Health

Shebadog

Self-managing chronic pain


I have long been a proponent of helping people who live with pain to take control of their situation and actively self-manage as much as possible. My rationale has been that people who feel they are in control of some parts of their life are more likely to feel confident when their pain flares up, or when they have a life set-back. Today I took a second look at some of the papers on self-management published over the past few years, and I think it’s time to be a little critical.

The first issue to deal with is defining self-management. To me, self-management means knowing as much as possible about the health condition (whatever it is), knowing as much as possible about various treatments, working hard to learn and integrate ways of coping so that I (because yes, self-management is something I use for my fibromyalgia) can do the things I most value. By doing this, I can be more like who I want to be, rather than being defined by my pain, or what other people expect from me. But, self-management isn’t nearly as clearly defined as this in many people’s minds.

Here’s one definition “We defined self-management as the strategies individuals undertake to promote health (e.g., healthy living, exercising), manage an illness (e.g., manage symptoms, medication, and lifestyle changes), and manage life with an illness (e.g., adapt leisure activities or deal with losses caused by illness)” (Audulv, Asplund & Norbergh, 2012). Morden, Jinks and Ong (2011) found from a study of individual’s perceptions that managing chronic conditions is not solely related to medical recommendations and that self-management is central to maintaining a sense of ‘normality’ in everyday life or to reasserting one’s position in the social world when living with a chronic illness and demonstrating competency from a moral perspective.

Interestingly, a definition from COPD management describes self -management as “… programmes that aim to teach the skills needed to carry out medical regimens specific to a long-term disease and to guide behaviour change to help patients control their own condition and improve their well-being”(Effing,  Bourbeau, Vercoulen, Apter, Coultas, Meek, et al.2012). The distinction between chronic pain self-management and other chronic illness self-management lies in the need to address broader “living” issues rather than just learning to “carry out medical regimens”. And that is both the problem and the distinction between chronic pain self-management and other chronic disease self-management approaches.

Let me unpack this: For people living with COPD, or diabetes, there are critical medical management practices that need to be learned and integrated into daily life so that the underlying medical condition doesn’t get worse and lead either to complications, or even early death. The focus on self-management in these situations seems to be on the medical tasks that must be undertaken. The end results are often measured in terms of reducing the number of extreme events – like having hyperglycaemia, or being admitted with a chest infection and needing oxygen.

Now if I turn to the qualitative literature on self-management in chronic pain, what is very obvious is that self-management isn’t about the medical procedures that must be followed. It’s far more about living life – and integrating ways of getting to do what’s important without too many flare-ups that get in the way of doing these things. In fact, Morden, Jinks & Ong (2011) found that in people living with knee osteoarthritis, self-management wasn’t something people identified with – what might have been classified by clinical people as “exercise” or losing weight or keeping active weren’t thought of as “self-management” by people living with knee OA. They thought this was “just getting on with it”. I particularly liked one comment : “because people perceived their activities to be an integral part of their daily routine they were not surfaced as deliberate action.” In other words, when people focus on living life, coping strategies become habits and routines that are secondary to the doing of life.

Mike Nicholas and colleagues have looked into coping and self-management extensively as part of ongoing research associated with the Royal North Shore Pain Management Programme. they were interested in whether it’s possible to find out if adhering to strategies introduced within a programme was predictive of outcome: in other words, did people who strongly adhered to what they learned during a programme ultimately gain better quality of life, lower pain, less disability and feel better? Surprisingly, they did – I say surprisingly because in a couple of meta-analyses (for example Kroon, an der Burg, Buchbinder, Osborne, Johnston & Pitt, 2014; Oliveira, Ferreira, Maher, Pinto et al, 2012) self-management approaches made very little, if any, difference to pain and disability both over the short and long-term.

What does this mean? Well, quite apart from the blurry definitions of self-management, and the lack of standardisation inside self-management programmes, I think we need to ponder on just what we’re asking people to do – and how they (we) regard the strategies we hope people will develop. Cutting to the chase, in chronic pain management we risk people knowing “about” strategies, but failing to adopt them in daily life because we haven’t really thought about daily life and what this is to each individual. When I think about the vast number of changes to self-concept that chronic pain wreaks on people, I think it’s hard to be ready to adopt these new techniques until “who I am” is included in the mix. Maybe one reason for the modest improvements after self-management is that we’re not thinking about self-identity and values and that these need attending to so that using coping strategies is worthwhile. It’s yet another reason I think occupational therapists offer a great deal in chronic pain self-management – who are you? what do you want your life to stand for? what things do you do (or want to do) that makes your life yours? Finally, to paraphrase as my colleague Ben Darlow, living with low back pain (read: any chronic pain) means balancing the need to minimise pain fluctuations with the things that make life worth living. That’s what I call “flexibly persisting”.

Audulv, A., Asplund, K., & Norbergh, K.-G. (2012). The integration of chronic illness self-management. Qualitative Health Research, 22(3), 332-345. doi:http://dx.doi.org/10.1177/1049732311430497

Effing, T. W., Bourbeau, J., Vercoulen, J., Apter, A. J., Coultas, D., Meek, P., . . . van der Palen, J. (2012). Self-management programmes for copd moving forward. Chronic respiratory disease, 9(1), 27-35.

Morden, A., Jinks, C., & Bie Nio, O. (2011). Lay models of self-management: How do people manage knee osteoarthritis in context? Chronic Illness, 7(3), 185-200.

Nicholas, M., Asghari, A., Corbett, M., Smeets, R., Wood, B., Overton, S., . . . Beeston, L. (2012). Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16(1), 93-104. doi:10.1016/j.ejpain.2011.06.005

Oliveira, V. C., Ferreira, P. H., Maher, C. G., Pinto, R. Z., Refshauge, K. M., & Ferreira, M. L. (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64(11), 1739-1748.

look what's coming

What should we do about acute low back pain?


There’s no doubt that low back pain presents a major healthcare problem in all parts of the world. It’s probably the most common form of musculoskeletal pain around, it can be highly disabling – and its management is one of the most contentious imaginable. As someone once said “if there was an effective treatment for low back pain, there wouldn’t be such a range of treatments available!”

I want to take a step back and consider people living with nonspecific low back pain only, it’s by far the most prevalent, and while no-one would say there is a single diagnosis that can be applied to all forms of back pain, there seem to be some similarities in how this kind of pain responds.

What we’ve learned over the past year is that acetaminophen hardly touches the pain of nonspecific low back pain Machado, Maher, Ferreira, Pinheiro et al, 2015). This means anti-inflammatory medications (NSAIDs) are the most likely group of medications to be prescribed, or perhaps codeine. Exercise was the recommended treatment for osteoarthritis of the hip and knee, suggesting that this approach might also be recommended for low back pain.

