Education

Niagara Falls

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.

Trimpuh cub

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

lost

How well do people understand their neuropathic pain?


ResearchBlogging.org
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

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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.

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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?!

don't leave me honey

Information is to behaviour change as spaghetti is to a brick


ResearchBlogging.org
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


ResearchBlogging.org

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

A wish list for a pain management programme


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As I review the last few people I’ve had the privilege to assess, I can see numerous factors that have lead them down the road to chronic disability from their persistent pain.  One of the most common would have to be multiple medical assessments with medical management that has failed to address the person’s disability, while in some cases actually increasing the person’s beliefs that they are not in control of their lives.  An example? A man I saw who, four years after the initial event firmly believes the annular tears must ‘heal’ before he can return to work.  Two orthopaedic surgeons indicated to him that surgery wasn’t an option (and he didn’t want it anyway) but also advised him ‘these things take time to heal’ – or at least that’s what he heard.

Another reason for ongoing disability is the failure of pain management programmes to address the person’s beliefs about pain.  As Bill Fordyce is reported to have said ‘Information is to behaviour change as spaghetti is to a brick’ – hence my concern when I read a very authoritative book written by three highly respected clinicians and researchers where ‘education’ is the term used for the process of helping the participants develop a new understanding of their pain and their role in managing it.

Education, information and teaching are often words used around the concept of helping people reconceptualise their pain.  Sadly, without very good skills by the clinician, this can turn into an ‘information dump’ and leave the participants only slightly less confused than before!  The processes that seem to work better involve ‘guided discovery’ or Socratic learning, and experiential learning with the opportunity to reflect.

There are arguably four broad groups of techniques for helping people to understand their pain and their role in pain management for themselves.

  1. Learning the various connections between thoughts, situations, and emotions
  2. Gathering evidence from their own experience, and becoming more objective about the patterns of thinking that each person has
  3. Using mini experiments to try different approaches out
  4. Exploring underlying beliefs and assumptions

This process is collectively called ‘collaborative empiricism’ where the participants and the facilitator join together to explore experiences and understand what is going on.  In a group setting this becomes a process where the participants both become exposed to their own processes, but also the processes of others – and by the end of the programme, become adept at being therapists for one another, asking questions rather than giving advice or feedback.

The process of helping participants become their own therapists is not easy.  It requires the facilitator to be very knowledgeable about pain in order to correct myths, and it also requires the facilitator to be very adept both with Socratic questioning and guided discovery as well as group facilitation.  No wonder facilitators get tired after a group session!

Often, clinicians who get involved in pain management group programmes come from a background of clinical psychology or occupational therapy.  Unfortunately, having professional registration does not mean that the clinician has specific skills or training in pain management or group facilitation.  It does take time to develop these skills.  Unfortunately in the literature on pain management within groups, there is a real dearth of research looking at the necessary skills clinicians require to help develop effective group therapy.  Instead, the majority of research into cognitive behavioural approaches for pain management is carried out by psychologists, with the assumption that this training is sufficient.  It’s great to read in Main, Sullivan and Watson’s book Pain Management 2nd edition (2008) that the skills required are emphasised rather than the professional discipline.  Certainly many other health professionals have specific training and skill in group therapy, amongst them social workers and occupational therapists.

Something that has been investigated very recently is the stabiliy of membership within a clinical team working in group pain management.  Interdisciplinary teamwork has been identified as a strength in pain management – it requires that each profession become very familiar with a common model (cognitive behavioural approach within a biopsychosocial model), with each other’s strengths, and ultimately, to be able to work almost across disciplines to support each other’s interventions.  This takes time.  The communication between team members must be very strong, and decision making processes including conflict resolution need to be well-established.

A paper recently available by Amanda Williams and Henry Potts looked at two factors that they thought may affect outcomes achieved after group CBT for persistent pain.  Both group membership (who the participants were in the programme) and staff turnover were examined.  The data was collected over 16 years (3050 participants), and included pre- and 1-month post-programme questionnaires.

Their findings?  ‘Linear regression showed that high periods of staff turnover were significantly
related to poorer outcomes on self-efficacy and distance walked at end of treatment, with the
effect on self-efficacy persisting to 1 month follow-up.’

