Five things I learned about pain this year

1. Our definitions of pain matter more to researchers and people who like to philosophise about pain than to people experiencing pain. At the same time, definitions do matter because when the IASP definition of pain was first established, the distinction between the neurobiological underpinnings of pain – and the experience – was clear. And this matters because neurobiology is only part of the picture. (Chekka & Benzon, 2018; Cohen, Quintner & van Rysewyk, 2018; Reuter, Sienhold & Sytsma, 2018; Tesarz & Eich, 2017; Williams & Craig, 2016)
2. The idea of “tribes” in pain and pain management is a misinterpretation of our need to work together as clinicians because pain is complex. The old argument that we’ve omitted “the bio” because we use a biopsychosocial framework for understanding pain is, frankly, ignorant. It’s also destructive because we need one another when we try to help people who are seeking our help. And even if someone has a straightforward sprain, fracture, or whatever – that sprain is happening to a living, breathing, thinking, emoting, motivated person. If we are to break down the silo thinking in pain management, we also need to learn how to work together within an interprofessional team. This means learning to speak a common language. This also means including the person with the pain as part of the team. To think that we can ignore the person and focus only on “the tissues” means we also must agree that our contribution as health professionals could be replaced by an algorithm (Gordon, Watt-Watson & Hogans, 2018; Lötsch & Ultsch, 2018; Shluzas & Pickham, 2018 .
3. The gap between what is investigated in research institutions and both the concerns of clinicians and patients, and implementing research findings is enormous. Accusing researchers of ‘living in ivory towers’ fails to recognise that most of our active pain researchers in rehabilitation still continue in clinical practice. The gap seems to be between funding agencies (valuing high tech, high impact research) and the concerns of clinicians (often about high value, low tech, and low cost research). There are very active discussions about “how do I use this study” on social media across the board – Twitter, Facebook, LinkedIn, blogging – and these represent possibly the most important vehicles for clinicians, policy-developers, researchers and people living with pain to break down silo thinking and begin to address the factors that contribute to the knowledge translation gap. Many discussions on Exploring Pain: Research and Meaning (Facebook group) end with acknowledgement that funding systems simply do not support collaborative evidence based teamwork (Arumugam, MacDermid, Walton & Grewal, 2018; Bérubé, Poitras, Bastien, Laliberté, Lacharité & Gross, 2018; Chen, Tsoy, Upadhye & Chan, 2018; Romney, Salbach, Parrott & Deutsch, 2018; Tougas, Chambers, Corkum, Robillard, Gruzd, Howard,… & Hundert et al., 2018).
4. The social part of pain is receiving increased research and clinical attention – and it’s a messy area of study. Social isn’t well-defined – it can mean social psychology, sociology, culture, health systems, media, feminism, political science, legislation – anything where people interact. Social psychology studies investigate things like trustworthiness, gender effects in interactions, stigma (Naushad, Dunn, Muñoz & Leykin, 2018; Sherman, Walker, Saunders, Shortreed, Parchman, Hansen, … & Von Korff, 2018; Wesolowicz, Clark, Boissoneault & Robinson, 2018), while sociology examines diagnoses and power relationships in healthcare – things like being “too young” for a diagnosis of arthritis (Kirkpatrick, Locock, Farre, Ryan, Salisbury & McDonagh, 2018) or validating the pain of menstruation (Wright, 2018) or a diagnosis of fibromyalgia (Mengshoel, Sim, Ahlsen & Madden, 2018). It seems no accident that many of the pain problems needing “validation” occur more often in women, and fail to have “objective” signs. But social means more than labeling and interacting, it’s also about community values and ideas – and how pain is portrayed by people experiencing pain, and in the media (Kugelmann, Watson & Frisby, 2018). The way WE talk about pain, and how we talk about people living with pain. How people living with pain are portrayed and how they portray themselves (ourselves). I suspect the social aspects of our experience with pain are amongst the most complex and most potent in determining suffering (loss of sense of “who am I?”) and disability (“what can I still do?”).
5. Finally, I am encouraged by the wealth of information being shared freely, discussed passionately, and applied in many different forms around the world. I am proud to have been associated with many different groups as we – you, me, people living with pain, us – keep this topic alive and up-front. While I am no great productive scholar, I publish few peer-reviewed articles, and in the eyes of University hierarchy I am insignificant, I believe the conversations had on social media and into the real world have an impact on how we work in the clinic. If we can achieve the things we talk about, even if we achieve only a fraction of those things, we will have helped more people than we can ever imagine. I feel so privileged to have got to know some of the greatest “lived experience” advocates for greater ‘patient’ involvement in our conversations about pain. Isn’t it time we remembered the old adage “nothing about us without us”? Social media allows us to break the code of silence – and the distinction between “us” and “them” in the world of pain. After all, many of “us” are also living well with persistent pain.

Arumugam, V., MacDermid, J. C., Walton, D., & Grewal, R. (2018). Attitudes, knowledge and behaviors related to evidence-based practice in health professionals involved in pain management. International journal of evidence-based healthcare, 16(2), 107-118.

Bérubé, M. È., Poitras, S., Bastien, M., Laliberté, L. A., Lacharité, A., & Gross, D. P. (2018). Strategies to translate knowledge related to common musculoskeletal conditions into physiotherapy practice: a systematic review. Physiotherapy, 104(1), 1-8.

Chen, E., Tsoy, D., Upadhye, S., & Chan, T. M. (2018). The Acute Care of Chronic Pain Study: Perceptions of Acute Care Providers on Chronic Pain, a Social Media-based Investigation. Cureus, 10(3).

Chekka, K., & Benzon, H. T. (2018). Taxonomy: definition of pain terms and chronic pain syndromes. In Essentials of Pain Medicine (Fourth Edition) (pp. 21-24).

Cohen, M., Quintner, J., & van Rysewyk, S. (2018). Reconsidering the International Association for the Study of Pain definition of pain. Pain reports, 3(2).

