22(12), 2884-2895. https://doi.org/10.1093/pm/pnab189

Sandvin Olsson, A. B., Strom, A., Haaland-Overby, M., Fredriksen, K., & Stenberg, U. (2020, Aug). How can we describe impact of adult patient participation in health-service development? A scoping review. Patient Educ Couns, 103(8), 1453-1466. https://doi.org/10.1016/j.pec.2020.02.028

Wagemans, J., Bleakley, C., Taeymans, J., Schurz, A. P., Kuppens, K., Baur, H., & Vissers, D. (2022). Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis. PLoS One, 17(2)http://dx.doi.org/10.1371/journal.pone.0262023

Rehab fails: What goes wrong in pain rehabilitation (1)

Well obviously I’m not going to cover everything that goes wrong – and certainly not in one post! But inspired by some conversations I’ve had recently, I thought I’d discuss some of the common #fails we do in rehabilitation. Things that might explain why people with pain are thought to be “unmotivated” or “noncompliant” – because if the rehab doesn’t ‘work’ of course it’s the person with pain who’s at fault, right? So for today, here goes.

Starting at the wrong intensity

One of the main things that happens when someone’s in pain is to reduce overall activity level. Pain has been called “activity intolerance” and it’s common for people to stop doing. So naturally when a clinician is developing an activity or exercise programme, the aim is often to simply increase how much movement a person does in a day. So far, so good. Muscles and cardiovascular systems improve when we use them.

But guess what? There’s a person inside that body! And people have minds. Minds with opinions about everything and in particular, anything to do with doing. There’s often a “should” about how much movement or activity to do. This rule might be based on “pain is a sign of tissue damage” so anything that increases pain clearly “should not be done”. There may equally be a “should” about how much exercise this person used to do, or wants to do, and often mental comments about “what kind of a person does this amount of exercise.”

I’ve heard good clinicians say that their patients “have unrealistic goals” – this is probably because the person’s mind has an opinion about what he or she “should” be able to do!

What can good therapists do about this? Well, firstly to ignore the person who inhabits the body is plain wrong. Secondly, flashy gadgets like coloured tapes or special elastics or foam thingies probably won’t do much for the person’s opinionated mind except to temporarily distract — oooh! shiny!!

Something I might do would be to ask the person what level they think they can begin at – beginning where the person is at, and moving at his or her pace is a solid foundation for developing a relationship where experimenting with movement becomes about the person and his or her relationship with their body. I think one of the aims of movement rehabilitation is to help the person develop trust in their own body and how it moves, so enhancing playfulness and experimentation can be a good start.

I might ask the person “what shows up when we begin doing this set of movements/exercises”? By “showing up” I’m talking about thoughts, images, sensations in the body that pop into a person’s mind (minds are soooo opinionated!). We might need to guide the person to notice quick thoughts or images, to put words to emotions and feelings, and to get in touch with fleeting sensations in the body.

Some of the things I’ve heard people say include: “only weak losers would call this exercise”, “I used to be able to lift 40kg sacks of cement and now all I can move is this pathetic 5kg dumbbell”, “he wants me to do what?! I hate boring exercises”, “but what am I going to feel like tomorrow?”

What do we do with these thoughts?

First: make room for them to be present. Don’t quickly deny them “Oh of course you’re not weak”, “5kg isn’t pathetic”, “exercise is great fun”, “you’ll be fine, you can do this”. Saying these sorts of things dismisses the validity of the person’s fears and won’t win you any friends.

Second: empathic reflection. Indicate that you’ve heard what the person has said, validate that this is their experience, their thoughts. Something like “it’s a long way from what you used to lift, and that’s hard”, “it’s tough beginning to build up again”, “you’re worried that this is going to be unrewarding”, “you’ve had pain flare-ups before, and it’s hard to deal with”.

Third: Ask the person where they’d like to begin, put them in control of the intensity. Then ask them “how do you think that’s going to pan out” – in other words, will their option get them to where they want to be? What’s good about it? What’s not so good about it? from their perspective not yours! The idea is to establish how workable the person’s starting point might be. It might be perfectly fine, even if it’s not your choice!

Fourth: Affirm that the choice is the person’s – and that this is an experiment that will be reviewed at the next session. You might say something like “So you’d like to try doing 5 minutes of walking instead of the treadmill that I suggested, because you think this shouldn’t flare your pain up as much. What’s your choice now that we’ve talked about the good and not so good? We can review it next time.”

