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What does biopsychosocial practice really mean?


It’s still a bit of a buzzword, biopsychosocial. I’ve argued before that in pain, it’s more of a biopsychological model in practice (and here).*

I’ve had my wrist firmly slapped when I’ve suggested that a group of medical practitioners doesn’t really practice biopsychosocial pain management. I’m not the only person to point out how unidimensional some pain management practice is,  as Roth, Geisser & Williams (2012) point out. This paper argues that interventional pain management focuses narrowly on nociception as an exclusive target, challenges this biomedical view of peripheral nociception as a primary source of pain and discusses the potential that this viewpoint has to foster unhelpful beliefs about pain, discourage using pain coping strategies, and (my addition) may even reinforce fear of pain.

I originally thought I’d discuss just this paper, but in mulling things over, I want to extend my discussion beyond this one example, and think more deeply about what it means to practice biopsychosocial pain management.

So what makes me biopsychosocial?

Someone once said “You don’t always need a team of people to help someone with chronic pain, you just need to think biopsychosocially“. I can see their point. But what does that mean in my practice?

To me, practicing in a biopsychosocial framework means answering two questions:

  1. Why is this person presenting in this way at this time?

  2. What can be done to reduce distress and disability?

The first question is about this unique individual and the choices that have led to them seeing me, today. It’s also about the social context and attitudes that mean this person frames their situation as a problem. When I read that so many people have chronic pain but continue to work, or don’t seek treatment, I want to understand how and why this person has found it necessary to look for help.  The different motivations for seeing me will influence how we work together. For example, if someone has decided they can do more than they have been, but don’t quite know how to go about it, this will lead me to one set of “tools” from my toolbox (sorry Jason!). If, on the other hand, they’ve been sent to me by a compensation funder, they may not even want to do more than they currently can – or that may not be their priority at present. A different set of tools will be required.

I want to understand their problems as they see them. I want to look at the various factors that influence their problems, that may also influence any changes we make. I want to look at how the problems first arose, and then how they’re being maintained – these may not be the same! And it may take time to work through the various aspects to develop a case formulation that can explain why this person is presenting in this way at this time.

It’s only once I’ve taken some time to listen to the person and generate this case formulation that I can then begin to work on the second question. Distress and disability. Both of them, together. You see, it’s easy to address one or the other. Most health professionals want to reduce distress, it’s part of our reason for choosing healthcare as a job. If someone is distressed, our belief is that they’re suffering, and we have a duty to alleviate suffering. But if we’re not careful, we can treat distress but actually perpetuate disability, and disability can mean prolonged suffering. For example, if we give someone short-term relief through acupuncture (or massage, manipulation, medication or even empathy) the effect is to reduce distress immediately – but if and when the same situation comes up again, what do you think that person will do? Yes – head straight for you. It’s a great business model – but not so good for living a life that is half-way normal.

We need to think about how this person can begin to take the reigns him or herself to reduce disability, or the interference value of pain (and treatments and coping strategies and exercise associated with the pain). How can we as health professionals help this person do what’s needed to let pain interfere less?

And I guess that’s part of my frustration with needle jockeys, or people who push procedural pain management without considering that humans make sense of whatever happens to them. If managing pain means attending a treatment clinic every three months for a series of injections, when does that begin to interfere with life? At the end of one year? Two years? What about in 10 or 15 years? When do we call it quits?

And what do I do if I’ve been “trained” to go back for more jabs when my pain returns? And what do I now believe about my ability to deal with pain by myself? How much do I now fear having pain because I’ve been taught I need a quick fix? And from a social perspective, if I need to go to a clinic every three months for life, after a while, how are they going to see any new patients? At what point do they need to stop seeing new patients, or do they need to stop seeing old patients? And if they stop seeing old patients, what happens to me now?

You see, when a person doesn’t know there are any alternatives for managing their pain, how will they do anything differently? If the clinician doesn’t take the time to understand the person inside the pain, and doesn’t take a responsible stance towards what they offer as treatment, I think we end up with unethical practice. By selectively reporting outcomes, failing to assess psychosocial factors, and attending only to nociception and “identifying the source”, perhaps some clinicians are inadvertently creating dependence. Is this OK?

*ps the biopsychosocial model isn’t really a “testable” scientific model, it’s more of a heuristic or framework for thinking and integrating various aspects of human life.

Deyo, Richard A. (2015). Biopsychosocial care for chronic back pain. BMJ, 350. doi: 10.1136/bmj.h538

Engel, George L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. doi: http://dx.doi.org/10.1126/science.847460

Kamper, Steven J, Apeldoorn, A T, Chiarotto, A, Smeets, R J E M, Ostelo, R W J G, Guzman, J, & van Tulder, M W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis (Vol. 350).