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).

Kirkpatrick, S., Locock, L., Farre, A., Ryan, S., Salisbury, H., & McDonagh, J. E. (2018). Untimely illness: When diagnosis does not match age‐related expectations. Health Expectations.

Kugelmann, R., Watson, K., Frisby, G (2018). Social representations of chronic pain in newspapers, online media, and film. Pain, in press.

Lötsch, J., & Ultsch, A. (2018). Machine learning in pain research. Pain, 159(4), 623.

Mengshoel, A. M., Sim, J., Ahlsen, B., & Madden, S. (2018). Diagnostic experience of patients with fibromyalgia–A meta-ethnography. Chronic illness, 14(3), 194-211.

Naushad, N., Dunn, L. B., Muñoz, R. F., & Leykin, Y. (2018). Depression increases subjective stigma of chronic pain. Journal of affective disorders, 229, 456-462.

Reuter, K., Sienhold, M., & Sytsma, J. (2018). Putting pain in its proper place. Analysis.

Romney, W., Salbach, N., Parrott, J. S., & Deutsch, J. E. (2018). A knowledge translation intervention designed using audit and feedback and the Theoretical Domains Framework for physical therapists working in inpatient rehabilitation: A case report. Physiotherapy theory and practice, 1-17.

Sherman, K. J., Walker, R. L., Saunders, K., Shortreed, S. M., Parchman, M., Hansen, R. N., … & Von Korff, M. (2018). Doctor-patient trust among chronic pain patients on chronic opioid therapy after opioid risk reduction initiatives: A Survey. The Journal of the American Board of Family Medicine, 31(4), 578-587.

Shluzas, L. A., & Pickham, D. (2018). Human Technology Teamwork: Enhancing the Communication of Pain Between Patients and Providers. In Design Thinking Research (pp. 313-325). Springer, Cham.

Tesarz, J., & Eich, W. (2017). A conceptual framework for “updating the definition of pain”. Pain, 158(6), 1177-1178.

Tougas, M. E., Chambers, C. T., Corkum, P., Robillard, J. M., Gruzd, A., Howard, V., … & Hundert, A. S. (2018). Social Media Content About Children’s Pain and Sleep: Content and Network Analysis. JMIR Pediatrics and Parenting, 1(2), e11193.

Wesolowicz, D. M., Clark, J. F., Boissoneault, J., & Robinson, M. E. (2018). The roles of gender and profession on gender role expectations of pain in health care professionals. Journal of Pain Research, 11, 1121.

Williams, A. C. D. C., & Craig, K. D. (2016). Updating the definition of pain. Pain, 157(11), 2420-2423.

Wright, K. O. (2018). “You have Endometriosis”: Making Menstruation-Related Pain Legitimate in a Biomedical World. Health communication, 1-4.

Mind your language!

“Words are pale shadows of forgotten names. As names have power, words have power. Words can light fires in the minds of men. Words can wring tears from the hardest hearts.”
― Patrick Rothfuss, The Name of the Wind

So much has been written about language, and I am not a linguist. I am, however, often accused of being pedantic because I like to use words with precision.

In the world of pain rehabilitation/management/treatment/care (see what I did there?!) certain words seem to spark a huge debate. Words like “pain”, “nociception”, “suffering”, “harm”, “avoidance”, “catastrophising” all get a regular hammering in online discussions. Less frequently, words like “guru”, “expert”, “master”, “authority”, “sage” reach the discussion boards and in the same way as “pain”, elicit an almost visceral response.

Before I begin commenting in earnest, I want to preface this piece by making it absolutely clear that I am not commenting on any particular person, organisation, group, business, or endeavour. Please read the whole piece thoroughly before commenting!

I’m not an expert, authority, sage, master or guru. I have years of experience and lots of learning, I’ve studied a lot, I’ve worked with lots of people living with pain, and I’ve worked across a wide range of settings – but they’re all in NZ. I work in an academic institution. I teach postgraduate pain and pain management from a certain perspective. I encourage my students and readers of this blog, as I do all the people I’ve tried to help, to always, always read and be critical of what I say.

I don’t know whether it’s part of growing up in the 1970’s, or it’s the religious upbringing I had, or whether it’s a New Zealand characteristic, but self promotion and the idea that I’m “more important” or more authoritative than anyone else is anathema to me. It’s probably why I give information away, and why I’m not a business owner.  Whatever the case I really dislike the idea of guruism. As a concept. As it is applied to healthcare.

When I think of the word guru, I think of someone who believes he or she knows more than normal people, someone who wants (or has) followers (disciples). It smacks of a lack of acknowledging that the more we know the more questions we have and the less we feel we actually know. The word puts the person on a pedestal.

Some people have been my gurus. People I’ve admired, wanted to emulate, who have influenced the way I think about things. I’ve put those people in a position of influence over me. I need to remind myself to be critical, to think independently, to hold different opinions if I’ve thought about the things they say. That’s not easy to do – highly charismatic people are great at influencing me, and in a field of practice where there is great uncertainty, it’s tempting to grasp what looks like an appealing concept and run with it. At this point I’m reminded of the quote: “For every problem there is an answer that is clear, simple, and wrong” (HL Mencken).

What strikes me is that guru is a term derived from Hindi (Sanskrit, actually) and according to Wikipedia and a few other etymology references, was a term accorded to “one who dispels the darkness and takes towards light, traditionally a reverential figure to the student, with the guru serving as a “counselor, who helps mold values, shares experiential knowledge as much as literal knowledge, an exemplar in life, an inspirational source and who helps in the spiritual evolution of a student.” (Thanks Wikipedia) Wikipedia goes on to say “the term is sometimes used in a derogatory way to refer to individuals who have allegedly exploited their followers’ naiveté.”