Fifth: Review how it went at the next session! Note down the rationale the person had for the level of intensity they chose, and then review how well that intensity worked from this perspective. For example “you wanted to do 5 minutes of walking because it wouldn’t flare you pain up as much, what did you notice? What showed up? How well did it work?” Notice all the open-ended questions, the reminder that the person thought this intensity wouldn’t flare their pain as much, and the focus on workability. Because at the beginning of a movement or exercise programme, what you’re looking for is adherence, sticking to the level of intensity chosen. Habits take time to make, and often adhering to a programme is because the opinionated mind is having a go at the person, interfering with their willingness to stick with it. If we avoid that roadblock, we have at least one point on the board.

Your opinionated mind might now be telling you that “oh they’ll never make progress at that pace”, “they’ll do themselves an injury if they lift that much”, “this is just pandering to their lack of motivation”

Be careful! At this point you could reflect on what’s showing up for you. Are you worried their outcomes will reflect badly on you? Do you only have a few sessions with the person and need them to get somewhere or you’ll have failed? Make room for those uncomfortable feelings. Let them be present and listen to what your opinionated mind is telling you. Maybe remind yourself that outcomes don’t depend on you – they depend on the person sticking to the programme, and a programme that doesn’t start because the person’s mind tells them it’s not worth it is a #rehabfail Remember also that you’re aiming for the person to gain confidence in their body, learn to listen to what happens when they try something out – the repeated progress reviews you do with the person are the actual active ingredients in therapy, they’re the bits that help the person to reflect on what works, and what doesn’t. That’s gold.

ps The technique I’ve described above is – gasp! – a psychological approach, based on ACT and motivational interviewing. You won’t find a specific study examining this approach in journals (at least not in a cursory search like I did!), but it’s an application of well-studied approaches into a movement or exercise context. It’s the same approach I use in contextually-relevant occupational therapy. Reading Bailey et al, 2020, affirms to me that we have a way to go to define and measure adherence, so I feel justified in using these strategies!

Bailey, D. L., Holden, M. A., Foster, N. E., Quicke, J. G., Haywood, K. L., & Bishop, A. (2020, Mar). Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review. Br J Sports Med, 54(6), 326-331. https://doi.org/10.1136/bjsports-2017-098742

Eynon, M., Foad, J., Downey, J., Bowmer, Y., & Mills, H. (2019). Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 29(5), 638-650. https://doi.org/10.1111/sms.13403

Levi, Y., Gottlieb, U., Shavit, R., & Springer, S. (2021). A matter of choice: Should students self-select exercise for their nonspecific chronic low back pain? A controlled study. Journal of American College Health, 1-7. https://doi.org/10.1080/07448481.2021.1960845

Making sense of pain

It’s been said many times, so many times I can’t locate the originator of the saying “humans are meaning-making machines” – no more so than when a person experiences pain. Whether it’s a stubbed toe, sprained ankle, thundering headache – or, in my case, weird and ongoing widespread body pain AKA fibromyalgia – we would like to make sense of what’s going on. And mostly we tell simple stories about what we were doing, what happened to the body and that’s that.

In the case of weird or persistent pains the challenge becomes harder. The original story might not fit any more, or because of that story, we limit what we do in case we do damage.

Now philosophers and other commentators have taken up the matter of what this experience really is: sensation or perception? Frankly, I don’t think this matters a jot to the people I see who are trying hard to make sense of what their pain means to them. One person I’ve seen recently said “I feel adrift, like a pingpong ball bobbing on the sea” – life is what isn’t making sense any more. And life, dear readers, is not as simple as sensation or perception.

One of the concepts used to understand what constitutes health is the construct “meaning in life.” Meaning in life is associated with resilience, better health outcomes, and very importantly, recovery from Covid and dealing with the stress of how Covid and other world events have played out over the past few years (Arlsan & Allen, 2021; King & Hicks, 2021; Lin, 2021). But where meaning in life has been extensively studied is….chronic pain.

This makes sense to me! Chronic pain is known to disrupt “normal” life for the person experiencing it. Movements that used to be done without thinking are now etched into memory. Sleep isn’t the respite from world cares it was – now it’s endless hours of aching. Assumptions about how quickly a person should recover from injury are smashed. Chronic, persisting, ongoing pain can disrupt life as we know it.

Meaning in life is thought to comprise three facets: coherence, purpose, and mattering. Coherence is about comprehending or “making sense of the past, present and imagined future aspects of life, being able to integrate their life story into a coherent whole (King & Hicks, 2021).” Purpose is “a central, self-organizing life aim that organizes and stimulates goals, manages behaviors, and provides a sense of meaning (McKnight & Kashdan, 2009).” Mattering is about how a person believes their life counts – a sort of transcendence beyond self to a bigger world.