Roth, R. S., Geisser, M E, & Williams, D. A. (2012). Interventional pain medicine: retreat from the biopsychosocial model of pain. Translational Behavioral Medicine, 2(1), 106-116. doi: 10.1007/s13142-011-0090-7

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Who are you? The effect of pain on self


My client, let’s call him Al, is a plumber. Or was a plumber. He sees himself as a hard-working, reliable guy who takes pride in doing a job once, doing it well, and not stopping until the job is finished. He’s worked for most of his adult life in his own plumbing business, something he’s very proud of. He’s supported his partner while she’s been at home caring for their two now adolescent boys. In his spare time he goes fishing, loves the outdoors and likes to wander the hills whenever he can.

Al isn’t very happy. He’s been told that his back pain, which he’s had for six months now, is not likely to go away. He’s been having treatments from physiotherapy, had a return to work programme developed by an occupational therapist, tried medications and injections but nothing has taken his pain away. He’s slowly stopped seeing his mates, isn’t sleeping well, hasn’t been out fishing in months, and he’s even had trouble keeping from shouting at his boys.

Al doesn’t sound all that different from many of the men I’ve seen in pain management. Some people call him “unmotivated” because he’s stopped thinking about goals for the future, and does his exercises in a half-hearted sort of way. He doesn’t always attend his appointments. It’s hard to know whether he’s actually doing his home exercise programme. A far cry from the “hard-working, reliable” man who runs his own business.

What’s going on? We could say he’s depressed, and maybe he is. But more importantly, why is he depressed? He doesn’t describe his pain as anything more than a 5/10 where 10 is the most extreme pain he can imagine. He’s still getting an income from his worker’s compensation, he’s still in a loving relationship and in their own home. But he’s not a happy man.

We’ve all met an Al, I’m sure. Superficially he looks fine, but a throwaway comment nails it: “I’m just not myself any more, I want things to be normal”.

Self-concept

All of us have an idea of who we are. A self-concept is a set of representations about who we are, what we do, how we do it, and why we do it. We all have several self-concepts – the “actual” self, the “ideal” self (who we would like to be), the “ought” self (the person others think we should be), the “feared” self (the person we really don’t want to be) and so on (Higgins, 1999; Markus & Nurius, 1986). Our sense of self is based on a collection of memories, a pattern of behaviours that we’ve developed and continue to develop as we aim to be the person we want to be.  Our sense of self guides our choices and the way we do things.

What happens when we can’t do things the way we think we “should”, or the way our sense of self would guide us to? Let’s think about this for a minute.

Al is used to getting up early in the morning, usually about 6.00, so he can get out to the site he’s working on that day and begin work by about 7.30. He prides himself on being at work, ready to go, before his apprentice gets there. He’s always organised, got his gear ready and in the truck with a cup of tea all sorted so he can plan his day.

Since he developed his back pain, Al’s had trouble getting out of bed before 8.00. He’s always tired. He’s not sleeping. He’s the last one in the house to get up, and he can’t even get to the work site until 9.00 because his body is sore and he can’t seem to wake up. He’s getting picked up by his apprentice who keeps giving him grief over not having his gear ready in time. He’s not the man he used to be, in fact, he’s become the man he swore he’d never be, a compensation bludger. He doesn’t like who he’s become. He feels lazy and useless.

Achieving self-coherence by re-occupying self

One of the neglected aspects of pain management is how to help someone deal with the changes to his or her sense of self. Life becomes chaotic when assumptions we make about the world no longer apply. The main concern of someone who is learning to deal with chronic pain is how to make life and self make sense again, to regain some coherence.  When they successfully solve this problem, it’s like all the various aspects of “self” have been reassembled. This is usually a new “self”, one that incorporates pain and the things that need to be done to accommodate pain while still expressing important aspects of “who” he or she is.

The process of learning to live comfortably with a new self is, I believe, a process of re-occupying self. Making a new self that feels recognisably “me”, doing the things that make “me” feel like myself, including some of “my” usual standards and attitudes and interests.

Yet what do we so often do when we doing pain management? We tell people like Al to “relax” and “pace” (Al learned as a child that you don’t stop until the job is done). We tell him he needs to move in certain ways (as a plumber? under buildings, in roof cavities, hauling gear out of the truck, carrying it over building sites). We suggest he needs to not do some things (work for the whole day without a break), but ask him to do other things (carry out a set of exercises three times a day). We say he needs to be back at work, but he doesn’t feel he’s pulling his weight.

What can we do?