I see a couple of risks associated with identifying or being identified as a guru. The first is that we believe it ourselves. That we have the knowledge to “dispel the darkness”, and the right to “mould values… an exemplar, an inspirational source”. This can tempt us to be less aware of our own biases, to accept them or make exceptions for them. It can encourage us to think our view is “right”, to stop constantly asking ourselves those difficult questions.

The second is that our followers may do the same. Follow what we say without thinking independently. To read what we write without reading others. To forget to cross-check our work. Add to this the reality that most people who are adopted as gurus have years of experience and knowledge that underpins their superficially-simple (or should that be deceptively simple?) and readily digested approach. This experience and knowledge often can’t be replicated, or isn’t even explicit to adherents – so rather than a multi-layered and complex emergence of understanding, followers may simply pick and choose sound-bites, and apply them liberally and without the nuances the originator brought to the concept. Tell me you haven’t see this in pain rehabilitation over the years! And then, of course, comes the fighty talk and internet wars and tribalism we’ve seen so often.

The third problem or risk is that the people we try to help, those with pain, can be vulnerable to the hype. They too can believe that they “should” respond to the simple message, and if their own experience doesn’t accord with the “wisdom” of the guru, they can begin to blame themselves – and at times, be blamed by adherents.

There are undoubtedly other risks, but these are my key concerns about anyone being viewed as an expert or guru.

Every word begins with a few meanings within a certain context. Then the words grow a life of their own. Words are sociocultural – they have power despite “sticks and stones will break my bones but words with never harm me”. Words continue to acquire meaning and subtle use-changes over time. People in different parts of the world, of different backgrounds, at different ages and in different settings will use words quite differently. For me, guru is a word I really dislike, but for others it’s a legitimate term to describe themselves and their word. The thing is, whether we like it or not, the word has both good and not-so-good associations for people. And both matter. Guru might speak of “aha! here’s someone who can help”, or “a group I feel comfortable with – my tribe”, or “expert with lots of knowledge”. But it might also just as equally speak of hype, inflated ego, a need to be worshiped and collect adherents, blind allegiance.

Along with thinking hard about how I want to represent myself while writing this blog, I’ve also been pondering a list of various ways to describe pain and the neurobiological and experiential apparatus underpinning the experience.

Defining pain is incredibly difficult – while we’ve all experienced pain, we’ve never been able to share the “what it is like” to experience pain. Our personal experience of pain is within contexts we’re familiar with – for many people it really is a short-term experience, a warning of potential damage or threat to bodily integrity (and social, too), a symptom of “something else” that must be attended to, and something that will be resolved once that “something” is fixed. For others it is a stigmatising experience.

For some it’s an experience used to represent going through an ordeal and coming out the other side having learned something. For still others it’s a deeply scarring, personally disruptive experience that isolates and depresses and angers. For some it’s a mystery to be solved. For others it’s a neutral, uncomfortable yes but not distressing experience because it’s familiar and no longer understood to be representing anything much.

Most of these contextual experiences reflect appraisals of the ineffable experience, rather than distinguishing this experience from other experiences such as joy, hunger, fatigue. And I think it’s useful to remember the purpose of a definition – in the case of IASP pain definition, it has allowed researchers, clinicians, and people living with pain to acknowledge that nociception (and associated processes that contribute to our experience of pain) is not the same as pain. And that behaviours we do when we experience pain are also not pain. And that how we view or appraise our experience influences both the experience itself, and our response to it. And FWIW I use the term “it” as a placeholder for “the experience we know as pain”. 

Given that words are fluid, why on earth am I trying to argue the toss about how I view words like “guru” and “pain”? Because in this context, where people are talking with one another, clarity of meaning aids us to understand the concept we’re discussing. And because this is a particular context. And this is my opportunity to express my opinion. Readers will undoubtedly interpret what I’ve written in their own way. What I would ask is that people don’t interpret this post as having intentions I don’t have. After all, as the author, I’m probably the only person who can determine my intentions for what I write.

Occupational therapists’ knowledge of pain

I am mightily bothered by health professionals’ lack of knowledge about pain. Perhaps it’s my “teacher” orientation, but it seems to me that if we work in an area, we should grab as much information about that area as possible – and pain and pain management is such an important part of practice for every health professional that I wonder why it’s so often neglected. So, to begin exploring this, I completed a search looking at occupational therapists’ knowledge of pain – and struck gold,  kinda.

Angelica Reyes and Cary Brown conducted a survey of Canadian occupational therapists, to explore how well occupational therapists knew their stuff.

Members of the Canadian Association of Occupational Therapists were asked to participate and a total of 354 therapists (mainly from Ontario, Alberta and Nova Scotia) took part. Curious that few were from British Columbia where I know of quite a few occupational therapists working in the area, but there you have it.  Over half of the respondents had 10 years or less experience – so they were fairly recent graduates and should reflect a “current” educational bias. Only 5% of the total number of members of CAOT responded, so this is a fraction of the occupational therapists working in Canada – but you’d think the motivated (ie knowledgeable) would be more likely to respond than those who don’t work in the area….

What they found was consistent with previous studies (prior to 2000) showing that these respondents, who were surveyed using the City of Boston’s Rehabilitation Professionals’ Knowledge and Attitude Survey (Rochman & Herbert, 2015), had disturbing “potential knowledge gaps” in the following areas:

• children’s ability to feel pain;
• use of analgesics in orthopedic pain
• use of nondrug treatments
• thermal modalities
• prevalence of malingering
• impact of therapists’ values on assessment of veracity
• mind/body dualism in chronic pain
• measurement of pain intensity
• effect of under-treatment on chronicity
• prevalence of patients who over-report pain
• prevalence ofpatients who are likely to become addicted if treated with opioids.

Of particular concerns was 45.7% of participants believed that malingering is common; 38% believed that pain intensity can be objectively measured, 39.7% believed people with pain over-report their pain, and 59.8% believed that opioid addiction is likely to occur in more than 5% of the patient population.

OUCH!