All three of these constructs contribute to an overall belief that life makes sense, and that we are effective agents that contribute over and above our lifetime. You can see how this can erode when living with a meaningless pain like neuropathic pain, or ongoing migraines, or low back pain that just doesn’t settle.

Where does that leave us, if we’re clinicians working with someone experiencing weird pain? I think one of the most important parts of our work is to help people achieve a sense of coherence – that despite pain, it’s possible to still be “me” and that while the future may be different from what was previously imagined, it can still fit into a coherent whole. What this means is helping the person to establish what matters in their life, then figuring out ways for the person to resume those things, whether pain is present or not. This might look like helping the person come up with a story about their pain – a narrative that moves from damage to perhaps recognising that we don’t know why they hurt, but that they know of various factors that influence the severity, frequency and interference of their pain (Hadley & Novitch, 2021).

I also think we need to recognise that people living with pain may also find their purpose is challenged – and some of our work is helping people recognise their purpose in life and find ways to keep moving towards what matters to them. This is the part where we recognise values and life direction – perhaps “occupational drive” or the things that people want and need to do.

Finally, throughout our work with people, we need to remember that mattering matters. That the person we’re working with isn’t “the wonky knee” or “the shoulder” or “the bad back.” Being willing to see the person behind the eyes, the talk, and the pained body. This takes time, and most of all – listening with heart and curiosity.

Arslan, G., & Allen, K. A. (2021, Jan 25). Exploring the association between coronavirus stress, meaning in life, psychological flexibility, and subjective well-being. Psychology, Health and Medicine, 27(1), 1-12. https://doi.org/10.1080/13548506.2021.1876892

Hadley, G., & Novitch, M. B. (2021, Apr 1). CBT and CFT for Chronic Pain. Current Pain and Headache Reports, 25(5), 35. https://doi.org/10.1007/s11916-021-00948-1

King, L. A., & Hicks, J. A. (2021). The science of meaning in life. Annual Review of Psychology, 72, 561-584.

Lin, L. (2021, May). Longitudinal associations of meaning in life and psychosocial adjustment to the COVID-19 outbreak in China. British Journal of Health Psychology, 26(2), 525-534. https://doi.org/10.1111/bjhp.12492

Your patient has psychosocial risk factors: what now?

Congratulations! You’re an insightful clinician who’s offered your patient a screening assessment to find out if she or he has psychosocial risk factors – and yes! they do! Well done. Now what?

Do you…

• send your patient to the nearest psychologist?
• spend at least one treatment session offering pain neurobiology education?
• scramble to find a “psychologically informed physio” to send them to, because it takes really highly trained and special clinicians to work with these people
• give your patient the same exercise prescription you were going to anyway because, after all, they still have things going on in their tissues (or is it their nervous system? I forget – whatever, they just need to move, dammit!)
• throw your hands up in horror and say “I never wanted to deal with people in pain anyway!”

You’d have to be hiding beneath a rock to avoid learning that people with musculoskeletal pain with psychosocial risk factors such as feeling that back pain is terrible and it isn’t going to get better, believing that it’s not safe to move or exercise with back pain, having worrying thoughts going through their mind, or not enjoying things very much should have special attention when they seek help for their pain. And we’ve all read studies showing that many of our frontline clinicians who see people with musculoskeletal pain aren’t comfortable, confident or clear about what to do with people who are, frankly, scared and distressed.

Papers like Caneiro, Bunzli & O’Sulllivan’s (2021) Masterclass clearly show that messages people with pain get told include avoiding certain movements to prevent damage, being advised that special exercises ‘protect’ the body, and that clinicians believe that certain postures and movements are inherently unsafe (bending, lifting with a rounded back). At the same time, Sajid, Parkunan & Frost (2021) found that only 11.8% of people referred by GPs for musculoskeletal MRIs had their mental health problems addressed, while only 16.7% of the MRI results were correctly interpreted by GPs and in 65.4% of cases were referred for “spurious overperception of surgical targets.”

Worse, Nicola, Correia, Ditchburn & Drummond (2021) conducted a systematic review of the effects of pain invalidation on individuals – invalidation from family, friends and healthcare individuals, and the person themselves. They found five themes: not being believed, lack of compassion, lack of pain awareness and understanding, feeling stigmatised and critical self-judgement. Perceived social unacceptability of experiencing pain was found to have an impact on the emotional state and self-image of those with persistent pain. Ya think?!

If I return to the case I presented last week, Angelina, a pretty common case of someone with a neck pain who is having trouble sleeping and generally handles her pain independently, we could assume that she doesn’t have significant psychosocial risk factors. After all, she’s managing to stay working, does a bit of self-help, and she’s not depressed though she’s a bit irritable.