Turning to exercise, it seems that there is no clear indication that any particular type of exercise is any better than any other exercise for low back pain (not even motor control exercise)(Saragiotto, Maher, Yamato Tie, Costa et al, 2016), and all exercise improves pain and disability – and even recurrences (Machado, Bostick & Maher, 2013). What seems important is that people get moving again, and do so quickly after the onset of their back pain.

Graded exposure has also been in the news, latest being a study using graded exposure for elderly people living with chronic low back pain, where it was found to not only improve function (reduce disability) but also found to reduce pain (Leonhardt, Kuss, Becker, Basler et al, in press). OK, pain reduction wasn’t reduced a great deal, but neither have many treatments – and at least this one has few adverse effects and improves disability.

Where am I going with this?

Well, recently I made some apparently radical suggestions: I said that

  1. sub-typing low back pain doesn’t yet seem to be consistent;
  2. that no particular exercise type seems better than anything else;
  3. that ongoing disability is predicted more by psychosocial factors than by physical findings – even when injection treatments are used (van Wijk, Geurts, Lousberg,Wynne, Hammink, et al, 2008).
  4. that people with low back pain seem to get better for a while, and often find their back pain returns or grumbles along without any particular provocation;
  5. and that perhaps treatment should focus LESS on reducing pain (which doesn’t seem to be very effective) and LESS on trying to identify particular types of exercise that will suit particular people and MORE simply on graded return to normal activity.
  6. Along with really good information about what we know about low back pain (which isn’t much in terms of mechanics or anatomy, but quite a lot about what’s harmful and what doesn’t help at all), maybe all we need to do is help people get back to their usual activities.

For my sins I was asked not to remain involved in the group planning health system pathways (I also suggested maybe osteopaths, chiropractors, massage therapists and both occupational therapists and psychologists might also be good to be involved – maybe that was the radical part because I can’t see an awful lot radical about my other suggestions!).

Here’s my suggestion – when one of the most difficult aspects of low back pain management is helping people return to normal activities within their own environment (work, home, leisure), why not call in the experts in this area? I’m talking about YOU, occupational therapists! So far I haven’t been able to find a randomised controlled trial of occupational therapy graded exposure for low back pain. I’m sorry about this – it’s possibly a reflection of the difficulty there is in even suggesting that DOING NOTHING (ie not attempting to change the tissues, just helping people return to normal activity) might be an active form of treatment, and one that could work.

I don’t want to denigrate the wonderful work many clinicians do in the field of low back pain, but I suspect much of what seems to work is “meaning response” – well-meaning clinicians who believe in their treatments, patients who believe in their therapists, treatments that appear plausible within the general zeitgeist of “why we have low back pain”, all leading to a ritual in which people feel helped and begin to do things again.

Many of us have read Ben Darlow’s paper on The Enduring Impact of What Clinicians Say to People with Low Back Pain (Darlow, Dowell, Baxter, Mathieson, Perry & Dean, 2013). We have yet to count the cost of well-meaning clinicians feeding misinformed and unhelpful beliefs (and behaviours) to people with acute low back pain. I think the cost will be extremely high.

I just wonder if we might not be able to cut out much of the palaver about low back pain if we went directly to the “feeling helped and begin to do things again” without the misinformation and cost of the rituals involved. While other clinicians can contribute – the process of doing in the context of daily life is where occupational therapy research, experience and models have focused for the discipline’s history. That’s the professional magic of occupational therapy.

 

Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine, 11(6), 527-534. doi:10.1370/afm.1518

Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S.(in press). Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study. Journal of Geriatric Physical Therapy.

Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.

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

Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012004/abstract doi:10.1002/14651858.CD012004

van Wijk, R. M. A. W., Geurts, J. W. M., Lousberg, R., Wynne, H. J., Hammink, E., Knape, J. T. A., & Groen, G. J. (2008). Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain. Pain Medicine, 9(2), 212-221.

P1000573

Live Plan Be


There are times in my work when I feel like I’m banging my head against a brick wall. Even though I’ve been saying most of what I write about on here since forever, it seems to take SUCH a long time for anything much to change! BUT then along comes something totally cool to brush my frustration away, and today I want to talk about Live Plan Be developed by Pain BC in Vancouver, Canada.

A couple of years ago I was given the privilege of being asked to prepare a document analysing the content and approach of self management programmes. I reviewed the Cochrane systematic reviews which all supported a multidisciplinary self management approach as the foundation for chronic pain management. I then turned to the qualitative research to investigate what it’s like to be part of a programme from the participant’s perspective. I found that people attending these programmes enter a journey of self-discovery, that some of the skills don’t seem to make sense at first – but do when the person returns to their own setting. I also found that people living with chronic pain relish the opportunity to feel that their pain is acknowledged, that others on the programmes know what it’s like to live with chronic pain so they don’t have to spend ages trying to explain themselves, and to have the chance to be with others who ‘get it’ means breaking out of the isolation that chronic pain can bring.

I also took a look at the ways these programmes can be delivered. While many programmes are face-to-face, with technology making online programmes increasingly more responsive and flexible, I wanted to see whether there were major differences in the outcomes of each programme. Although it’s difficult to tell because the populations using both approaches are not exactly the same, from what I could find, the outcomes were comparable. This is really exciting because it means more people can get access to approaches that have solid research underpinning them without having to travel to and from, and without the staffing needed for face-to-face programmes.

As a result of my report, I suggested that Pain BC might like to investigate developing a whole new programme for helping people live well with chronic pain, and to make this an online programme with some of the features that the research into online behaviour change programmes has identified as useful. Things like having a discussion forum so participants can connect and share their experiences of the reality of living with chronic pain. Having action prompts so that people don’t just read something – but also get prompted to DO something with that information – and most importantly, have this tied to where the person is currently at in their journey towards making changes to live with their pain. I recommended having some self-assessments so people can track their progress, and a place where they could record the things that worked, and those that didn’t work, so it’s easy to share with other people including health professionals.

I’m SO excited to see how Live Plan Be has come together – and it’s now LIVE!

The team that has put this together has done an amazing job, exceeding my wildest dreams of what the programme might look like. It’s sophisticated, easy to use, has lovely graphics and video recordings of real people doing real things, has SO MUCH information on it – and it’s free! If you have chronic pain, or you work with people living with chronic pain, I would love you to take a look at it, and try it out. Then let me know what you think. Whatever feedback you give, you’ll know that the team will work hard to keep on making it better and more useful, so please let them know.