So, it seems that these occupational therapists had some very outdated ideas about pain, and in particular, seem to have missed the point that because pain is a biopsychosocial experience, we have no way to determine whether someone is “faking” – or malingering.

Now, I will lay good money on a bet that if we were to carry out this very same survey amongst any other health profession, we’d still arrive at these rather unsavoury findings. Folks, I live in a pain nerd bubble and I still hear these kinds of discussions amongst knowledgeable health professionals, so it’s unsurprising that so many people hold these beliefs. Beliefs that will hamper developing good relationships with the people we want to help, and beliefs that fly in the face of what we know about pain.

I am SO not pointing the finger at Canadian occupational therapists, neither am I pointing the finger at my profession alone. I think this lack of understanding reflects many things:

1. Pain is a complex experience, and the legacies of ancient models lingers everywhere (dualism, medical model, reductionism, etc);
2. We devote very little time in our professional training to learning about pain – and often, it’s limited to “here is the nociceptive system”;
3. The research around pain has exploded over the last 15 years – it’s hard to keep up, which is why I blog;
4. The problem of persistent pain is under-estimated, so if a person works in paediatrics, older person’s health, neurology, brain injury, spinal cord injury – it’s quite probable that pain is almost completely ignored, because “it’s not relevant”. After all, pain is something for specialist pain services, yes? NO
5. Prevailing attitudes within the healthcare community are that pain is a difficult area to understand – and “should” be treated with medication or surgery otherwise….

You can see that this year’s IASP Global Year for Excellence in Pain Education has much to do.

Did you know that IASP have produced NINE comprehensive curricula – including occupational therapy  (thank you to Emeritus Professor Jenny Strong, Professor Cary Brown and Dr Derek Jones for developing this wonderful resource). This means there is no reason for us not to begin integrating this import area of practice into our undergraduate training.

Research examining occupational therapy’s contribution within pain management is in its infancy – but oh how my occupational therapy heart went pit-a-pat when, at the Australian and New Zealand Pain Society Scientific Meeting I presented alongside two other occupational therapists with PhD’s (or nearly there!) to a room full of clinicians, not just occupational therapists. While we have little specifically occupational therapy research, occupational therapists have been and are continuing to be part of research efforts around the world. And what clinicians do is apply what is learned into the daily lives of the people we work with. That, friends, is what occupational therapy is about – helping people live full, rich lives doing what’s important to them.

Reyes, A. N., & Brown, C. A. (2016). Occupational therapists’ pain knowledge: A national survey. Disability and Rehabilitation: An International, Multidisciplinary Journal, 38(13), 1309-1317.

Rochman D, Herbert P. Rehabilitation professionals knowledge and attitudes regarding pain (COBS). Accessed 18 March 2015. Available from: http://prc.coh.org/html/rehab_professionals.htm.

You are unique, and if that is not fulfilled, then something has been lost: Martha Graham

In an era in healthcare where administrators prize standardisation, algorithms and consistency, it’s no wonder that in chronic pain management there are concerted efforts to make a standard treatment recipe to suit everyone. After all, there are common things that people living with pain need: accurate information about pain, accurate information about tissues and how they contribute to pain, assurance that pain doesn’t mean ongoing damage, and being introduced to some safe movements that don’t threaten an already agitated nervous system. There’s even a call for clinicians to use a kind of curriculum to make sure all the important bits are covered based on the individual’s presentation. This is valuable stuff!

But, I think standardisation* is both an admirable and a futile effort. Admirable because we know there are so many clinicians and patients who don’t get told much  of this information. Admirable because it would be great to know that once given, this information should make a difference to the person living with pain. Admirable because it’s easier to remember a “standard” list of topics, or a standard management approach than to generate a fresh new one every time a person comes in to see you. But I think a standardised approach (used unthinkingly) might not be the most efficient way, it could almost be futile, and here’s why.

*(note: not the curriculum for pain education, but the notion of a standard list of topics that every person with pain should have covered)

I’m a nerd. That’s right, when I get on a topic I love, I can talk for hours! I have seen the eye rolls, and that subtle slump that tells me that I’ve gone on too long. I think there’s a very fine line between being enthusiastic and being too intense, particularly when it’s a topic I love but maybe the other person is less enthralled with. I know I’m not alone in this enthusiasm (thank goodness!) but I also know that I need to be aware of all those cues that tell me when someone has had enough and I’m boring them. If I want to do more than lecture, I need to go about my conversations in a different way.  I have to actually converse not harangue!

Conversations, especially where one person is knowledgeable about a subject and the other isn’t, are really guided discoveries. A guided discovery is where one person asks a question and the other person, who knows the answers, is able to answer. The questioner listens because he or she wants to find out. Various skills underpin conversations – mirroring body language, use of gaze (looking at the person, looking away), using metaphors and those little “listening cues” like “uhuh” or “mmmm” or “tell me more”. The thing about conversations is that although one person is finding out about the other, in fact most times both parties will learn something new.

We’d expect the person asking the questions to learn something new, but the person responding? How do they learn something new? There’s quite a large body of research that considers conversation to be one of the main ways humans develop meaning, and that these meanings are then reflected in the way we perceive events and act on them (Strong, 1999). In other words, as we converse with one another we develop a shared understanding of the subject under discussion – or at least it’s possible to do so.

This view is part of a social constructivist view of reality.  Strong’s paper states that people living with chronic pain experience suffering when “chronic pain sufferers and others are engaged in conversations that yield no differences in meanings for the participants” (Strong, 1999, p. 39). In other words, when one person is not heard, or the conversations they have with others don’t influence the beliefs or meanings they have, the conversations themselves contribute to suffering.

It’s not hard to see that if one partner in the conversation isn’t really listening; or if the questions being asked are only done to confirm a prior belief; or if the person answering doesn’t think the other is listening – well, neither person will change his or her understanding. And I think this is what we risk if we use a standardised way to provide information to people.