What would you do?

I guess my first thought is: would Angelina even get a screening assessment to see whether she has any psychosocial risk factors? Might she present superficially well enough for her therapist to think she’s fine, let’s just treat the neck?

Of all the neck pain treatments available, what would she be given? And what might she be told about the rationale for that treatment? A recent systematic review with meta-analysis pointed out that while specific exercises helped in the short to medium term, the quality of that evidence was low (Villaneuva-Ruiz, Falla, Lascurain-Aquirrebena, 2021), while a systematic review with network meta-analysis of 40 RCTs found “There is not one superior type of physical exercise for people with chronic non-specific neck pain.
Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective.” (de Zoete, Armfield, McAuley, Chen, & Sterling, 2020).

More than this: would her sleep and relationship concerns be discussed? What about her safety while driving? How about how she manages her work, and her belief that perhaps her pain is happening because of a period at work where she wasn’t positioned “correctly”?

You see, at the moment in our musculoskeletal treatment literature, the focus has been almost entirely on grouped data. And this, folks, is where Steven Hayes points out that the ergodic theorum is violated. Ergodic theory is “…the idea that a point of a moving system, either a dynamical system or a stochastic process, will eventually visit all parts of the space that the system moves in, in a uniform and random sense. This implies that the average behavior of the system can be deduced from the trajectory of a “typical” point. Equivalently, a sufficiently large collection of random samples from a process can represent the average statistical properties of the entire process.” (I stole that from https://en.wikipedia.org/wiki/Ergodicity).

Hayes, Hofmann & Ciarrochi (2020) point out that “We cannot assume that the behavior of collectives (e.g., a volume of gas) models the behavior of an individual element (e.g., a molecule of gas) unless the material involved is “ergodic” and thus all elements are identical and are unaffected by change processes.” Humans are not ergodic (only a few noble gases are…) and what this means is that “statistical techniques based on inter-individual variation cannot properly assess the contribution of given elements to phenotypic change.” In other words: humans actively respond and change to what they’re exposed to – each of us presents to treatment with our own incredibly unique range of responses and past history, and these influence how we respond to a treatment. And perhaps this explains why most of our treatments (RCTs, using grouped data and uniformly applied and consistent treatments) particularly for persistent pain problems end up showing pretty small effect sizes. We’re violating the assumptions of the ergodic theorum. What we need are more sophisticated ways to analyse the impact of any therapy, and far fewer algorithms and cookie cutter treatments.

Where does this leave us? I have loads of ideas about where to from here, but not nearly enough space today to write about them!

My first suggestion is to avoid blindly following a treatment algorithm that fails to support YOU to sensitively and reflexively offer treatments that fit for your patient.

My second is to avoid measuring the impact of what you do only at the end of treatment (or worse, not at all!). Measure often, and measure things that matter – either to how you get to the end outcome, or that the person values. Or both.

And third: Get reading outside of your profession. Dig into psychology (I especially recommend Hayes); look at sociology (try Jutel); anthropology (try Sarah Pink’s “Sensuous futures: re-thinking the concept of trust in design anthropology”); make 2022 the year that you lean into uncertainty. I know the past two years have been incredibly unsettling – but this is the perfect time to continue on this journey into new ideas, fresh concepts, and ambiguity.

Caneiro, J. P., Bunzli, S., & O’Sullivan, P. (2021). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther, 25(1), 17-29. https://doi.org/10.1016/j.bjpt.2020.06.003

Nicola, M., Correia, H., Ditchburn, G., & Drummond, P. (2021, Mar). Invalidation of chronic pain: a thematic analysis of pain narratives. Disability and Rehabilitation, 43(6), 861-869. https://doi.org/10.1080/09638288.2019.1636888

Sarah Pink (2021) Sensuous futures: re-thinking the concept of trust in design anthropology, The Senses and Society, 16:2, 193-202, DOI: 10.1080/17458927.2020.1858655

Sajid, I. M., Parkunan, A., & Frost, K. (2021, Jul). Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Quality, 10(3). https://doi.org/10.1136/bmjoq-2020-001287

Villanueva-Ruiz, Iker, Falla, Deborah, Lascurain-Aguirrebeña, Ion. (2021) Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise—A Systematic Review with Meta-Analysis, Physical Therapy, 2021;, pzab259, https://doi-org.cmezproxy.chmeds.ac.nz/10.1093/ptj/pzab259

de Zoete, R. M., Armfield, N. R., McAuley, J. H., Chen, K., & Sterling, M. (2020, Nov 2). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2020-102664

Making first contact: What to do with all that information! Part 4

In the previous few posts on what to do with all that assessment information I’ve talked about generating a formulation to guide treatment, and a little about how teams might work together to generate one. This post is a little different because I want to situation the discussion around the ultimate aim of therapy.