Meantime, I’m hoping that this will bring some hope to people who have struggled with chronic pain, and would like to learn to live well.

a-different-point-of-view

Stigma and chronic pain


Stigma is about devaluing and discrediting behaviours made by people towards those who have or are “different” from the average Joe or Josie Bloggs. For people experiencing and living with chronic pain, stigma may occur because the “average” experience of pain is associated with actual or potential tissue damage (or described in these terms) and for most chronic pain the “issues in the tissues” are less than expected by people holding a biomedical viewpoint.  Add to this that most people in the world know about acute pain which settles as expected whereas chronic pain persists, seems “disproportionately” bad in comparison with what’s expected.

De Ruddere and Craig (in press) have reviewed the literature to understand what is known about stigma and chronic pain, and what can be done about it. I thought it an apt paper to include in this blog because almost every person with chronic pain has, at some point, said they don’t feel their pain is either being taken seriously, or is accepted as real, or feel like they’re not being believed. Of course, pain is not the only condition where self-report is the only thing that we can use to determine the experience – depression, anxiety, post-concussion syndrome, fatigue are among the common experiences that are not given the kind of acknowledgement that we give to fractures or appendicitis or asthma.

People living with chronic pain say their partners, family and friends don’t seem to believe them, and that health professionals think their pain is exaggerated, imagined. They feel they’re being told it’s their fault, to “pull yourself together”, just “harden up” and often feel they’re being told to go away because they don’t have a real problem. Whether this is in fact the case undoubtedly depends on the persons involved – but it’s a common story and one I’ve heard in my clinical experience over and over and over again.

I guess some of the worst things I hear about stigma is that experienced by people seeking help for their pain from health professionals. If things don’t seem to add up, in the eyes of the observer, then people experiencing chronic pain can get less sympathy, are disliked, thought of as less meriting help, and often suspected of simply wanting attention.

The effect of this kind of behaviour from those charged with the duty to care is on distress and disability. People who feel misunderstood or maligned by treatment providers may receive less care and as a result, are able to do less, and feel rejected – social rejection and chronic pain share some similar neurobiological pathways (Eisenberger, 2012). Additionally, because the people experiencing the pain probably also hold similar beliefs to those who reject them (because the most common beliefs about pain are that there’s something going on in the tissues, and pain should fit with that tissue damage), they begin to doubt themselves, question their own responses, wonder if they really are as badly off as they feel. I know I felt this during my recovery from mild traumatic brain injury, when I wondered if I was actually just wanting a break from having to do things – yet at the same time I couldn’t doubt the performance deficits I experienced every day, and the need to sleep for several hours a day because otherwise I just could not function.

De Ruddere and Craig posit some reasons for other people stigmatising those living with chronic pain. One is that with acute pain, behavioural responses are often involuntary, automatic responses such as reflex withdrawal, vocalisations (groaning), or facial expressions. These elicit a primitive caring response in most people. Yet with chronic pain, many of the responses are less reflexive, and more voluntary – such as withdrawing from doing things or describing pain. These are usually thought to indicate that we’ve thought about them, and we’re doing them on purpose or deliberately.  When these behaviours take place alongside the general belief that pain “should” be acute and related to tissue damage, not showing automatic pain behaviours begins to look kinda fishy.

In evolutionary biology, altruistic behaviour towards others is based on an underlying assumption that if we do to others, they will do to us in turn. A sort of reciprocity. When people don’t look like they’re genuinely in pain (ie their behaviours aren’t the same as those carried out with acute pain), suspicions rise – “Are you really hurt, or are you wanting to get something for nothing?”

De Ruddere and Craig suggest some other theoretical explanations for the high level of suspicion applied to people with chronic pain, but I think this evolutionary one is an especially challenging one to deal with. Most treatment approaches attempt to upskill people living with pain to be able to communicate their problems effectively, and to reduce the frequency and interference of pain behaviour. This is only half the answer. We need to continue giving healthcare providers a deep understanding of a biopsychosocial approach: that pain is ALWAYS involves biological processes, psychological processes and is set within a social context, so that healthcare delivery goes well beyond assuming that “if the pain is gone the person is back to normal”.

Get this paper once it comes out in print. I think it’s time the social aspects of our pain management treatments were given more airtime, and this paper provides some exciting direction for future research and clinical practice.

 

 

 

De Ruddere L & Craig KD. (2012). Understanding stigma and chronic pain: a state of the art review. Pain.

Eisenberger NI. The pain of social disconnection: examining the shared neural underpinnings of physical and social pain. Nature Reviews Neuroscience 2012;13(6):421-434.DOI: 10.1038/nrn3231

Lake Selfe

Your brain has no delete button


Yesterday, nearly five years after the devastating earthquakes in Christchurch, New Zealand, we had another rude reminder that we live on an active fault zone. A 5.7 magnitude earthquake hit just after lunch, throwing me to the ground, breaking our pendant lights, and a bottle toppled off the shelf beside the toilet, falling into the toilet and smashing the rim (lesson to the men in the house: do not leave the toilet seat up!). Needless to say, my heart was racing for a wee while afterwards!

People living in our fair city have had thousands of quakes to deal with over the past five years, most of them not as powerful as yesterday’s one, but nevertheless rather unsettling. In reflecting on the experience I’m reminded that our nervous system is wired more towards learning and reacting to immediate threat – and anything that represents a threat – than it is to calming and soothing the beast within. In fact, there’s good evidence to suggest that we don’t ever “unlearn” a learned response, instead we develop new pathways that can become stronger and more heavily myelinated than the learned paths – but given a similar context we’re as likely as not to activate that same old set of neural impulses and some researchers suggest this is because of epigenetic changes. (Take a look at this study in rats for one reason – it seems contextual memory triggered by cues is more powerful than we thought!)

As I mused on my startle response which is as well-developed as ever (though I jump less often at trucks going past than I did in the months just after the big quake), I thought about our experience of low back pain – or indeed any other chronic pain. While we’ve got very excited about neuroplasticity, and I think we should, I also think we need to temper our enthusiasm with some reality checks. Even though we seem to be able to reduce pain by using neuroplasticity within our treatments (see Pelletier, Higgins and Bourbonnais, 2015, among others), we need to remember that the pathways associated with chronic pain are many – and not just those to and from the sore part! In fact, because we’re fantastic learning creatures, there are many, many ways in which we encode an experience.

We have already seen that seeing a painful limb can increase the experience of pain in people with CRPS and vice versa (Sumitani, Shibita, Iwakura, Matsuda, Sakaue, Inoue et al, 2007), and this phenomenon has been used in mirror therapy and virtual reality treatments for people with CRPS and some other forms of pain (Foell, Bekrater-Bodmann, Diers & Flor, 2014). As a result of this fascinating finding, treatments using laterality, graded motor imagery and novel movements have all become very popular with varying degrees of effectiveness (especially outside the clinic!).