I think we need to take some time to understand Al and what’s important to him. Not just the occupations (activities) but also the way he does them, and why he does them. How do they contribute to his sense of self? And then we need to work with him to give himself “permission” to do things differently – for a while. It’s like putting on a temporary “self”, a “rehabilitation” self. We can revisit this “rehabilitation” self as time goes on, and help him identify important values and occupations so he can begin to feel more like himself. Perhaps help him develop a new self that lets go of the old “normal” but includes some of the most important values expressed differently. I call this flexibly persisting – as Antony Robbins says, “staying committed to your decisions, but staying flexible in your approach”.

BTW – if you’d like to help me share this concept, you can! The idea of re-occupying self emerged from my PhD studies, and I want to present this at the Pain Science in Motion Colloquium in Brussels at the end of March. If you’d like to help me raise the airfare to get there (and back!), go to Give a Little and my page “Live well with pain”. Every little bit counts! I’ve had some wonderful people help me get almost half the money I need – will you help me get the rest? Thank you!!

 

Beekman, Claire E., Axtell, Lois, Noland, Kathy S., & West, Jaime Y. (1985). Self-concept: An outcome of a program for spinal pain. Pain, 22(1), 59-66. doi: http://dx.doi.org/10.1016/0304-3959%2885%2990148-4

Charmaz, K. (2002). The self as habit: The reconstruction of self in chronic illness. Occupational Therapy Journal of Research, 22(Suppl1), 31S-41S. doi: dx.doi.org/10.1177/15394492020220S105

Hellstrom, Christina. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology & Health, 16(1), 111-124. doi: http://dx.doi.org/10.1080/08870440108405493

Higgins, E. Tory. (1999). Self-discrepency: A theory relating self and affect The self in social psychology (pp. 150-181). New York, NY: Psychology Press; US.

Markus, Hazel, & Nurius, Paula. (1986). Possible Selves. American Psychologist, 41(9), 954-969. doi: dx.doi.org/10.1037//0003-066X.41.9.954

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Mike “KnowPain” Stewart is coming to New Zealand!


I’m very proud to announce that Mike Stewart, Clinical Specialist Physiotherapist in pain management for East Kent Hospitals University Foundation NHS Trust is coming to New Zealand to take three of his award winning Know Pain Workshops for allied health professionals.

Mike is widely known amongst the pain clinicians, particularly physiotherapists on social media, and is a keen advocate of therapeutic neuroscience education (TNE) as a means for improving health outcomes for people with chronic pain. Therapeutic neuroscience education is a key component of the Moseley and Butler Explain Pain approach to pain management, and there have been numerous research papers demonstrating effectiveness of this approach.

Mike is coming to New Zealand (Auckland, Wellington and Christchurch) at the end of April, beginning of May 2015.

This is his website – http://knowpain.co.uk/

And here’s what you can expect:

CaptureNOW is your chance to register for this workshop in Christchurch –

2nd & 3rd May 2015
Department of Orthopaedic Surgery &
Musculoskeletal Medicine
University of Otago
Christchurch, NZ

Workshops are also being held in Auckland and Wellington.

For more details, contact Dr Bronnie Lennox Thompson, ph 64-3-364-1086 or 027 270 4225

For even more details, contact Paul Lagerman (aka The Naked Physio!) – thenakedphysio.com

These workshops are supported by AUT University and University of Otago.

AUT LogoUniversity of Otago - Te Whare Wānanga o Otāgo

A pierless morning

Fabulous FREE pain education resource from Cardiff University


It’s amazing what you find on the interwebs. Thanks to Pete Moore from Pain Toolkit -you can find him on Twitter as @paintoolkit2 – I’ve been introduced to Cardiff University’s amazing Pain Community Centre. This is a site developed by pain educators and clinicians to provide authoritative and practical information on a wide range of pain topics. FREE CPD, a chance to chat amongst others with the same inclination, clear video recordings, a list of events in the UK, and a set of “Pain  Toolkits” on topics such as migraine, central post-stroke pain, general management of osteoarthritic pain and so on. This is by far the most comprehensive and well-organised site that I’ve stumbled on in a long time. Well worth the visit (and you’ll probably lose some hours as well!). Oh, and Pain Community Centre is also on Twitter as @paincommunity

Tauhou "New arrival"

Pain management and the political


There are only a few more weeks before a general election in New Zealand. This means the usual rounds of promises, muck-racking, hoardings and defaced hoardings. As I browse the research into chronic pain, and bemoan the lack of attention to the SOCIAL of the biopsychosocial model, I find myself looking at factors that almost entirely depend on a political solution. Let me explain.