I usually work with people who have long-standing pain that hasn’t changed much and doesn’t seem to be disappearing. I’m not a nihilist, but I do wonder if clinicians are trying too hard to “change pain” when the body doesn’t seem to respond all that much to whatever we offer when it comes to musculoskeletal pain! Perhaps all we do is offer support to the person as their body gets on with the job of settling down…?

Anyway, my focus is to help people respond flexibly to what life has thrown at them – because while pain poses one of the greatest problems for people, often it’s not the pain as such but what we do to avoid or control pain – or, for that matter, what we do to avoid or control the results of avoiding or controlling pain. Confused? Let me unpack it a little with an example.

About the time I started this blog wayyyyy back in 2007 I had a concussion and developed post-concussion syndrome. I found it incredibly difficult to concentrate, find words, remember things, switch my attention from one thing to the next, and to deal with sensory overload. I was advised to rest and let my brain recover in its own time – all good. BUT I never expected that recovery to take almost two years! so I returned to part-time work after two weeks. In my head I was balancing my fatigue/headache/difficulty concentrating against my need to return to work, keep my employer happy, and do things that mattered.

If I flip that motivation on its head, I wanted to control both my symptoms and my fear/guilt of failing and perhaps losing my job/fear of sitting still and doing nothing/fear of feeling useless. After all, I was the vocational rehabilitation therapist for the service I worked in!

By trying to control my fear of not doing, I created a whole bunch of trouble for myself – I failed at controlling my symptoms – they grew out of hand and I eventually had to take some time off work, got quite depressed, and achieved exactly what I’d hope to avoid – needing to stay at home doing nothing!

When we think of ACT (Acceptance and Commitment Therapy) for living with pain, we often think of the person working hard to control or avoid pain and our focus is on helping them to be willing to make room for pain and begin doing things – and yet I’ve met a great many people who have got caught up in a vicious cycle of over-doing and under-doing, or who “get on with it” with gritted teeth and sheer determination! So one thing we can be looking for in our “first contact” is to identify how workable are the ways the person is approaching this time in their life, a time when they’re dealing with pain and life restrictions, stress, balancing priorities, working, family and so on.

ACT provides a series of six processes that together offer a way to be flexible about how we handle what life throws at us, and help us do what matters in our life. In an ACT formulation, we’re looking for unhelpful patterns that constrain how flexibly we can do what matters. Some of the patterns we might see could be:

1. Unwillingness to stop and create space for pain so the person gets stuck acting as if there is no pain, trying to do everything the same way as normal but either getting fatigued and stressed and just hanging on in there, or doing short bursts of “normal” and crashing periodically.
2. Getting stuck with rigid beliefs about what’s going on like thinking the pain must be able to be fixed and quickly, or that the pain is the most horrible disaster ever and everything about life must be shelved until it’s fixed.
3. Comparing what he or she can currently do against a previous level of performance and being frustrated and angry because this doesn’t fit with how they see themselves, and especially thinking that this is the way it’s going to be forever…
4. Losing sight of important things like being with family, or seeing friends because of feeling irritable, sad, thinking they don’t want to see them like this, not being able to do the things they used to do, waiting for the pain to reduce, or looking for the fix.
5. Anticipating calamity or remembering disasters either about “the last time I tried doing this” or “because I saw this happen to [name]” and then feeling utterly stuck.
6. Casting about being erratic or just not sticking to a plan, getting off track maybe because results don’t happen, or maybe because it’s something new and feels unfamiliar, or perhaps because someone else suggested another option…

There are always other ways people respond to pain, not just the patterns I’ve listed here, but these are some common ones I’ve seen. In ACT we’re looking for unworkable patterns that don’t lead the person towards being the kind of person they want to be, doing the things that bring meaning in their life.

When I’m jotting these things down, I’m looking to identify the core things the person isn’t willing to experience: thoughts, emotions, memories, situations. I want to understand what the person does to avoid them – like things the person has stopped doing or deliberately avoids, the ways the person avoids or controls emotions associated with that thing (like drinking more alcohol, zoning out, lashing out), and what I observe during our initial assessment like skipping over topics that feel uncomfortable.