What perhaps we’ve forgotten is that because we’re incredibly good at learning, we’ve associated not just the “internal” location/intensity/quality of that experience, but also a whole bunch of other associations – words (pain, ouch, suffer, back, leg, doing, lifting, crumbling, disc – and others!), movements (sitting, walking, turning, twisting, crouching, climbing), emotions (happy, sad, glad, awestruck, helpless), images (of a back, leg, someone else sitting or walking or moving), locations (treatment facilities, workplace, the garage, making the bed, the pill bottles in the bathroom) – the list goes on! Even the smell of liniment or whatever rubbing lotion was used can bring all those associations back into consciousness.

And each association branches off and associates with other things in a never-ending network of related experiences and memories and relationships. Is it any wonder that some people don’t miraculously “get better” when we decide to “educate” someone about their pain? Especially if we haven’t given them the respect of listening to how they’ve made sense of their situation…

Now in the series of earthquakes from 2011 until now, I haven’t ever really become overwhelmed with anxiety and helplessness. Yes I have been fed up, frustrated, saddened, and I’ve grieved, got angry at bureaucracy and thought that things surely could be done more quickly. Until yesterday, when the growing anxiety (because the houses being built close to us mean there are many hundreds of thumps and thuds as foundations are hammered into the ground far deeper than ever before) I’d been feeling over the past month or so really got triggered by a very real and unexpected event.

Intellectually I know this quake is just another in the same series as we’ve been having. Nothing terribly awful happened. No-one got hurt. BUT my jitters are back – and every time I look at cracks in the ring foundation, the smashed toilet, look at my broken vase, or go to use the Pyrex jug that got smashed, I’m reminded that this event has happened – and could again. Pictures of the cliffs falling at Sumner, clouds of dust rising from them as they tumbled into the sea; images of broken crockery at Briscoes and wine and beer at the local supermarket; the news, and friends talking on Facebook – all of these remind me of what we’ve just been through and have been for so long.

Now picture the person you’re about to see today. That person with the painful back. The person who flicks through the magazines in your waiting room and sees adverts for lotions, analgesia. Who smells the scents in your area. The one who finds it so hard to roll over in bed every night. Or to sit and watch TV. Just remember that you may be able to develop new and novel pathways for moving so that the pain itself isn’t triggered by movements – but all these other associations are still there, and will be from now on. And think beyond the clinic door and into your patient’s daily life. How will you help them transfer the feeling of safety that being with YOU evokes into a feeling of safety everywhere they are? This is why developing effective self management skills, especially becoming nonjudgemental despite experiencing pain is so very, very important.

 

Foell, J., Bekrater-Bodmann, R., Diers, M., & Flor, H. (2014). Mirror therapy for phantom limb pain: Brain changes and the role of body representation. European Journal of Pain, 18(5), 729-739. doi:10.1002/j.1532-2149.2013.00433.x

Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Addressing neuroplastic changes in distributed areas of the nervous system associated with chronic musculoskeletal disorders. Physical Therapy, 95(11), 1582-1591.

Sumitani, M., Shibata, M., Iwakura, T., Matsuda, Y., Sakaue, G., Inoue, T., . . . Miyauchi, S. (2007). Pathologic pain distorts visuospatial perception. Neurology, 68(2), 152-154.

jewels

Waitangi Day – or how to live together in unity


Today is New Zealand’s Waitangi Day ‘Mondayisation’ – the actual day was Saturday 6th Feb. It’s an important day in New Zealand because it’s the day when two completely different nations signed a treaty allowing certain rights between them – and allowed my ancestors to travel from Ireland and England to settle in the country I call my home. Unlike many country’s celebrations of nationhood, Waitangi Day is almost always a time of turbulence, dissension and debate. This is not a bad thing because over the years I think the way in which Maori (Tangata Whenua, or original settlers) and non-Maori settlers (Tangata Tiriti) relate in our country is a fantastic example of living together well. Not perfectly – but certainly in a more integrated way than many other countries where two completely different cultures blend.

Thinking of Waitangi Day, I’m reminded of the way in which the multidimensional model of pain attempts to integrate biological, psychological and social factors to help explain this experience and how such a primitive response to threat can ultimately lead to adaptation and learning – in most cases – or the most profound misery and disability in others.

Like the treaty relationship in New Zealand, there’s much room for discussion and debate as to the relative weight to place on various components of the model.  And like the treaty relationship, there are times when each part is accused of dominating and not giving the other/s due credit. Truth, at least to me, is, we need all of us (and all the factors) to integrate – not to become some bland nothing, but to express the components fully.

Just last week I was astonished to find that a clinician thought that I believed low back pain is “psychological”. Absolutely astonished because this has never been my position! While this blog and much of my teaching and reading is around psychological and more recently social factors influencing pain and disability, my position has never been to elevate the influence of these factors over the biological. I suppose I shouldn’t be surprised – it’s hard to deal with the state of play in our understanding of low back pain which finds that many of the assumed causal mechanisms (like disc prolapses, poor “core” muscles, the biomechanics of lifting and so on) just don’t apply. It’s also really difficult to know that so far there are no particular exercise treatments that work more effectively than any other. Cognitive dissonance anyone? Just because these factors are less relevant than presumed does not mean that (a) I think low back pain is psychological and (b) that all biological factors are irrelevant. What it does mean is that we don’t know. I’ll say that again. We. Don’t. Know. Most back pain falls into this “nonspecific” group – and by calling it “nonspecific” we are actually admitting that We. Don’t. Know.

How do people assume that because I point out that we don’t know the causal mechanisms of low back pain but we DO know the critical importance of psychosocial factors on disability associated with low back pain – and the treatments that can mitigate these factors – that I believe back pain is psychological? I think it’s a simple fallacy – some people believe that because a person responds to psychosocial interventions this therefore means their problem is psychological. This is not true – and here are some examples. Exercise (a physical modality) is shown to be an effective treatment for depression. Does this mean depression is a purely biological disorder? Biofeedback provides visual or auditory information related to physical aspects of the body like blood pressure, heart rate, and muscle tension – does this mean that blood pressure is “psychological”? Diabetes management often includes learning to resist the urge, or “urge surf” the impulse to eat foods that increase blood sugar levels – does this mean diabetes is psychological?

Here’s my real position on nonspecific low back pain, which is let me remind you, the most common form of low back pain.

Causes – not known (Golob & Wipf, 2014), risk factors for onset are mainly equivocal but one study found the major predictor of an onset was – prior history of low back pain, with “limited evidence that the combination of postural risk factors and job strain is associated with the onset of LBP” (Janwantanakul, Sitthipornvorakul,  & Paksaichol, 2012), exercise may prevent recurrence but mechanisms of LBP remain unclear (Macedo, Bostick and Maher, 2013), while subgroup analysis carried out by therapists were “underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting” (Mistry, Patel, Wan Hee, Stallard & Underwood, 2014).