Social. What is meant to fit into this part of Engel’s model? Drawing from one of his earlier works, Engel stated in his Cartwright Lecture at Columbia University College of Physicians and Surgeons (1977), that

“Health restored is not the former state of health but represents a different intersystemic harmony than existed before the illness, with characteristics based on all the system changes incurred during the illness. By virtue of the illness not only is the individual changed as a person, but so too may be changed others in relationship to him, in the family as well as the community…”

I interpret this segments of Engel’s work, and in particular the diagram he included in the published version of this speech, as a clear indication that while a biomedical model looks at the levels from quarks to systems, a biopsychosocial systems approach looks beyond this and into the person right up to society and nation.

biopsychosocialAnd this is where it gets political. While individuals reappraise their self worth, learn new skills, develop new living patterns (well within the contributions of most allied health including occupational therapists), Governments and economic policy have a direct influence on what occurs in the interaction between what the individual does and the effect on the family, community, culture and subculture (however you define this), and ultimately society-nation.

Here’s some recent research illustrating how these factors interact.

When a person develops chronic pain, clinicians are likely to ask “How did it begin? What happened?” The person will probably talk about an event in the last few months or years that may have triggered the most relevant experience of pain. What clinicians may not think to ask about, and the person with pain may not even consider, is what happened in early life.

Goosby (2013) looked at socioeconomic disadvantage and maternal depression in individuals during their teenaged years, and found that the probability of chronic pain increases in magnitude over life in those adults who had parents with less education, and in those who had mothers who were depressed. She points out that mothers who live in low-income households (e.g. single mothers on a benefit?) are “especially vulnerable to psychological distress and disorders such as depression” (p. 77). She calls this “intergenerational transmission”, and goes on to describe “risk amplification” that occurs for children with low socioeconomic status who continue to experience deprivation as they become adults, while those who are not disadvantaged continue to maintain their health and wellbeing at least in part because of economic stability.

She continues by describing that childhood disadvantage increases the risk of depression and pain in adulthood and that adult socioeconomic status is a key factor through which adult health and wellbeing emerge. Interestingly, she found that adult depression is influenced by fewer factors than adult chronic pain – in fact, she found that all indicators of childhood socioeconomic status had significant interactions with the RR of adult chronic pain relative to no conditions, and particularly for those who had mothers who were depressed.

A similar finding was made by Lacey, Belcher, & Croft (2013) in a study looking at life-course socioeconomic position influencing chronic pain in older adults.

It doesn’t take a rocket scientist to see that this is political. In a climate where single parents (most often women) are told they are “welfare dependent”, receive a tiny sum of money or are asked to return to work when the child is 5 years old, often to work that is poorly paid (because more senior and well-paid positions rarely allow workers time to attend to children’s needs, mind you neither are poorly paid jobs), life is stressful and anyone vulnerable to depression and/or chronic pain is at high risk.

A sense of injustice can exist where individuals feel that circumstances are not fair, and that they are the victims of an injustice. In New Zealand there is a mitigating factor in that all accidental injuries are covered by the state-owned and tax-payer funded Accident Compensation Corporation. BUT, and this is a big one, there are incentives for those case managers to encourage and support people to return to work, while those who are injured while not working may receive far fewer entitlements and will not receive rehabilitation to return to work. This shouldn’t matter because access to rehabilitation is available to all – but in practice, does it?

McParland & Eccleston (2013) found that a sense of injustice can affect emotions, cognitions and behaviours. A particular point they raise is that when there is inequality between two people in a relationship, ie where one has money but the other does not (one is working, while the other is unwell with chronic pain) there may be adverse responses between the individuals. In New Zealand, if one person in a longterm relationship becomes unwell, while the other person is employed there is very little if any financial support for the couple. If the earner is only receiving a minimum wage, this presents a huge obstacle even to attending treatment.

My final review today (and believe me, there are SO many more than I’ve touched on!) comes from Antao, Shaw, Ollson, Reen and colleagues (2013).  They looked at intermittent work incapacity and how this influenced the way we can support people to sustainably remain working despite having times where their chronic pain interferes with this ability.  They draw on Bronfenbrenners Ecological Systems Theory which views child development within a context of social and interpersonal environments. Antao and colleagues used the environmental framework to analyse the workplace: .Micro level issues are defined as issues within the individual and personal realm and include factors such as cognitive deficits. Meso level issues are related to the workplace, such as workplace policies and accommodations. Finally,macro level issues are related to socio-cultural or political issues, such as benefits and insurances. (p. 13).

What these researchers found was there is considerable literature discussing micro-level support for people with pain. These are things like the individual learning about his or her condition, maintaining physical fitness, working on routines that can maintain or support work. Education, for example, focused on giving individuals information about worker’s rights, how to maintain quality of life through coping changes.

Meso-level strategies were rather more scarce in the literature, but they were present – things like educating employers and supervisors, modifying tasks or workstations, ensuring people are aware of the benefits of working on the individual and so on. I guess some of these fit into the “ergonomics” category.

Macro-level strategies were even less often presented, but included using flexible work practices (shifts, glide time, sharing tasks), providing timely financial support during times when an individual is unable to work, anti-discrimination laws and similar.