I want to understand the cost or “unworkability” from the person’s perspective: what’s the impact of responding in these ways. I need to understand what’s going on in the person’s context – their family life, employment situation, influence of case manager or insurance/compensation, friendships. And I want to look at the factors that might be adding to the person’s inflexible responses, and these are myriad and often include what we do as clinicians – like being told to stop doing a favourite hobby “because it might be damaging” (how many people with low back pain have been told to stop running, stop fishing, stop dancing, stop lifting, to sit in a certain way, walk in a certain way, lift in a certain way, stop slouching, walk faster, slower…?). And of course I want to understand a person’s strengths: have they had an experience like this before? Do they have strong values? Have they succeeded in some area in life? What brings them joy and takes them into the zone? How have they modified the way they do things so they can do what matters?

I like to do this in collaboration with the person (how else could I do it?!) and to look at the good and not so good of everything they’ve done along with the context. Because one thing that always resonates with me is that people do what they do because it’s worked in the past. Always. At least once.

For more on ACT, you can’t go past the Association for Contextual Behavioural Science – https://contextualscience.org/

And Chapter 2 from Lance McCracken’s book Mindfulness and Acceptance in Behavioral Medicine, 2011, Context Press, New Harbinger:

Vowles, K.E, & Thompson, M. (2011). Acceptance and Commitment Therapy for Chronic Pain, pp31 – 60.

Making first contact: what to do with all that information! Part 3

In my last post I described the “4 P” model (sometimes called the 5P!) of formulation for pain. In today’s post I want to talk about an integrated approach for a team.

Teamwork in pain management is an enormous thing – IASP (International Association for the Study of Pain) endorses multidisciplinary (I prefer interprofessional) teamwork but gives little information on how teams best work together. In fact, research exploring teamwork processes in pain management is remarkably absent, even though there’s considerable research elsewhere in healthcare showing that effective teamwork is quite distinct from being an effective solo clinician. The processes of coming together, learning about one another and what each person and profession contributes, learning how to make decisions, how to negotiate differences of opinion, to trust one another: all of these have been explored in other health settings, but not in pain management ones. This matters because of all the areas in healthcare, pain management presents us with the most complex inter-related problems where the model of pain adopted by a team must be consistent or the person with pain will likely feel utterly confused.

’nuff said. Let’s take a look at a team mental model of pain, because this is where learning from one another and across professions becomes “live”.

The basic assumption for the whole team must be that pain is a multifactorial experience, influenced by (broadly) biological, psychological and social elements. In other words, a team won’t work well if some of the members think that pain can be “fixed” by addressing only one piece of the puzzle. Even in acute pain, the team needs to recognise that what a person believes is going on, the meaning they draw from the experience, the influence of others (the family, hospital staff, community) will make a difference to the person’s distress and disability. Context always matters and people always bring their previous experiences (either personal or drawing from what they’ve seen/heard from others, including media) with them when they’re in pain.

If the team takes this idea on board, then the weight that’s placed on the various factors contributing to distress and disability should be equal, at least initially. For example, although anxiety might be a key influence in one person’s pain experience, this shouldn’t be valued above possible biological factors. Each contributing factor needs to earn its way into the overall formulation, and it’s only from reviewing the formulation as a whole that it’s possible to determine where to begin with treatment.

This sounds complicated – and it can be in some cases! But it is really a mindset rather than being horribly complex. If we hold each piece of the puzzle lightly, look to the relationships between each piece, then we can begin to see how one factor influences another. And teams can, if they share their ideas, put the pieces together much more effectively than any single person can – even the person with pain.

Yes, the person with pain IS part of the team – always. How else will the team know they’ve been effective?

Teams form a mental model of what each other knows, what the team (as a whole) thinks matters, and who in the team might offer the mix of skills the person needs. This mental model doesn’t happen instantly: you can’t put six clinicians in a room and an hour later expect them to have a common understanding of pain, each other, and what the team can do. There’s good research showing that teams need time together – even virtual teams (Maynard & Gilson, 2021) – and that frequently changing team members reduces the teams’ effectiveness (Bedwell, 2019; Williams & Potts, 2010). Mental models emerge as teams share knowledge – the problem is that group members often share knowledge that is common, rather than unique information that could be the linchpin to an effective decision (Levine, 2018).

In my experience, and reading through an enormous amount of research, the most commonly adopted model in persistent pain management is a cognitive behavioural approach. Now this is not “CBT” the therapy, but instead an approach that recognises:

• People are active processors of information and not passive reactors.

• Thoughts (e.g., appraisals, expectations, and beliefs) can elicit and influence mood, affect physiological processes, have social consequences, and also serve as an impetus for behavior; conversely, mood, physiology, environmental factors, and behavior can influence the nature and content of thought processes.

• Behaviour is reciprocally determined by both individual and environmental factors.

• People can learn more adaptive ways of thinking, feeling, and behaving.