My take from this brief review? The mechanisms presumed to be involved in nonspecific low back pain are unknown.

Treatments – mainly ineffective but self-management provides small effects on pain and disability (moderate quality) (Oliveira, Ferreira, Maher, Pinto, Refshauge & Ferreira, 2012), “the evidence on acupuncture for acute LBP is sparse despite our comprehensive literature search” (Lee, Choi, Lee, Lee, Shin & Lee, 2013), no definitive evidence supports the use of orthoses for spine pain (Zarghooni, Beyer, Siewe & Eysel, 2013), acetaminophen is not effective for pain relief (Machado, Maher, Ferreira, Pinheiro, Lin, Day et al, 2015), and no specific exercises are better than any other for either pain relief or recovery – not even motor control exercises (Saragiotto, Maher, Yamato, Costa et al, 2016).

My take from this set of references is that movement is good – any movement, but no particular form of exercise is better than any other. In fact, the main limitation to exercise is adherence (or actually continuing exercising after the pain has settled).

The factors known to predict poor recovery are pretty clear – catastrophising, or thinking the worst (Kim, Cho, Kang, Chang, Lee, & Yeom, 2015), avoidance (usually arising from unhelpful beliefs about the problem – see commentary by Schofferman, 2015), low mood – which has also been found to predict reporting or treatment seeking of low back pain (see this post from Body in Mind, and this one).

What can I take from all of this? Well, my view is that because psychosocial factors exert their influence at multiple levels including our nervous system (see Borkum, 2010), but also our community understanding of what is and isn’t “illness” (Jutel, 2011) and who to see and what to do about it, the problem of nonspecific low back pain is one of the purest forms of an integrated biopsychosocial and multifactorial health concern in human life. I therefore rest my case: nonspecific low back pain is not psychological, but neither is it biomechanical or biological only. It is a biopsychosocial multifactorial experience to which humans are prone.

The best we can do with our current knowledge base is (1) limit and avoid the use of nocebic language and attempts to explain low back pain via biomechanical or muscle control mechanisms, (2) be honest about the likelihood of low back pain recurring and our treatments essentially doing very little, and (3) encourage return to normal activity by doing normal activity including exercise. Being honest about the state of play in our knowledge is a good starting point for better understanding – sounds a lot like race relations, doesn’t it?

 

Borkum, J. M. (2010). Maladaptive cognitions and chronic pain: Epidemiology, neurobiology, and treatment. Journal of Rational-Emotive & Cognitive Behavior Therapy, 28(1), 4-24. doi:http://dx.doi.org/10.1007/s10942-010-0109-x

Golob, A. L., & Wipf, J. E. (2014). Low back pain. Medical Clinics of North America, 98(3), 405-428.

Janwantanakul, P., Sitthipornvorakul, E., & Paksaichol, A. (2012). Risk factors for the onset of nonspecific low back pain in office workers: A systematic review of prospective cohort studies. Journal of Manipulative & Physiological Therapeutics, 35(7), 568-577.

Jutel, A. (2011). Classification, disease, and diagnosis. Perspectives in Biology & Medicine, 54(2), 189-205.

Kim, H.-J., Cho, C.-H., Kang, K.-T., Chang, B.-S., Lee, C.-K., & Yeom, J. S. (2015). The significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 238-246. doi:http://dx.doi.org/10.1016/j.spinee.2014.09.002

Lee, J. H., Choi, T. Y., Lee, M. S., Lee, H., Shin, B. C., & Lee, H. (2013). Acupuncture for acute low back pain: A systematic review. Clinical Journal of Pain, 29(2), 172-185.

Macedo, L. G., Bostick, G. P., & Maher, C. G. (2013). Exercise for prevention of recurrences of nonspecific low back pain. Physical Therapy, 93(12), 1587-1591.

Machado, G. C., Maher, C. G., Ferreira, P. H., Pinheiro, M. B., Lin, C.-W. C., Day, R. O., . . . Ferreira, M. L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials. BMJ, 350, h1225.

Mistry, D., Patel, S., Hee, S. W., Stallard, N., & Underwood, M. (2014). Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: A systematic review. Spine, 39(7), 618-629.

Oliveira, V. C., Ferreira, P. H., Maher, C. G., Pinto, R. Z., Refshauge, K. M., & Ferreira, M. L. (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64(11), 1739-1748.

Saragiotto Bruno, T., Maher Christopher, G., Yamato Tiê, P., Costa Leonardo, O. P., Menezes Costa Luciola, C., Ostelo Raymond, W. J. G., & Macedo Luciana, G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, (1).

Schofferman, J. A. (2015). Commentary on the significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 247-248. doi:http://dx.doi.org/10.1016/j.spinee.2014.11.003

Zarghooni, K., Beyer, F., Siewe, J., & Eysel, P. (2013). The orthotic treatment of acute and chronic disease of the cervical and lumbar spine. Deutsches Arzteblatt International, 110(44), 737-742.

letting it all hang out

Taking a peek beneath the hood


What would it be like to lift the hood and take a good hard look at the skills needed to carry out various chronic pain management treatments? You know, take each profession’s jargon away and really look at what a clinician needs to know to conduct safe, effective treatment. Oh I know, this is skating on thin ice – each profession’s treatment paradigm and assumptions are incredibly important and I’m an outsider looking in, so please, before you push me under the cold, cold water, let’s think about the parts that really do the business in pain management.

The first set of skills that are crucial to effective pain management are those to do with communicating. The ability to listen carefully, reflect what’s being said, and to ask questions to genuinely understand what a person believes and feels, and how they got there.  To be able to help the person identify what’s important to them, their main concerns, their values and the direction they want to move towards. To know what to say and how to say it (Bensing & Verhuel, 2010; Hall, 2011; Hulsman, 2009; Klaber & Richardson, 1997; Oien, Steihaug, Iversen & Raheim, 2011).

These skills are generic to all health professionals, although perhaps enhanced and refined in those clinicians who are involved in talking as the therapeutic process.

The second set of skills involve being able to change behaviour. To be aware of operant conditioning, classical conditioning, and to use these principles along with those involving cognitions (eg “education” or providing information).  Interestingly, while these principles are derived from psychology, and perhaps educational research, ALL health professionals use these skills when they’re involved in asking the person to make a change outside of the treatment room.

Unless the clinician is doing something TO the patient, treatments for chronic pain typically involve asking the patient to DO something (Honicke, 2011; Persson, Rivano-Rischer & Eklun, 2004; Robinson, Kennedy & Harmon, 2011).