Meso- and Macro-level strategies are about social change and political will.

Where does this leave me?

When I consider the influence socioeconomic deprivation has on people, right from childhood through to the flow-on effects in adults, I worry about the effects of policy on people in New Zealand. There is an increasing disparity between those earning above $100,000 per annum, and those on the minimum wages of $14.50 or so. Worse for those on a benefit who are also labelled “benefit dependent”.

I’m worried that very often there is an outcry if a policy is introduced to support the situation of workers – employers complain that this is unsustainable, that they won’t remain in business and there will be economic fall-out because of this. I’m concerned at labelling that occurs if a person is on a benefit. Being on a benefit is not a life of luxury, yet benefit fraud is pursued more vigorously than so-called “white collar” crime, and in research conducted by Victoria University in 2011 “22 per cent of tax offenders received a custodial sentence” while “approximately 60 per cent of welfare fraud offenders received a custodial sentence.” Sophie Rule, Report Writer, Youth Parliament 2013, Ministry of Youth Development.

I am unhappy that the “trickle down” of economic growth hasn’t trickled, and that people who have few resources in so many ways are in a very real situation of social injustice. It’s a brave person who challenges an employer who decides to fire a worker who, having been in the same job for 20 years, has a heart attack and needs three months time off work. True story. Or a woman who, since the business she works for has moved from town to Rolleston, now has to travel by bus for an hour, then cycle for another 30 minutes to work in a job that pays minimum wage. And do the same again in the evening, despite her chronic obstructive pulmonary disease. In Christchurch. In winter. Oh and she lives with the man who had the heart attack. She doesn’t get paid when she needs a week or two off work because of her COPD as happened recently.

The social is largely, I think, a political matter. And chronic pain affects one in six New Zealanders. And they all vote.

 

Antao, Lilian, Shaw, Lynn, Ollson, Kaitlyn, Reen, Kavleen, To, Flora, Bossers, Ann, & Cooper, Lynn. (2013). Chronic pain in episodic illness and its influence on work occupations: A scoping review. Work: Journal of Prevention, Assessment & Rehabilitation, 44(1), 11-36.

Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91. Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91.

Lacey, Rosie J., Belcher, John, & Croft, Peter R. (2013). Does life course socio-economic position influence chronic disabling pain in older adults? A general population study. European Journal of Public Health, 23(4), 534-540.

McParland, Joanna L., & Eccleston, Christopher. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.

Yealands Winery

Sticky back beliefs


ResearchBlogging.org
I get excited when I can write about New Zealand research! Especially when it’s done by a nice guy like Ben Darlow.
Ben’s just completed his PhD looking at the effect of what we say on people’s beliefs and behaviours when they have low back pain. And believe me, it’s not pretty! I think it’s David Butler from NOI who described the concept of “sticky” words, or words that have great power to influence beliefs about pain, and Ben’s research absolutely supports this.

What Ben and his colleagues did was survey 1000 New Zealanders using a postal survey. He used the Back Pain Attitudes Questionnaire (Back-PAQ), and, with a response rate of 602 (pretty good Ben!), worked to establish the relationship between attitudes and beliefs and (1) back pain experience and (2) health professional exposure. Respondents were from the New Zealand electoral roll, so were 18 years of age and older.

Unsurprisingly, Ben found that 87% (95% CI 84% to 90%) of people had experienced low back pain – yes, it’s very common – and that 27% (95% CI 24% to 31%) were experiencing back pain at the time of the survey.

Now, here’s the tough stuff: While 76% of people responding to this survey thought that their back was “one of the strongest parts of their body” and 78% thought that their back was “well designed”, and enormous 89% thought that their back was easy to injure and 95% believed that they could injure their back if they were not careful.

No wonder people rush off to see a health care provider when their backs hurt! And no wonder many people are too scared to move when they’re sore.

Worse than this, however, were the findings that 99% thought that good posture was important to protect the back, and 97% believed that they needed strong muscles. 94% of respondents believed that it was not safe to lift without bending the knees.  Thank YOU Mr Precious McKenzie and the ACC “Don’t use your back like a crane” messages from the 1980’s and 90’s!

Of course, just because people believe this does not mean they actually try to keep “good posture” or “strengthen muscles” or even lift with bent knees – but it goes to show how pervasive these erroneous beliefs can be in the general population.

One interesting finding that I think gives us a bit of hope: people who had been to see a health professional were more likely to believe it’s OK to remain active despite pain. Praise be!

What worries me is that public health interventions to promote remaining active despite back pain are few and far between. People still believe their backs need protecting, yet they can look at pictures of people doing amazingly strenuous activities with flexible and strong backs without reflecting that their own backs could be just as strong and flexible. Please oh please can we begin to recognise that backs were meant to be flexible, move and bend and twist and give us an enormous range of positions from which we can do things! And please, can we stop telling people they need to “lift properly”??!