• People should be active collaborators in changing their maladaptive thoughts, feelings, and behaviour. (Turk & Flor, 2013)

We might disagree on how these points might be operationalised, and treated, but a team should have something like this as a critical understanding of how the factors influencing a person’s distress and disability might fit together.

I’ve written plenty of times about the formulation approach that I’ve often used – here and here – and I’ll show you another ACT-based formulation next week. In the meantime, perhaps it’s time to consider how well you and your team know one another, and consider whether you have enough trust in one another to debate issues (not people), bring unique information (rather than shared), and collaborate rather than compete?

Bedwell, W. L. (2019). Adaptive Team Performance: The Influence of Membership Fluidity on Shared Team Cognition. Frontiers of Psychology, 10, 2266. https://doi.org/10.3389/fpsyg.2019.02266

Levine, J. M. (2018). Socially-shared cognition and consensus in small groups. Current Opinion in Psychology, 23, 52-56. https://doi.org/10.1016/j.copsyc.2017.12.003

Maynard, M. T., & Gilson, L. L. (2021). Getting to know you: The importance of familiarity in virtual teams. Organizational Dynamics, 50(1). https://doi.org/10.1016/j.orgdyn.2021.100844

Turk, D. C., & Flor, H. (2013). The Cognitive-Behavioral Approach to Pain Management. In S. B. McMahon, M. Koltzenburg, I. Tracey, & D. C. Turk (Eds.), Wall and Melzack’s Textbook of Pain (6 ed., pp. 592-602). Saunders. https://doi.org/10.1016/b978-0-7020-4059-7.00043-7

Williams, A. C., & Potts, H. W. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain. Pain, 148(3), 481-486. https://doi.org/http://dx.doi.org/10.1016/j.pain.2009.12.011

Making the first contact

How do we begin working with someone who is asking for help with their persistent pain? In this post I’ll describe some of the considerations I have when I begin, because as Benedetti points out, the “meet the therapist moment” is one of the most potent times in the therapeutic ritual (Benedetti, 2011). It’s the time when the person’s expectations and the clinician’s empathy and competence meet, and the “meaning response” blooms.

My two clinical questions are:

1. Why is this person presenting in this way at this time, and what’s maintaining their predicament?
2. And what is this person’s main concern?

But before I ask these questions, I want to take a moment to think about the person and what might be going on in his or her mind.

Benedetti points out that expectancies are an important part of a response to treatment – whether that treatment has any active action, or not. Expectancies are about what a person brings to a therapeutic encounter: there are two, one is stimulus expectancies (anticipations of external events – eg that the next painful experience will be less), and the other is response expectancies (predictions of your own nonvolitional response – eg that after doing this thing, I expect to experience less pain) (Kirsch, 1985).

People who come to see a clinician, especially a clinician from a little-known profession (occupational therapy!) will hold expectancies about what that person will do, but these will likely be weaker than the expectancies a person might hold about seeing a well-known profession. The strength of an expectancy is different from the direction of an expectancy – for example, a negative experience with a physiotherapist might lead to a strongly negative expectancy about future treatments, while not having had an experience with an occupational therapist might lead to a weakly positive expectancy about what’s about to happen.

Along with expectancies, the person will likely be anxious about what’s to come. The possibility of something that might help (or not), meeting a new clinician, and living with pain are all stressors – and anxiety erodes a person’s ability to absorb lots of information, while biasing them towards remembering threatening words (Reidy & Richards, 1997).

So there’s a lot going on in the person’s mind when they attend that first session.

There’s also often a large power imbalance (Joseph-Williams, Edwards & Elwyn, 2014). This emerges from the fact that often clinicians hold a lot more information about the person we’re seeing than they do about us. Especially after we’ve asked a bunch of questions, often quite intimate in nature. For a person seeking help, this imbalance can make it hard to ask questions, to direct the conversation, to hold a sense of independence throughout the encounter.

So having set the scene for you, I’m sure you can agree that how we go about collecting information from a person is incredibly important – especially so that relationship can begin to build.

Introductions

In the introduction, I seek to give the person some information about who I am – not just as a clinician, and the kind of treatments I use, but also about who I am. I’ve drawn inspiration from tikanga Māori here, where the cultural tradition entails letting the person know where I come from and who I’m connected to. I like to let people know my childhood roots are in Turanganui a kiwa, or Gisborne. That the mountain my heart connects with is Mount Hikurangi – the first mountain in NZ to see the sun. The river I connect with is the Taruheru, flowing into the sea in Gisborne. I also let people know my whanau connections – the Lennox’s, and the Thompson’s, are my whanau (extended family), and I’m a 5th generation New Zealander. I now live in Otautahi/Christchurch. This introduction only takes a few minutes, and your culture might not value this form of introduction. For me in Aotearoa/New Zealand, it’s one way I can show respect and follow a tradition that means the person I work with knows something more about me than just my name.