I’ll discuss the group membership findings in another post, but it’s interesting to see the areas that were directly influenced by staff turnover.

Membership of the teams were ‘… multidisciplinary teams of psychologists, physiotherapists, occupational therapists and nurses, with doctors working across teams. This meant that patients usually related mainly to a core team of four staff members, but up to seven if staff were part-time. The inpatient treatment programme remained largely consistent in content and process over the years covered by this study.’

One of the psychologists, one of the physiotherapists and one doctor remained constant throughout the study period.  New staff were usually less experienced than those who had left, and worked under supervision for several weeks before commencing with the programme.

The results showed ‘for each change in staffing, patients on average had a PSEQ score that was 1.2 points lower, a Normalized catastrophizing score that was 0.04 standard deviations higher, and walked 4.6 m less at the end of treatment.’

Some very useful ‘managerial’ aspects are considered in this paper: Therapist emotional wellbeing has been reasonably consistently related to better outcomes.  The treatment unit had periods of strengthened institutional support and growth and others when its future was uncertain. It is likely that these difficult periods were reflected in poorer team cohesion as well as in turnover, and that staff who were expending energies on the unit’s survival had less to offer patients.

I wonder what steps organisations take to address these issues, particularly when calls to ‘be efficient’ often demand therapists see more patients in less time.  In the end, outcomes are what matters – what is the point of seeing a large volume of patients, only to have them return as re-referrals later?

It’s clear that a combination of the right treatment for the right patient is important – but it seems equally clear that the role team members play, the level of skill, the level of support and the team processes are also important.

Williams, A., & Potts, H. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain Pain DOI: 10.1016/j.pain.2009.12.011

Back to the basics: Cognitive-Behavioral Therapy and Psychosocial Factors in Low Back Pain


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In New Zealand, the national accident insurer, Accident Compensation Corporation, has been reviewing its pain management service contracts. The latest message from both the Government and ACC is the need to reduce costs (not that I’ve ever heard anyone say ‘let’s go for broke, let’s spend all we can!’) and one way to do this is to look at how to reduce the risk of long-term disability associated with chronic pain. So, in their pursuit of ways to do this, ACC has consulted with providers and reviewed opinions about services provided to claimants under the various pain services contracts and come up with some pretty sensible options.

Some of the findings from examining current services simply do not surprise me – amongst two of the most common services, pain interventions (ie nerve blocks and infusions etc), and ‘functional reactivation’ programmes (ie let’s get fit in a gym), the providers rarely use a biopsychosocial model – apparently, these services are provided within a biomedical model, and those factors that are so well known to complicate recovery are simply not addressed. Now I’ve mentioned before in this blog that some interventional doctors actually believe that if they can abolish the pain the person’s problems will simply disappear and they’ll return to normal – and this is an opinion that now ACC is fully aware of, and hopefully will reconsider! The evidence from empirical studies just does not support the idea that pain and disability are linked in a nice tidy causal relationship. In fact, for a really lovely illustration of this in another health condition, angina, by Gill Furze, I think you’ll enjoy it.

So, from my somewhat cursory reading of the recommendations from ACC, it looks like a ‘stepped care’ approach is being adopted.  In this, ‘low risk’ people are provided with fairly simply input – advice from a GP, maybe a DVD or pamphlet advising people that it’s OK to move, that returning to work is good, and to simply get on with it.  ‘Medium risk’ people are provided with ‘reactivation’ but with some attention to psychosocial factors, and a comprehensive pain assessment is less likely to be on the cards for them.  Finally, ‘high risk’ people will be able to access ‘the whole works’ including comprehensive pain assessment, multidisciplinary and interdisciplinary pain management, and with a strong emphasis on attending to the psychosocial factors that are known to influence recovery.  Good ideas. With one catch – how ‘risk’ is identified is not yet clear.

In New Zealand we’ve used the Orebro Musculoskeletal Screening Questionnaire in some form since 1997 or so.  Unfortunately, this wonderful tool is often either not interpreted, or the ‘warning signs’ are not addressed, and for some people, a high score can almost be a flag for a case manager to be especially punitive in terms of ‘lets get this person back to work any way we can’ rather than using it as an indication that this person requires more support.  If this tool is used to screen for risk, and used well – then there could be some excellent results, and hopefully ‘low risk’ people won’t be over-serviced, while ‘high risk’ people will receive that help that they need.  But it will need case managers and other service providers to really come to grips with what the biopsychosocial model actually is, and how to truly address psychosocial factors in a systematic way.