Darlow, B., Perry, M., Stanley, J., Mathieson, F., Melloh, M., Baxter, G., & Dowell, A. (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand BMJ Open, 4 (5) DOI: 10.1136/bmjopen-2013-004725

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Don’t worry, be happy: Could optimism counteract negative effects of pain?


ResearchBlogging.org

Warning: there is an earworm contained in this post!

How on earth could anyone be happy when they have pain, huh? Well, more about that in a minute, first let’s look at this interesting study from Maastricht University by Jantine Boselie, Linda Vancleef, Tom Smeets and Madelon Peters.

We know that having chronic pain reduces a person’s ability to undertake complex cognitive tasks, particularly those that involve making decisions or problem solving. People become overwhelmed, fatigued and then perform poorly when they need to maintain concentration when they’re experiencing pain, and researchers have found that this is, at least in part, because pain demands attention. More than this, self regulation, or the ability to modify thoughts and behaviours in order to achieve what is important, can become depleted over time, compounding the original loss of capacity. It’s enough to make you feel just a bit unhappy!

These researchers investigated whether optimism might (a) be able to be induced in people who are currently experiencing pain, and (b) might be able to reduce some of the fatiguing effects of self-regulation depletion. This is based on the notion that people who remain optimistic keep persisting with tasks even when the going is tough. They also investigated whether experimental pain has a direct effect on self-regulation (well, actually, executive task performance which is in turn affected by self-regulation status).

Once again, healthy undergraduates were the participants in this study, so for what it’s worth, these are people who are warped enough to participate in a pain study, and who are generally well. It’s also an experimental pain, so probably doesn’t have the same effect on people as chronic pain, but then again, it’s probably one of the few ways to carry out this kind of research.

There were four conditions: (1) pain plus optimism induction; (2) no pain plus optimism induction; (3) pain without optimism induction; and (4) no pain and no optimism induction. The pain induction was a cold pressor test cold pressor test

Yes, that’s ice. 2 degrees C. For a maximum of 3 minutes. Ouch.  This is what participants were told: ‘‘The aim of the task is to submerge your right hand in this cold water tank for as long as possible until you cannot
take it anymore. When you cannot take it any longer, you are allowed to remove your hand from the water. Try, however, to hold on as long as possible.” They weren’t told of the maximum time limit.The optimism induction was taken from the “Best Possible Self” technique developed by King, while the neutral or control condition was simply writing about a typical day.

All the participants were asked to complete a working memory test (the operation-span task).

As with most studies of this type, every participant also completed a set of questionnaires, to help determine some of the characteristics that might be associated with their ability to do the task, or influence the outcome.

What did they find?

Firstly, they found that the optimism induction did have an effect. That’s good – people can indeed feel more positive and optimistic if they imagine themselves succeeding.

Secondly, they found that people who went through the cold pressor test did, in fact, report more pain. Whew! That’s good.

They also found that irrespective of whether the participants went through the optimism induction, or the neutral writing task, they reported the same pain intensity. So – it’s not possible to “think yourself pain free”, at least, not in this study.

Now for the good stuff: using ANOVA (Yay! ANOVA is awesome! Read the link if you want to know more about the maths), the researchers found that there is an interaction between optimism and performance on the executive task, in the presence of pain. In other words, when a person experiences pain and has not participated in an optimism induction, their performance on the executive task is poor. If they’ve participated in an optimism induction, their task performance did not suffer.

What this means

Well, bearing in mind that this is an experimental study, so we can’t translate directly to clinical practice for people who have chronic pain, what it shows is that pain degrades performance, particularly complex executive functioning. IT also shows that people who can become optimistic don’t show this kind of performance degradation.

Optimism is a complicated construct. Some people appear to be more cheerful, happier, more likely to think they’re doing well, and this seems to be their normal state. I’m not one of these people! However – it’s been shown that people CAN increase their sense of optimism by doing certain things, such as imagining themselves succeeding and doing well, feeling grateful for what they have in life, “counting blessings” and so on  (Meevissen, Peters, & Alberts, 2011).

The authors of this research suggest that these findings might be important for people who have chronic pain. We know that chronic pain depletes self-regulatory functioning. We also know that people with chronic pain can become more optimistic if they use something like the Best Possible Selves induction on a daily basis. The argument is that perhaps, by using an optimism induction, people with chronic pain might be able to mitigate their self-regulatory depletion.

I’m a little less optimistic (heh! heh!), but I do think there’s some merit in looking at this further.

I wonder what would happen if we focused on helping people identify some of the positive aspects of having chronic pain. And yes, there ARE some positives.