The third involve being able to progressively grade activities from simple to complex – modifying them so that the demands just slightly exceed the person’s capabilities or confidence.

  1. Those demands might be physical (repetitions, range of movement, loading, isolation to integrated movement),
  2. Cognitive (simple one-step directions through to complex multi-stage decision-making activities),
  3. Social (working alone, in a pair, in a small group, large group, being the follower, being the leader),
  4. Emotional (joyful flow or frustrating, touching on highly important values or those that are not especially relevant).
  5. Contextual (controlled contexts like a clinic room vs highly chaotic like a shopping mall on Christmas Eve)

It’s this latter set that I think we may forget when looking at skills and professionals. There can be an assumption that being able to do an exercise programme in a gym or clinic should lead to greater participation in life outside that setting. Exercises can be prescribed to isolate a small set of muscles, using all the usual suspects to increase strength, flexibility, speed and stamina – and the techniques to progress along this kind of training are, sorry guys, reasonably simple to learn. The challenge is for the person doing them to be able to transfer this training to the real world where movements are integrated, where the environment is complex and the demands and distractions are myriad.

Likewise with graded exposure training – beginning with the least feared movements, progressing to more and more feared situations using a graded hierarchy is something any one of us can learn provided we take the time to understand how and why this approach is used. What’s far more difficult is helping the person doing these activities in new and evolving situations so the skills generalise. Occupational therapists, for what it’s worth, are explicitly and uniquely trained to analyse occupations/activities to do precisely this kind of generalisation.

When we look at what works in chronic pain management, there are four things:

  1. Placebo or meaning effects which are strongly influenced by the way we communicate, and the person’s expectations from us and our interaction.
  2. Providing accurate information so the pain is “de-threatened” or at least loses a large degree of the threat value even if the pain doesn’t reduce as a result.
  3. Supporting the person to do more, whether that be through exercise or just doing more of what they want.
  4. Generalising those skills so that irrespective of the pain fluctuations or context, the person can remain able to participate in what’s important in their life.

And the skills needed to do these things? They’re the ones I’ve listed above.

What I think this means is the time has come to stop describing various treatments as “belonging” to any single discipline. They don’t “belong” to anyone – they’re generic skills that we ALL use. So I, as an occupational therapist warped by psychologists, will have greater technique in communicating, noticing psychosocial obstacles, and helping a person generalise skills into a range of contexts by virtue of my training. Paul, as a physiotherapist, will have greater technique in prescribing specific exercises for certain muscles, and have more confidence in exercise progression. Scott will have greater expertise in enhancing expectations and helping a person reconceptualise their pain in a way that dethreatens it. We ALL have effective skills across all of these areas, but at the same time we have particular expertise in what we originally trained in.

Finally, what I think this means is that when the call is made for clinicians to work in primary care, or alongside GPs or in ED, to help reduce healthcare use, increase participation in life and so on, it’s time we stopped saying “The (X profession) and the GP should form a team”, I think it’s time for us to say “The allied health team (made up of people with the following skills) should form a team with the person living with pain”.

 

Bensing, J. M., & Verheul, W. (2010). The silent healer: The role of communication in placebo effects. Patient Education and Counseling, 80(3), 293-299. doi:http://dx.doi.org/10.1016/j.pec.2010.05.033

Eakin, E., Reeves, M., Winkler, E., Lawler, S., & Owen, N. (2010). Maintenance of physical activity and dietary change following a telephone-delivered intervention. Health Psychology, 29(6), 566-573.

Hall, J. A. (2011). Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. Patient Education & Counseling, 84(3), 319-324.

Hardcastle, S., Blake, N., & Hagger, M. S. (2012). The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. Journal of Behavioral Medicine, 35(3), 318-333.

Honicke, M. (2011). Acceptance and commitment therapy as a challenging approach for occupational therapists in pain management. Ergotherapie und Rehabilitation, 50(7), 28-30

Hulsman, R. L. (2009). Shifting goals in medical communication. Determinants of goal detection and response formation. Patient Education & Counseling, 74(3), 302-308.

Klaber, M. J., & Richardson, P. (1997). The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13(1), 89-96.

Okun, M. A., & Karoly, P. (2007). Perceived goal ownership, regulatory goal cognition, and health behavior change. American Journal of Health Behavior Vol 31(1) Jan-Feb 2007, 98-109.

Oien, A. M., Steihaug, S., Iversen, S., & Raheim, M. (2011). Communication as negotiation processes in long-term physiotherapy: A qualitative study. Scandinavian Journal of Caring Sciences, 25(1), 53-6

Persson, E., Rivano-Fischer, M., & Eklun, M. (2004). Evaluation of changes in occupational performance among patients in a pain management program. Journal of Rehabilitation Medicine, 36(2), 85-91.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Review of occupational therapy for people with chronic pain. Australian Occupational Therapy Journal, 58(2), 74-81.

Rosser, B. A., McCullagh, P., Davies, R., Mountain, G. A., McCracken, L., & Eccleston, C. (2011). Technology-mediated therapy for chronic pain management: The challenges of adapting behavior change interventions for delivery with pervasive communication technology. Telemedicine Journal & E-Health, 17(3), 211-216.

clearing

Connecting: A cognitive behavioural approach to initial interviews


As I’ve been reading and thinking about the ways health professionals work with people who live with pain, my mind keeps coming back to the power of human connection. Pain is ephemeral: we can’t touch it, see it or truly understand the “what it is like” for that person to experience that pain.  The only way we can get to understand even a little of another’s pain is when we take the time to hear what they’re saying. This post is about how a cognitive behavioural approach can inform our communication and build a bridge towards shared understanding. Only once this is begun can we start “treatment”.

A cognitive behavioural approach is based on the idea that people are not blank canvases, reflecting whatever is thrown at them. Instead people actively think about what is happening, seeking out information they think is relevant, depending on their past experiences, the framework they use to understand what’s going on, and to make predictions in light of what they want to do (goals).

What this means is that a conversation about pain is like dipping your toe into a stream. The stream keeps moving on, but the water gets swirled around where your toe is dipped. Whatever is upstream comes down along the waterways, where you dip your toe is here and now, and depending on the depth of your toe-dipping (and the stream’s flow) will influence the stream’s direction downstream. If your conversation is superficial and only concerned with issues the person doesn’t feel is relevant, your toe-dipping isn’t going to have much influence. But if you take the time to get into the water, immersing yourself in what the person is really saying (where they’ve been, what they’ve learned, where they want to go), you may well have a huge influence on their future directions.

What’s the focus of an initial interview?