I can see that instead of being a conversation in which both parties learn, “educating” could become an opportunity for one person to lecture the other. Now I know this isn’t the intention of pain neurophysiology education. I know that it’s intended to be conducted within the framework of genuinely wanting to help the person living with pain view their pain as less threatening and less mysterious.

I said before that I think standardising a “pain education” for people living with pain might be futile. This is why: when each person has a unique understanding of their body, their pain and their life, and when they’ve had a unique pathway to getting to see a clinician, they’ve probably also had any number of unique conversations in which their understanding of their pain has been changed. They’ve taken a bit here, and a bit there. A piece of this and a dab of that. And then they’ve infused this with their own experiences and arrived at their own theory for why they have pain. Each one of those thoughts and beliefs and attitudes needs to be revisited in the light of new information. This is not something that will shift with just one “info dump”.

What I’ve learned from motivational interviewing and case formulation (thanks psychology!) is that until the person is ready to hear what we have to say, they’ll pick up on the parts of what we say that they want to hear. What this means is that we need to give them the respect they deserve for making their own theory for their pain, and we need to listen to what it is and how they’ve developed it. It makes sense to them. And we need to ask for permission to introduce a new idea. If we jump right on in there without being given permission I know how that will go down! In a few cases the person will be absolutely fine with it: they were ready to hear something new. But in many cases, we’ll be generating resistance because we’re challenging something the person has learned for him or herself.

I think we also need to recognise that people pick and choose the bits of information that resonate for them. This means their understanding of pain is unique to them. We know that reviewing existing knowledge in light of new information is a really good way for students to develop a deep understanding of their subject matter – the same occurs for people learning about their pain. By gently guiding people through both their current understanding, and then through a combination of information and experience, they will draw their own conclusions about what this new material means. Our “education” needs to be a guided discovery together with the person so they can make sense of their experience in the light of new information.

Some resources for guided discovery: – teaching physical education

Socratic questioning – Padesky

Priory – guided therapy

Psi – Balancing thoughts

Strong, Tom. (1999). Macro- and micro-conversation in conspiring with chronic pain. Journal of Systemic Therapies, 18(3), 37-50.

Book review: 2nd Edition of Pain: A textbook for health professionals

I’m an educator, and always on the lookout for a good textbook that summarises and presents up-to-date material in a format that’s easy to read and yet comprehensive. The first edition of this book was a great one and I’ve been hoping a new edition would come out – well, the wait was worth it!

Pain: A textbook for health professionals is edited by Hubert van Griensven, Jenny Strong and Anita M Unruh, published by Churchill Livingstone (Elsevier), and released in November 2013. It’s a whole lot of new material wrapped up in a shiny new cover, over 400 pages of fully-referenced patient-centred pain geekery.

What makes this book different from many is the focus on functional outcomes for people with pain, and on the patient’s voice. The book opens with a chapter on “what is pain” from the perspectives of the person, the interprofessional team, the physician, nurse, psychologist, physiotherapist and occupational therapist – and other providers. The “textbook” nature of the book means there are reflective exercises scattered throughout in which you are invited to reflect on your experiences and perspectives, also clear objectives for each chapter, and study questions at the end of many chapters. This is great, because it can be so easy to read with the head and not with the heart.

What’s in the book?

It opens with “what is pain”, the patient’s voice and social determinants of pain as the first three chapters. This is again unusual, because most texts open with neurobiology or models of pain, sometimes forgetting that it is people who experience pain, while neurobiology only transmits information.  It also reminds us that for us to know anything about what it is like to have pain, both the person with pain and the onlooker need to communicate – to encode, transmit and decode behavioural components to convey the pain experience to one another. And here is where so many problems begin! Because if either party fails to recognise the signals, communication is faulty and we have assumptions and opportunities for misinterpretation that can then lead to increased distress and disability.

The first section of the book then covers the psychology of pain, models of pain, neuroanatomy, and neurophysiology of pain. What I like about these chapters is their clarity and the level of detail which is not overwhelming but remains accurate (to the extent we can be!), and is well-illustrated for those of us who like pictures for learning.  The level at which it’s written is for those with a reasonable familiarity with anatomy and physiology, but it’s not dumbed down, and quickly gets into the level of detail needed to understand many of the latest publications in the area.

The second section relates to assessment and management, and its in this section (which has 10 chapters) that this book really shines. It incorporates biomedical, psychological, functional and complementary modalities, including manual therapy and workplace rehabilitation. Not something you’ll often see in a textbook on pain! I particularly enjoyed the chapter on neuropathic pain and complex regional pain syndrome, and it’s great to see discussion of newer modalities like mirror therapy, laterality training and graded motor imagery.

The third section is called “special issues” and has chapters on pain education for health professionals, pain in childhood and older adults, cancer pain and spinal pain, and then turns to some rather neglected issues: rehabilitation and ICF, life role participation, the law, psychiatric problems, and acute pain.  These are remarkable because they consider the impact of having pain on the individual’s identity and life even if the pain subsides. The focus of management is not simply on pain reduction, but on how an individual becomes well again.

What I like about this book:

It’s comprehensive, written by experts in the field, clearly written, and considers the person with pain and the effect pain has on identity and engaging in occupation. The index and referencing is great, nice clear illustrations, lots of aids to learning including the reflections and end of chapter study questions. The price is reasonable and I could see this book being used as a textbook in pain courses (I may even adopt it for my students!).

What I like less about this book:

For a textbook, the cover (I have a soft cover) is a bit light, and I am worried about the spine breaking down if it’s used the way I use textbooks – opened out, copied so I can highlight pages, pages marked with post-it notes, and used in a busy office space where someone else could “borrow” it! It’s definitely covetable, and that’s always a problem for me (I never remember to get them back!).

The price in New Zealand was about $85.00. I think that’s pretty good given the cost of many other textbooks. This book would sit well on anyone’s shelf, but especially for people wanting a good overview of pain and pain management, and anyone entering pain management practice.