How this plays out will be interesting.  Currently a claimant could see several providers concurrently: perhaps a doctor who is completing medical certificates, the physiotherapist providing the ‘reactivation’, an occupational therapist helping with return to work, and maybe an independent psychologist providing ‘CBT’ for pain.  If each of these providers has a slightly different understanding of the risk factors influencing disability in chronic pain, the poor claimant is going to be very confused.

For example, the doctor may be aware of the person’s home situation and certify fitness for work based on his or her knowledge of the overall ‘stress’ level of the person in context.  Without good understanding of how pain can influence function, the doctor could suggest ‘no heavy lifting’ – but fail to indicate how heavy ‘heavy’ is, whether this applies all day every day, whether there is a difference between lifting from the ground or above the head etc.  And the rationale for ‘no heavy lifting’ is fairly limited – what ‘damage’ will actually occur? or is the doctor responding to the person’s distress about ‘having to lift’ and experiencing pain?

The physiotherapist could be focusing on fitness generally, and asking the person to complete a full gym routine, maybe with some ‘core stability’ thrown in for good measure.  If the person is still fearful about his or her pain (because the doctor has said ‘no heavy lifting’), while completing the gym programme may actually be avoiding specific movements like bending because of this.  And be extremely fit – but not actually doing anything at home!  And you canbe very sure that this happens.  A lot.

The occupational therapist, with a really good ‘ergonomic’ approach, may recommend all sorts of wonderful gadgets, seating and break down the work tasks to ones the person ‘can do’, but the actual tasks the person does is really being established on the basis of what the doctor said about ‘no heavy lifting’.  The person feels pressured because there are lots of other movements that increase pain, apart from ‘heavy lifting’ (what about sitting? or twisting? or going up stairs?) but ‘has’ to do these movements because the doctor didn’t say they were ‘banned’, and there really are not that many tasks at work that the person can do!

And finally the psychologist, who is aware that the person isn’t sleeping, is feeling quite anxious and doesn’t have effective communication skills, works on these – but fails to address the confusion that the person has about what this pain actually means.

These situations are so common as to be the norm.  And while each provider is possibly working to ‘clinical standards’, the models they’re using don’t dovetail, and the person’s real concerns are not identified – and worse, the person gets caught in the middle between all these rather earnest providers who are actually talking past each other!

Now it’s not my plan here to lobby for any specific approach – I think plurality and choice is great in pain management.  But – and you knew there would be a but – there does need to be excellent communication and agreement amongst the providers and the claimant/person as to

  1. what the problems are
  2. what the hypothesised relationships between various factors are
  3. a consistent approach to managing specific beliefs and behaviours

Oh and it does need to be evidence-based.  That means ‘favourite’ treatments that individuals like to do (like acupuncture, pilates, adaptive gadgets and even CBT or mindfulness) need to be justified not only from the literature, but also in terms of how they ‘fit’ for this person in this situation at this time.  That means outcomes need to be measured.

I’m still not convinced that primary care, even secondary care, clinicians talk to each other enough in the same language.  If ACC wants to ‘risk profile’ patients, maybe it also needs to ‘risk profile’ providers.  And maybe providers could be given some further training (maybe even training through a tertiary institute like University of Otago’s postgraduate papers in Musculoskeletal Medicine, Pain, Pain Management etc?!), even psychologists who currently don’t receive any specific training in a cognitive behavioural approach in pain management.

Read this paper – it’s an oldie but a goodie.  Even though some of the recommendations have now moved on, the fundamentals remain.  Psychosocial factors continue to be the most important predictor of disability, and need to be managed from the outset.  After all, people with chronic pain had acute pain in the beginning!

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850

Pain management in groups using a CBT approach – Why do it?


I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion.

I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people might think…).  I know I’m not alone in feeling that when I’m with people I don’t know well, I am not exactly open to pouring out my woes and being emotional. It can take quite a while to feel comfortable about expressing feelings in a group setting – but at the same time there is something comforting in knowing that if I’m feeling wobbly there are probably a few other people also feeling the same way, so we may all reach for the tissues at the same time!