An initial interview usually focuses on “what are the problems?” and “what can I do?” Of course, most clinicians also recognise the importance of establishing rapport, and the need to be empathic. The actual factors considered important within an initial interview vary depending on the model of health or disease adopted by the clinician. For a strongly biomechanically-oriented clinician the factors may be muscle length, strength, range of movement, loading and tolerance. For a clinician using a biopsychosocial framework, hopefully weight will also be placed on beliefs, understanding, attitudes, past experiences, emotions, predictions for the future, past treatments and what has been learned from these, existing stressors, vulnerabilities and strengths. And of course, a whole heap of family, friends, workplace and social factors should also form part of this assessment.

I’ve attached a semi-structured interview I’ve used clinically when working with people who live with chronic pain – this interview can take 60 – 90 minutes, depending on the complexity of the person’s narrative – Self Management Semistructured interview. I don’t think this is the only way to approach learning about someone else’s pain, but it provides me with a very sound basis for deciding whether I can help the person, and more importantly, I think it gives the person a chance to feel that I’m really listening.

To abbreviate this interview, I’d hone in on two main questions that I need to answer:

  1. Why is this person presenting in this way at this time?
  2. What can be done to reduce this person’s distress and disability?

All of my questions are designed to help me answer these two questions. Of course, they’re not going to work at all unless the person I’m talking with is part of this conversation. After all, they have ideas about what they want from me, why they’re looking for help, and what’s led them to come to me now rather than seeing someone else, or at another time.

There’s something missing from this interview though!

Something you can’t get from a simple list of questions is how to ask them and how to respond to the answers. I used to think the art of asking good interview questions lay with the wording, but I’m not so sure now. I think it’s about my attitude. Let me unpack this.

Socratic questioning is the main orientation I use in my initial interview. Socratic questioning is about guided discovery, or a dialogue between me and the other person in which I guide both of us towards discovering things the person knows but may not know they know. Confused? Well, here’s an explanation of the process. (BTW I follow Christine Padesky’s approach for Socratic questioning – click here for more info)

Padesky states “Socratic questioning involves asking the client questions which: a) the client has the knowledge to answer; b) draw the client’s attention to information which is relevant to the issue being discussed but which may be outside the client’s current focus; c) generally move from the concrete to the more abstract so that; d) the client can, in the end, apply the new information to either reevaluate a previous conclusion or construct a new idea.”

To begin with, we need to find out what the person knows they know – so I will ask Informational Questions.  These include things like “what do you think is going on?”; “what’s your theory about your pain?”; “why do you think your sleep is so bad right now?”.

The second and equally important part is Listening. Not only am I listening to (and then reflecting that I’ve heard), I’m listening for words or phrases that are idiosyncratic, have emotional impact, those metaphors and images the person uses, the emotional feeling tone of their account.

The third is Summarising in which I gather together several phrases or responses given by the person, and present them back to him or her to make sure I’ve heard them correctly, but also to give them a chance to hear what they’ve been saying. Sometimes it’s only by talking that a person finds out what they’ve been thinking (ever had that happen to you?!). In Motivational Interviewing this is called “giving a bouquet” of what the person has been saying. I like that image!

The final phase is Synthesising, or Analytical questions. This occurs after you’ve spent the time finding out what the person thinks, listened carefully and then reflected this, explored the unique meanings the person puts on aspects of what is going on for them, and finally you’ve summarised and reflected their narrative as a whole – synthesising questions help the person make sense of what they’ve just said, pulling it all together. I sometimes use phrases like “so where does this leave you?” or “what does all that mean now?” or “what is your next best step?” Smart readers will recognise some of the Motivational Interviewing phrases in here!

The attitude I bring to this kind of encounter is one of curiosity. I’m genuinely curious to try to understand how this person has developed his or her understanding of their situation. This helps me step away from judging their situation as “good” or “bad, and in particular helps me avoid judging them as “good” or “bad” (or “coper” or “noncoper”). I constantly remind myself and others that people generally don’t get up in the morning to do dumb things. There’s usually a reason for people being in the situation they’re in – and often it’s about lacking accurate information.

Putting it together

Having gathered information, reflected what you’ve understood and confirmed this understanding with the person – now’s your chance to help that person develop their own, personal understanding of what’s going on. I like to call this their own personal model of pain. It won’t be complete, but it’s a great beginning. Padesky suggests asking “What do you make of this? How do you put this? How do you put these ideas together?”

For more information on a strengths based approach to cognitive behavioural therapy (not the same as a cognitive behavioural approach, but very interesting to read) – go here for a full paper by Padesky and Mooney, published in 2012, and for a much more detailed discussion of Socratic questioning in a panel – go here.

 

 

teenytiny

Pain Acceptance rather than Catastrophising influences work goal pursuit & achievement


We all know that having pain can act as a disincentive to doing things. What’s less clear is how, when a person is in chronic pain, life can continue. After all, life doesn’t stop just because pain is a daily companion. I’ve been interested in how people maintain living well despite their pain, because I think if we can work this out, some of the ongoing distress and despair experienced by people living with pain might be alleviated (while we wait for cures to appear).

The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption. Sophisticated mathematical procedures can now be used to model the effects of variations in individual’s experiences on factors that are important to an overall group. For example, if we track pain, fatigue and goals in a group of people, we can see that each person’s responses vary around their own personal “normal”. If we then add some additional factors, let’s say pain acceptance, or catastrophising, and look to see firstly how each individual’s “normal” varies with their own acceptance or catastrophising, then look at how overall grouped norms vary with these factors while controlling for the violation of usual assumptions in this kind of statistical analysis (like independence of each sample, for example), we can begin to examine the ways that pain, or goal pursuit vary depending on acceptance or catastrophising across time.

In the study I’m looking at today, this kind of multilevel modelling was used to examine the variability between pain intensity and positive and negative feelings and pain interference with goal pursuit and progress, as well as looking to see whether pain acceptance or catastrophising mediated the same outcomes.

variationsThe researchers found that pain intensity interfered with goal progress, but it didn’t do this directly. Instead, it did this via the individual’s perception of how much pain interfered with goal pursuit. In other words, when a person thinks that pain gets in the way of them doing things, this happens when they experience higher pain intensity that makes them feel that it’s hard to keep going with goals. Even if people feel OK in themselves, pain intensity makes it feel like it’s much harder to keep going.

But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.

The authors of this study point out that “not all individuals experience pain’s interference with goal pursuit to the same extent because interference is likely to depend on pain attitudes” (Mun, Karoly & Okun, 2015), and accepting pain seems to be one of the important factors that allow people to keep going. Catastrophising, as measured in this study, didn’t feature as a moderator, which is quite unusual, and the authors suggest that perhaps their using “trait” catastrophising instead of “state” catastrophising might have fuzzed this relationship, and that both forms of catastrophising should be measured in future.