When people with chronic pain successfully manage their pain, demonstrate courage, personal strengths, planning and problem solving ability. In bucketloads. They become capable of navigating through healthcare systems. They learn more about themselves. They become skilled at stress management, relaxation, exercising and delegating. They develop greater awareness of what is a priority in life. They recognise that energy is a precious resource – and they get good at allocating that energy where it matters the most to them.

More than this, we as health professionals can help people be more optimistic by focusing on what they want to achieve despite pain. We can help people recognise that they are making progress, developing skills, becoming their own pain experts. We can guide them to appreciate what they have, rather than what they do not have. This reminds me of coach John Wooden’s quote: “Do not let what you cannot do get in the way of what you can.”

Could we do more to show how a life with chronic pain CAN be good?

Meevissen YMC, Peters ML, Alberts HJEM. (2011). Become more optimistic by imagining a best possible self: effects of a two week intervention. Journal of Behavioral Therapy and Experimental Psychiatry, 42: 371-8

 

 
Jantine J.L.M. Boselie, Linda M.G. Vancleef, Tom Smeets, Madelon L. Peters (2014). Increasing optimism abolishes pain-induced impairments in executive task performance Pain, 155 (2) DOI: 10.1016/j.pain.2013.10.014

fencing

Trust, teamwork and transparency


ResearchBlogging.org
Teams are a feature of healthcare, and nowhere more so than in pain management.  This is because, at least for chronic pain, no single profession can claim to have all the answers.  Many of us know we need to rely on one another to address patient/client concerns and to provide a consistent approach for the person to have some confidence in.

However (you knew this was coming!), teamwork isn’t easy and some groups of professionals appear to have a good deal of difficulty overcoming implicit attitudes and assumptions about other disciplines.  Now before I’m annihilated, I acknowledge that the attitudes and behaviours within every group of practitioners varies in a bell-shaped curve!

I had occasion, recently, to address a group of health practitioners who shall remain nameless.  This group were discussing sharing of health information, and an approach to inviting patients to be part of a programme of self management in which health information sharing is a component.  To my perplexion, I found that there were two major concerns about this approach. 

  1. That “all” health information would be shared by all team members rather than being selected by this group of clinicians (the risk being identified was that mental health and sexual health information would be shared along with cardiology, musculoskeletal, immunological and so on)
  2. That inclusion on this programme would not be “controlled” by this group of clinicians. 

In other words, that patients would be able to decide for themselves whether they wanted to participate, and that all their health information would be available to other clinicians was viewed with anxiety. I’m venturing to suggest that this reflects a lack of trust in both other health professionals, and in their patients, with the latter being a somewhat outdated paternalistic view, IMHO.

I took it upon myself to have a quick flick through the literature on health professionals attitudes towards one another, and there is a wealth of it! Unsurprisingly, studies about biomedical attitudes towards professionals of other persuasion dominate, so I’ll summarise just a couple and let you draw your own conclusions about how widely the findings might apply.

Moret, Rochedreux and colleagues (2008) found that while physicians delivered diagnosis and prognosis (and nurses agreed), nurses thought they provided additional explanations about diagnosis, information on investigations, and benefits and risks of treatment to what physicians provided, while physicians appeared unaware of the contribution of nurses.  Concerningly, more than 20% of patients were not satisfied with information on benefits and risks of investigations and treatments, and wanted more.  This report suggested that lack of physician-nurse collaboration affects the quality of patient care, and that both professions should recognise the contributions of each other.

Gaboury, Bujold et al (2009) examined the collaboration between medical doctors and “complementary and alternative medicine practitioners”.  (For the skeptics amongst us, these are the practitioners included: naturopathy, massage therapy, chiropractic, and traditional Chinese medicine, including acupuncture. Other practitioners coming from a biomedical healthcare background, such as nurse practitioners, physiotherapists or pharmacists were also eligible participants. I make no comment on whether these practitioners provide useful/helpful input, kthx).  They found that “awareness of one’s own limitations related to one’s healthcare paradigm and similarly limitations in colleagues’ abilities … affect[ed] the level of collaboration among the clinic staff.”; and that “capacity to acknowledge one’s own limits was identified as a major personality characteristic [my emphasis] that stimulates appropriate patient referral and safer care for the patient.”  They also state that  “comprehensive understanding and knowledge of colleagues’ healthcare abilities, and perspectives based on their healthcare paradigm appeared to be vital to the team cohesion.”   Sharing patient records was found to enhance collaboration, and patients were asked to agree to this.

However, relating directly to my experience regarding power relationships, this study identified that “…even though patients could self-refer and specifically request to see a CAM specialist in all of the five clinics visited, the designated entry practitioner for two clinics was the medical doctor. One manager interviewed depicted his clinic’s referral system as if the medical doctors were the orchestra conductors responsible for ensuring continuity of care and integrative care.”