Processing emotional content in a group setting can be both an amazing experience and at the same time an opportunity to feel really weird.  It all depends on how the facilitator or therapist responds.  Through exposing emotional content, we have greater access to automatic thoughts, assumptions, beliefs and behaviours that are often otherwise well hidden underneath our protective cognitions.  It’s at times when we feel more emotionally vulnerable that we have access to underlying ‘rules of living’ that we may otherwise be completely oblivious to.

What should a facilitator take notice of?

– times when a participant appears disengaged, perhaps doodling, or closing the eyes, maybe rocking on the chair or fiddling with a pen.

What could a facilitator do? To illustrate one way of drawing out the emotional response and opening up an opportunity to talk about what is happening here and now, the therapist could say:

Therapist: ‘before we go on, I just want to check in with the group.  Tony I can see you’re looking a bit distracted, what’s going on for you right now?’

Tony: ‘Oh nothing’

Therapist: ‘Oh.  How does what we were talking about fit for you?’

Tony: ‘Well, I’m just thinking why do I have to be here? I mean, I don’t think my pain is really chronic, and I know I can have another injection if only I talk to the doctor again, so do I really have to do all this psychological stuff anyway?’

Therapist: ‘Does anyone else feel like it’s going to be a really difficult process to learn self management, and maybe there is an easier way other than looking at thoughts and emotions and things?’

Andrea: ‘Well, yeah.  I mean, some of the doctors have said that I can just increase my medications and then maybe my pain will go down and I’ll be doing more, but I just can’t handle the side effects any more.  Those side effects can be worse than having the pain, I think.’

Therapist: ‘Does anyone else feel like it might be easier to just carry on with a medical approach and not look at other things?’

Tessa: ‘I tried that for years, but in the end I still have my pain and my emotions go  up and down every time someone suggests another medication – but I’m still here because I am so fed up with that rollercoaster, and I want to take control again.’

Therapist: ‘ Tony, what is it like for you to hear that other people feel in two minds about doing this self management approach, and there are some appealing things about using medications, but also some not-so-good effects?’

Tony: ‘Well I guess it makes me feel more normal, after all I’ve been on that emotional rollercoaster for a long time, and I really hate the side effects from medications too.  And the doctor said that he wasn’t very keen to give me any more injections.’

This approach can feel risky if you’re not used to facilitating – it’s allowing people the space to feel ambivalent and to process that anxiety but also to recognise that others in the group have also had similar experiences and offer either the same insight (I’ve been here before…) or a new insight (She’s handling it by being open-minded) that can reassure the person.  Provided that the facilitator can trust the group that there will be someone else who has moved through this same thought and emotion before, and go with the flow (roll with resistance), it’s possible to allow people to air their worries or emotions and still be able to move towards the goal of sharing and normalising many of the experiences the group shares.

Group cohesion is that sense that the group are ‘bonded’. There has been much written about the stages of development within a group – the ‘forming, norming, storming etc’  stages amongst others.  What happens is that over time a group may move to the point where it’s OK to disagree with each other, to challenge each other and to risk being ‘real’ with each other.  This can happen quite quickly, but I find that groups often get to the ‘I feel comfortable with this group’ stage (ie they all ‘get along’) but may get stuck and don’t move to the ‘it’s OK to be honest and real and disagree with each other’ stage.  It’s only when groups move to this deeper level of cohesion, IMHO, that they start to ‘work’ each other.

The therapist or facilitator can encourage this deeper relationship and here are several strategies that can also help:

  1. Choosing a group that has similar characteristics – eg stage of change or readiness to adopt self management, maybe diagnosis or pain site, perhaps compensation status or job status
  2. Ensuring confidentiality and creating the group norms
  3. Ensuring a climate of acceptance, empathy and promoting sharing of information
  4. Connecting two or more participants experiences
  5. Responding to group process as it happens

More about this last one tomorrow. Group process is all about the things I’ve raised over the last couple of days – disclosure, optimism, inclusion, group learning, shifting from self to others, and managing both emotional processing and group cohesion.

I’ll review these tomorrow and add in some specific strategies that can be helpful to elicit each one.