Overall:

A very useable, readable textbook on pain for clinicians who want a thorough introduction to pain management, or to refresh and update knowledge without wading through all the journals.

And for people who would like a patient-oriented book: I’ve reviewed Dr Steven Richeimer’s book Confronting chronic pain in my Healthskills4Pain blog

How well do people understand their neuropathic pain?

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

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

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

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

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

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

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

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

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

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

 

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

 

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

Black and white thinking must be abolished

Black and white thinking, for those readers unfamiliar with cognitive distortions, refers to the tendency to reduce complex ideas and situations into simple, dichotomous, and mutually exclusive categories.

Think of good or bad, yes or no, all correct or all wrong, acute pain or chronic pain, neuromatrix or peripheral mechanisms, cure the pain or manage the pain.

It’s a way of simplifying arguments or decisions that can work well when the situation requires very fast decision-making, or where the options are very limited.

It doesn’t work at all in the messy and complicated worlds of clinical reasoning, theory development, or in discussions to broaden understanding.

I’m pondering this because of the way various aspects of pain management and the science of pain are misrepresented as opposed to each other, when maybe it’s not quite so simple.

I hope (crossing fingers and toes) that I’m not doing prone to doing it too often on the pages of this blog, or elsewhere for that matter!

There are multiple strands of research into pain at present. 

There are the reductionists who focus exhaustively on smaller and smaller elements of biology to explain the processes involved in nociception and transmission from noxious input to the perception of pain and back to the responses as a result. 

There are the phenomenologists who focus on the ‘lived experience’ of the individuals who have pain.

There are those who are furiously investigating laterality and cortical processing.

There are others feverishly working on ways to abolish all pain, and those who are equally enthusiastically researching why so many people are unbothered by their pain even though it’s severe.

Can you see all those opportunities for opposing views? for argument and debate?  It’s common for any of us to think mainly in terms of our own orientation, and there are many factors in human cognitive bias and group decision-making that get in the way of us working towards consensus – or even hearing each other.  And that can lead to trouble within teams, especially multi- or inter-disciplinary teams.

I wonder if it’s time to apply some of the cognitive techniques we can use with patients to ourselves as clinicians.  Let’s take a quick look at some of the basics.

Firstly, why do we use black and white thinking?  Well, it simplifies things.  If we’re feeling a little bit sad, we’re more likely to tell a loved one that we’re feeling “terrible”.  We don’t mean to exaggerate, we’re aiming to get empathy from the person we’re talking to, so we unintentionally use dichotomous language – we think in terms of feeling “amazing” vs feeling “terrible”.   Humans like to identify patterns, and to group similar things together so we can generalise.  We like to reduce an argument into “either – or”.  And when we do this, once again because of our tendency to look for information that confirms our own position, we often fail to recognise other alternatives, or information that doesn’t fit with our own views.

What we can do is step back and carry out some metacognition – thinking about our own thinking.

Some questions we can use to challenge our own position are:

• How did I come to that conclusion?
• What’s the evidence for the other position?
• Is it possible to use “and” instead of “either/or”?
• What are the other options?
• Are there parts of my argument that can’t explain something the other position can explain?
• This idea is only an idea – not my personal possession
• Consider saying things like “at the moment my position is…”, “I’m attracted to this idea currently…”

I’ve personally found it useful to relax a little and recognise that in the end, the data will speak for itself.  So, for example, I was initially not keen on mirrorbox and laterality training for CRPS.  The studies, especially in the early stages, weren’t carried out in people with the degree of chronicity and complex psychosocial background that I saw.   Over time, and as the evidence has been gathering, I’ve changed my position.  I don’t mind acknowledging this change – in the end, it’s not my ego that’s important, nor “my” ideas – it’s what helps this person at this time with this particular problem.

Having said this, developing critical thinking skills, and in particular, being able to unpack and delve into how a study has been conducted and whether the conclusions drawn are supported by the data is vital.  Cherry picking, or selecting studies that support one view or another while ignoring or failing to account for studies with conflicting findings, just doesn’t do – again I try to relax a little, because in the end the balance of evidence does fall one way or another.  Or, in the case of chronic pain management, maybe there is so much to learn that what we know now is not even beginning to find answers.

If you’re keen to learn more about how to develop critical thinking, Foundation for Critical Thinking has a wealth of information.

A year in review

This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too.

What has been the same this year is the endless need to repeat to all and sundry the following:

• All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand.
• All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model.
• Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological response to that nociception – because the two are indivisible.  Our brains are not just ‘waiting for’ peripheral events to reach them – the brain is not a blank slate, it’s actively involved in determining which aspects of our experience ‘we’ will experience.
• There is not a lot new under the sun in pain management really.  Not a lot of new drugs (mostly they’re derivatives of opium, or they’re old drugs that have been adopted for new uses), and not a lot of new procedures, and no, not even a lot of new psychosocial/nonpharmacological treatments.  With, perhaps, the exception of brain retraining a la Moseley, and the introduction of acceptance and mindfulness based treatments.

What has been different this year?

• More discussion across ‘Web 2.0’, or the medium of the internet – Facebook, Twitter, blogging and email.
• More detail of the aspects of the cognitive behavioural approach to pain management that is influential to change, and along with that, more recognition that one size does not fit all.
• More detail of what works for whom and when.
• More need to not only assess – but also treat people!
• More recognition that people with pain live in a network of relationships with other people, within communities and sociopolitical systems including legislation, and that all of these have an influence on the person’s ability to cope.
• Increasing recognition that the health provider relationship has as much influence on the individual as his or her own beliefs.  Yes folks, what we say and how we say it does have an effect! Maybe not quite what we had expected, but definitely we have an effect.
• More awareness that it’s not so much WHO delivers self management, but that self management IS delivered that is important!