I also include my profession – what I do. I’m an occupational therapist, my job is to help people do what matters in their life contexts.

I like to then let the person know that they’re brave and courageous for seeking help – it’s not easy to say you can’t do this on your own. It takes courage to tell someone that.

Questions

Then I open with a broad question about what has led this person to come to see me. I might add in something about “tell me about your pain and what you’ve done so far for it.” I’ll often ask what their theory is about their pain, what they think is going on.

Then I ask “What is your main concern today?”

Throughout this process I’m reflecting what I’ve heard, to ensure I’ve understood what the person has experienced. I’m NOT giving reinterpretations, I’m NOT giving out new information, I’m just listening.

I often spend time asking about four areas of life: relationships, fun, work, and health. Or I might ask the person to take me through a typical day, from the time they wake up.

I like to find out not just what the person has done to help themselves, but also what they’ve learned from these experiences. The messages they’ve received over time, and the things they’ve tried but perhaps didn’t like or that didn’t help.

Questionnaires

I was a big fan of questionnaires filled out ahead of time, and I am still a fan but don’t use them as much. This is mainly because so many people have filled out endless questionnaires and nobody has sat down with them to talk about what they mean! So I’m a little more selective and focus much more on listening first then choosing something that will offer me and the person some insight into what might be going on. For example, I might choose the PASS20 (McCracken & Dhingra, 2002) because it helps me figure out where to begin with reducing pain-related anxiety. It’s a good measure to use each week to track changes over time, and I’m beginning to delve into repeated measures of progress rather than a pre-post-follow-up approach that’s typical.

Observation

Covid has meant it’s not as easy to carry out observational assessments, but I’m always watching how the person sits, moves, walks, and body language. What I’m not doing is interpreting these observations without talking to the person about them! Too many clinicians make judgements about the person based on maybe one or two observations, out of context of the person’s life and environment, and without checking in with the person to work out what might be contributing to what they see. Let’s not do that – the person might be completely oblivious that they’re guarding their sore hand, or they keep shifting in the chair, or that a habitual movement like taking a jacket off might be easier to do than being asked to perform some weird movement at the command of the clinician!

Pulling it all together

Just as we wouldn’t expect to be marched in for surgery straight after our first consultation with an orthopaedic surgeon, I don’t believe it’s OK to offer something to a person on their first visit just because we feel internal pressure to do so. Having said this, I will often suggest to the person that they spend a bit of time doing some brief “noticing without judging” exercises. We’ll give it a go at this first appointment, so they’re not being expected to go do it without knowing how. The reason I start with brief noticing experiments is that it’s something we could all do more often, it gives the person a new skill (usually) to develop, and it’s often an introduction to being fully present without judging. Being fully present without judging is hard to do when you’re sore because the mind likes to anticipate how bad it’s going to be (“you’ll need to take it very quietly or you’ll pay for it”) or remember previous pains (“last time you just sat around your pain went nuts, you don’t want to risk that now do you?”).

Notes/Documentation

I write conversational notes directly to the person, going through what we’ve talked about and pulling together all the information I’ve gathered in this first meeting. I find it helps me to make sense of what’s going on, it allows me some time to reflect on what I’ve observed and heard, and I can assemble it in a case formulation that the person and I can explore if/when we meet again.

Assessment is never over. Every time I meet with a person I’ll be learning more about what’s going on. I don’t feel pressured to “find it all out” at that first session just because there are goals that must be developed. In fact, one goal I leave in for everyone is “develop goals” (well, I don’t use goal language – it’s more about directions and actions that take you there). Because seriously, how can anyone meet someone and immediately develop goals – that’s disrespectful to the person who may not have had time to think about what matters the most, and it’s disrespectful to the complexity of goal setting as a process anyway.

Theme and variations

I’ve written one approach I use for learning about the person I’m trying to help. There are others – a time line, drawing a life map, mind-mapping, walking and talking, making a coffee – all of these and more can be used to explore the same information.

Let’s not call it “the subjective” – let’s call it what it is, our first “getting to know you” meeting.

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189–1202.

Joseph-Williams, N., Edwards, A., & Elwyn, G. (2014). Power imbalance prevents shared decision making. Bmj, 348.

McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research & Management, 7(1), 45-50.

Reidy, J., & Richards, A. (1997). Anxiety and memory: A recall bias for threatening words in high anxiety. Behaviour Research and Therapy, 35(6), 531-542.