An important point when interpreting this study: acceptance does not mean “OMG I’m just going to ignore my pain” or “OMG I’m just going to distract myself”. Instead, acceptance means reducing unhelpful brooding on pain, or trying to control pain (which just doesn’t really work, does it). Acceptance also means “I’m going to get on with what makes me feel like me” even if my pain goes up because I do. The authors suggest that acceptance might reduce pain’s disruptive influence on cognitive processes, meaning there’s more brain space to focus on moving towards important goals.

In addition to the cool finding that acceptance influences how much pain interferes with moving towards important goals, this study also found that being positive, or feeling good also reduced pain interference. Now this is really cool because I’ve been arguing that having fun is one of the first things that people living with chronic pain lose. And it’s rarely, if ever, included in pain management or rehabilitation approaches. Maybe it’s time to recognise that people doing important and fun things that they value might actually be a motivating approach that could instill confidence and “stickability” when developing rehabilitation programmes.

Mun CJ, Karoly P, & Okun MA (2015). Effects of daily pain intensity, positive affect, and individual differences in pain acceptance on work goal interference and progress. Pain, 156 (11), 2276-85 PMID: 26469319

river gliding  by

Five critical skills for pain clinicians


I could be wrong: it might be seven or ten, but five is a good start. What do people working with those who have pain really need to know/do? What makes them effective? What keeps them positive in the face of what can be an extraordinarily demanding work?

  1. Effective listening skills, along with the ability to communicate that you’re listening. One of the most common complaints about health professionals made by people living with pain is that they don’t listen (Allegretti, Borkan, Reis & Griffiths, 2010; Stenberg, Fjellman-Wiklund & ahlgren, 2012).  While I’m sure there are some clinicians who deliberately protect themselves from engaging in a patient’s distress, I think there’s probably a more insidious version of this – some research shows that when patients report pain, physicians spend more time on technical tasks and less time helping the person actively participate in their own care (Bertakis, Azari & Callahan, 2003).  There’s also some research showing that when clinicians are trained in specific techniques for expressing empathy, patients believe they are more caring (Bonvicini, Perlin, Bylund, Carroll, Rouse & Goldstein, 2009). Physicians were trained to use “The 4 E’s” (engage, empathise, educate and enlist), with a particular focus on communicating that they had heard what was said. Techniques included rephrasing what a patient said; asking a question to elicit more detail; acknowledging or confirming that the person’s emotions are valid/legitimate; and expressing that he or she had experienced a similar feeling. Maybe it’s time for greater training in these skills for all clinicians working with those who have pain.
  2. Mindfulness skills to help deal with emotions during sessions. I hope I’m not just jumping on the mindfulness bandwagon, but I do think being able to be fully present but not caught up in judging or evaluating your own feelings is a critical skill to maintain openness in a clinical situation. A definition of mindfulness that I quite like is “a process of regulating attention in order to bring a quality of non-elaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiousity, experiential openness, and acceptance” (Bishop, Lau, Shapiro et al, 2004). Being mindful and open allows you to be there for your patient while also making space for yourself. There’s good evidence that mindfulness improves psychological health (Keng, Smoski, & Robins, 2011), and some studies also show that it improves your own communication skills and improves patient satisfaction (Beach, Roter, Kortuis, Epstein et al, 2013).
  3. Case formulation skills. These skills are about pulling your assessment information together in a coherent way so you can generate some testable hypotheses to explain why your patient is presenting in the way they are at this time. To me it’s a waste to conduct assessments and then fail to use that information when you’re developing your treatment plan. And it’s even more of a shame to fail to share that information with your patient. The thing is, there’s often little training given to how to generate a case formulation: it’s got to be based on broad theoretical knowledge fleshed out with the specific information you’ve gathered from your patient. This makes a formulation a unique ideographic set of hypotheses about your patient. I’ve written about case formulations here and here and here.
  4. Superb research reading skills. I don’t think it’s enough to say you’re evidence-based if you’re only using clinical guidelines. I think clinicians need to be critical readers of both qualitative and quantitative research. And I think it’s a crying shame that so much research is hidden behind paywalls. That’s one reason I write so often – I can access research and make it accessible. Of course I’d prefer it if everyone took to reading research, but the cost of doing so is atrocious! And we know that getting into print isn’t always easy, and with the current funding models in tertiary education institutes I think the range and depth of research being published is likely to stay a bit skinny. And until research is widely available for free (remember, authors write for free, reviewers review for free, and much research is published electronically, so where’s the money being spent?) I think it’s going to be tough for clinicians working in private practice. Having said that, even when I was a private practitioner, I always had a subscription to the local medical library – it’s a valid deductible expense.
  5. Effective social media skills. Really? Social media? isn’t that just for people who want to share their food pix? Uh, no. I’ve had the best CPD experiences via Twitter, Facebook, and blogging. Some of the most challenging and thought-provoking discussions occur every day on Twitter. Links to new and emerging research. Links to opinions that make you think. Apps that help you be there for your patients, even when you’re not. Ways to remain in touch with people working in your field from around the world. Is it really a healthcare skill? I think so. Social media allows me to connect directly with researchers, other educators, clinicians, people working in niche fields, people living with chronic pain (the very people I so want to know about). Social media gives people living with pain a voice that can be heard. It allows my niche field to be visible. It has an impact on the general public. If we want chronic pain to be taken seriously by policy developers, and if we want to influence how people living with chronic pain can be heard, then social media is, I think, the way forward. It’s not just me – here’s paper reviewing and with tutorials of applications in medicine and healthcare (Grajales, Sheps, Ho, Novak-Lauscher & Eysenbach, 2014).

This list isn’t exhaustive: what else do you see as critical skills for clinicians working with people who experience pain? Add your thoughts to the list below!

Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. doi: http://dx.doi.org/10.1093/fampra/cmq063

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Bertakis, K, Azari, R, & Callahan, E. (2003). Patient Pain: Its Influence on Primary Care Physician-Patient Interaction. Family Medicine Journal, 35(2), 119-123.

Bishop, Scott R., Lau, Mark, Shapiro, Shauna, Carlson, Linda, Anderson, Nicole D., Carmody, James, . . . Devins, Gerald. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230-241. doi: dx.doi.org/10.1093/clipsy.bph077

Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10. doi: dx.doi.org/10.1016/j.pec.2008.09.007

Grajales, Francisco Jose, III, Sheps, Samuel, Ho, Kendall, Novak-Lauscher, Helen, & Eysenbach, Gunther. (2014). Social media: A review and tutorial of applications in medicine and health care. Journal of Medical Internet Research, 16(2), 452-474.

Keng, Shian-Ling, Smoski, Moria J., & Robins, Clive J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041-1056.

Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. J Rehabil Med, 44(2), 163-171. doi: 10.2340/16501977-0912