In Christchurch, we’ve had the momentous earthquake and the aftermath.  Internationally we have had wars, rumours of wars, pestilence and plague – and yes we’ve even had locusts (in parts of Australia!).  Once again I’ve made friends with people from all around the world, all sorts of professional backgrounds, all sorts of interests in pain and pain management.  And I’ve continued to learn – from fellow clinicians, colleagues, patients, the journals I’ve read, the blogs I’ve read, the discussions (and maybe even arguments!) I’ve had – all have prompted me to think and learn and question.

And once again, I reflect on the incredible nature of science and the way in which I, as a clinician, ‘stand on the shoulders of giants’ to learn more.  To know that no ‘fact’ is sacred – that if there is evidence there to challenge a ‘received’ view, even a view that I’ve cherished, then it’s my duty to look at that evidence in the face and check it out.  There is no need to resort to mysticism, nor to hold to magical beliefs, or sacred texts.  Research is there for us all to learn from, and it’s my privilege to help share it to people who may not have the time or access to the information I do, and by doing this I might have a chance to help people live lives that are a bit better in quality than if I had written nothing.  At least that’s what I hope happens!

I’m incredibly thankful to the people who take time to comment and question me.  I’m not a guru, I’m definitely blinkered in my own perception of what I see, and I admit to being somewhat biased.  That’s another reason for writing – by putting my thoughts out to the interweb, hopefully people can bounce ideas off what I write – and then ask me questions!  And in doing that, I learn too.

2011.  Who knows what it will bring.  I expect (and yes, hope) it will bring even more questions!  Do ya feel like coming along for the ride?!

Information is to behaviour change as spaghetti is to a brick

I’m a great fan of books like ‘Explain Pain’.
This delightful publication by David Butler and Lorimer Moseley gives accurate information about pain, particularly chronic pain, in an accessible format for both patients and clinicians, and I’ve used it often with people I’m seeing. I’m also a fan of helping people to understand what we do (and don’t) know about pain to give them more awareness of their ability to influence their own body.

But as anyone who has worked in chronic pain management knows, telling someone something doesn’t always make an enormous difference – and here’s a case in point.  Before I go on, any cases I refer to on this blog are a compilation of several people and details are altered to protect confidentiality.

Yesterday I met with a person who has had chronic back pain for about four years.  She has had a discectomy for what the notes stated was a ‘large disc prolapse compressing the nerve root with neurological signs’, so a good candidate for this procedure.  The operation was a success four years ago – but, as is common in spinal surgery, she was left with persistent low back pain.  Her surgeon told her to ‘be careful of heavy lifting, twisting and bending’ and she had taken this to mean she shouldn’t do things like carry a full washing basket of clothes to the clothesline, do the vacuum cleaning (I can understand this decision!), load the back of her car up with groceries, mow lawns, or even play golf. Ooops, I’m not sure the surgeon meant ALL of these things, but you never know.

We met with one of the doctors I work with to review her clinical chart and to talk about her back pain because she was very wary of doing any of these movements even under clinical supervision.  The problem being that her surgeon, four years ago, had said she ‘shouldn’t’.

I want to add at this point that she was seeing us because of another, unrelated pain problem that was responding well to input although the pain from this other problem was not resolving.  The other pain problem was in her knee, and it had stopped her from walking comfortably and had also lead to her stopping work.  I also want to add that the doctor she was seeing with me is one of the best physicians I know for explaining medical investigations and treatment in a way that patients understand.

The consultation took about 45 minutes – so definitely not a quick’n’dirty consultation.  Together we reviewed all the clinical information including medical notes from the surgery.  We looked at a model of the spine and my patient was shown exactly what the surgical procedure was – she had no idea of what had actually been done to her vertebra or disc, and had visions of large chunks of bone being removed leaving a weak and vulnerable vertebra and disc that had lost most of its height.

We talked about the risk factors associated with having had one disc prolapse – that the risk of having other prolapses, and particularly another one in that disc, were somewhat higher than before her first disc prolapse.  We talked about the relationship between disc changes and pain (which is not entirely straightforward).  We discussed the signs and symptoms of a return of her original problem, and that her current back pain was quite different from the original leg pain.

And you know what?

Even though we followed best practice and used the kind of information that Lorimer Moseley describes in the paper I’ve linked this post to, and this woman has had this information given to her in several different ways by different clinicians in the Centre I work in, she is not convinced.  To her, having pain in her back inevitably means her surgeon was quite correct to tell her to avoid bending, twisting and lifting, and that unless she is very careful she risks needing the much more significant surgery of a spinal fusion.

The power of a surgeon who, with a few words, has helped this woman become trapped into no longer doing what she used to love.

What’s worse – her GP has said that she should ‘think of doing another job because it’s clear this one isn’t going to be good for your back’ – she’s a taxi driver.  So after the whole of her adult working life in the driving industry, at 52 she believes she needs to think of doing another job – even though she and her husband drive off in their motorhome every weekend, and she loved being a cabbie.

What to do, what to do.  Information alone in these cases doesn’t help this person feel confident enough to contradict the explicit instructions of her surgeon, nor the advice of her GP, nor her behaviour over the past four years.

It was Bill Fordyce who apparently coined the phrase ‘Information is to behaviour change as spaghetti is to a brick’.  While sometimes simply helping people to understand more about their body and what pain is and is not, can be enough for people to take their own steps towards changing their behaviour, for many others – and particularly people who are anxious about their health – it takes more.  That’s because knowing in the ‘I can tell you about it’ way is not the same as knowing in the ‘I really understand it’ way.

At heart, I’m a behaviourist I think.  While I know the value of working with thoughts and beliefs, and I thoroughly enjoy this part of my work, it makes very little difference to someone’s life if, after all our work together, they carry on doing what they’ve always been doing.  That’s one definition of insanity – doing the same thing again and again and hoping for a different result.  Something needs to change.

For me, with this person, I hope to start working using an exposure-based treatment.  Graded exposure, by identifying the movements she’s currently not happy to do, developing a hierarchy of avoided movements, and starting to help her recognise that the relationship between what she thinks is going to happen and what actually does happen is not the same, is one strategy that can help.  Underneath her almost religious adherence to this one surgeon’s advice is a potent fear that (a) she is going to do harm and (b) that she won’t cope with the changes in her pain if she disobeys his instructions.

Trying to convince her or to give her more information – even the very best information along the lines of Lorimer’s paper – isn’t, on its own, going to change her willingness to put her body on the line.  Successfully encountering movements and doing them without the scary consequences is probably the only way to help her gain confidence that she can manage it – and return to her normal work.

A pox on people who work with people who have pain and haven’t yet got up to speed with modern scientific knowledge about pain mechanisms.  And a bouquet to people like Bill Fordyce and Lorimer Moseley and David Butler and Nick Kendall who have, over the years, contributed so much to scientific and clinical knowledge about the biopsychosocial nature of pain and pain management.

Moseley, G. (2007). Reconceptualising pain according to modern pain science Physical Therapy Reviews, 12 (3), 169-178 DOI: 10.1179/108331907X223010

Here’s looking at us

For most of my clinical working life the focus in pain management has been on factors that identify people who have a high risk of developing long-term disability associated with their pain. The tide is turning, though, and increasingly we’re seeing papers published that look instead at treatment provider attitudes, beliefs and behaviours as equally influential in prolonging disability.

The truth is, the health care consultation is an interaction between two people who both have some sort of agenda, and who are part of a community and are influenced by what is the ‘normal’ way to respond to someone’s pain problem.  While it’s the person with pain who usually initiates a consultation, it’s the health provider who has a strong influence over what happens next.

One of the most interesting findings in recent years is that the ‘fear-avoidance’ beliefs of health providers strongly influence their advice to people with pain.  If a provider has beliefs that moving an acutely painful back is ‘wrong’, then the advice they’ll give will probably be to use pain as a guide.  This happens even after promulgation of acute low back pain guidelines.  Similarly, if a provider doesn’t believe in ‘psychosocial factors’ then it’s not likely that he or she will identify them and manage them – even if they’re incredibly obvious.

How to measure the effectiveness of an intervention to change provider beliefs has been quite problematic.   There have been several attempts, and these are briefly described in the paper by Bowey-Morris, Purcell-Jones and Watson (2010).  The problem with these measures has been the unidimensional nature of the measurement tools – and what occurs in a consultation is not unidimensional at all, along with the need to be valid for providers of different professional background.

This study looks at the use of the Pain Attitudes and Beliefs Scale with GP’s, or primary care providers.  The PABS was originally developed for physiotherapists, and aimed to identify whether a primarily biomedical view was held, or a biopsychosocial model.  The aim of the study was to firstly evaluate the test-retest reliability of the tool, then in a second study, to establish whether it measured change after the practitioners were given a two-hour presentation on the ‘modern management of acute low back pain’, including material about the biopsychosocial approaches.

The presentation on managing acute low back pain covered a review of 4 main topics: trends in disability, including the role of iatrogenic factors; the role of work in maintaining health; current guidelines on diagnostic triage and treatment for LBP; and the introduction of a new service initiative—a LBP triage clinic.  (I wish this could happen here in NZ!)

Briefly, the methodology was to identify a group of GP’s, give them the PABS at time one, give it to them again shortly afterward.  The presentations were given, and the GP’s asked to complete the questionnaire again for a third time.  Not all GP’s were asked to complete all three questionnaires to minimise any learning effects.

Results

The PABS test-retest reliability was good for the biomedical dimension, while the psychosocial was also good but less strongly so than the biomedical.  The authors suggest that because they conducted the retest measure about three months after the original measure, their variance was slightly greater than normal – this is because just giving a test can influence an individual to think about it.  Despite this, the test-retest reliability was good.

As a measure of change, however, the questionnaire didn’t perform quite as well, nevertheless, it did change in the direction expected – GP’s who scored more highly on the biomedical dimension moved closer to the biopsychosocial dimension.

What can we learn from this?

One of the points made by the authors of this study is very, very important: a change on a questionnaire doesn’t necessarily represent a change in actual practice.

Hopefully, the responses on the PABS did reflect in some way the thoughts and beliefs of the GP’s, but without an additional measure of what occurs in a consultation, and more importantly, what referrals are made and the factors that are addressed, we can’t tell whether education or information make any difference.

An ongoing complaint about ‘Guidelines’ for evidence-informed practice is that many of them appear to have minimal impact on behaviour.  The pragmatist in me suggests that the main influence over provider behaviour is payment – and we can certainly see this in New Zealand with ACC influencing who works in pain management and who does not.  20 years ago it was common for most physiotherapy practices in the private sector to give hands-on treatment in an almost unlimited way – now there are an increasing number of multidisciplinary teams with a clinical psychologist involved and a lot less ‘hands-on’ treatment.

I’d love to see the PABS, however, used alongside a couple of other measures – like the Orebro Musculoskeletal Screening Questionnaire, and referral rates to providers like occupational therapists and pain management centres – to establish whether clinicians have a biomedical orientation, or the more evidence-based biopsychosocial orientation.  At least that way there could be some monitoring of those who fail to identify glaring psychosocial risk factors – with ‘education’ or some sort of corrective action for those who do not, or will not attend to psychosocial risk factors.

Here’s another thought: what if you and I took this PABS ourselves, and asked ourselves some hard questions about our own orientation.  Probably readers of this blog will have a fairly biopsychosocial approach to pain management, but maybe a score on PABS would give us each a bit of a shake-up to review our own beliefs.

Bowey-Morris, J., Purcell-Jones, G., & Watson, P. (2010). Test-Retest Reliability of the Pain Attitudes and Beliefs Scale and Sensitivity to Change in a General Practitioner Population The Clinical Journal of Pain, 26 (2), 144-152 DOI: 10.1097/AJP.0b013e3181bada3d