There appears to me to be an easy assumption by the medical profession that they are at the top of a decision-making hierarchy in a healthcare team.  I’m not sure this is justified in all situations (I don’t mind if a doc decides for me if I have acute appendicitis!) – but it’s an attitude adopted very early in medical training.  A study of medical students by Weaver and Peters (2011) looked at factors contributing to medical students developing sense of professional identity.  They found two main elements could be identified : professional inclusivity and social exclusivity.  By professional inclusivity, they meant that as students participated in clinical placements and were treated as “members of the team”, and social exclusivity, they meant medical students tended to socialise with one another.  A commentary by Bleakley in the same journal suggests that “as medical students are drawn further into associating with those in medical culture, so other associations are denied or lost”, “as trainee doctors, medical students become ‘clinical reasoners’ and this, traditionally, identifies them and distinguishes them from others.” Bleakley says “Medicine has claimed a degree of autonomy that has progressively provoked its consumers – patients.” He goes on to say “When a student in the study … remarks that the medical profession is ‘something to look up to’, one wishes that this student had described it as ‘something to look forward to’. ‘Looking up to’ can so easily progress to ‘looking down on’, where meritocracy hardens into autocracy.

Bleakley writes strongly about the need to challenge medical students’ social exclusivity saying “The excluded ‘other’ (health care colleagues, patients, cultures other than medicine) should be a major focus for inclusion in medical education; otherwise students will continue to progress habits of exclusivity in their work as doctors, indicated by relatively poor communication with patients and colleagues”.

Really, I couldn’t say it better myself, so I’ll leave the last word to Bleakley:

Belonging to the medical team is an issue of professional identity, whereas belonging to the wider health care team is an issue of interprofessional identity.

 Applies to all of us, doesn’t it?

Bleakley, A. (2011). Professing medical identities in the liquid world of teams. Medical Education 45(12): 1167–1173

Gaboury, I., M. Bujold, et al. (2009). “Interprofessional collaboration within Canadian integrative healthcare clinics: Key components.” Social Science & Medicine 69(5): 707-715.

Moret, L., A. Rochedreux, et al. (2008). “Medical information delivered to patients: Discrepancies concerning roles as perceived by physicians and nurses set against patient satisfaction.” Patient Education and Counseling 70(1): 94-101.

 
Weaver R, Peters K, Koch J, & Wilson I (2011). ‘Part of the team': professional identity and social exclusivity in medical students. Medical education, 45 (12), 1220-9 PMID: 21999250

fencing

Living well with persistent pain – a problem solving model


Regions of the cerebral cortex associated with...

Regions of the cerebral cortex associated with pain. (Photo credit: Wikipedia)

ResearchBlogging.org

Chronic pain is abnormal. Living well with chronic pain seems a myth, a bit of an impossibility. After all, chronic pain starts with the kind of pain that most people would expect to go away – acute pain.  Acute pain is normal and most of us will experience some painful episode today.  Acute pain goes away – either by itself, or because we’ve done something to remove the stimulus that triggered the cascade of neurological events that eventually reached the brain that produced the experience of pain.

Because chronic pain begins just like any other pain, and because acute pain generates our attention and stimulates some sort of problem solving process so we can take appropriate action, it makes sense that we apply the same problem solving strategy to the problem of chronic pain.  Eccleston and Crombez (2007) proposed that one of the ways we can view the distress, loss of function and reduced quality of life is through a model of “misdirected” problem solving.

Problem solving is often discussed as if the problem exists outside of a context. “Here’s the problem, go solve it” fails to establish the frame of reference – why is it a problem? who has the problem? what contributed to the problem? what resources are available to fix the problem?

One of the major contributions of psychology in the field of pain, particularly a cognitive behavioural model, is helping people view their problem differently. If a situation is viewed differently, the “problem” may go away, or at least be seen as manageable.

BUT, in the case of pain, mostly people start by thinking that pain is something to be cured or fixed, the pain should go away, and life should return to normal.  In the case of chronic pain, when the pain persists, the same problem solving strategies that work so well for acute pain begin to get in the way of living. Life becomes a merry-go-round of searching for relief (maybe an explanation, diagnosis, medication, surgery, new treatment), hope being raised, then very often being dashed because nothing has changed.

Eccleston and Crombez describe this cycle in terms of the function of worry.  “Where such problem solving leads to success, pain and worry abate. However, when the problem solving attempts fail to find a solution, worry is fueled. A ‘perseverance loop’ is established in which the failure of a solution to the problem of pain amplifies worry. In this loop increased worry functions to strengthen motivation to persevere in solving the problem. Problem formulation becomes narrowed and inflexible, whilst greater effort is employed repeating the same solutions. If on repeated attempts a solution is achieved, again pain and worry will stop. “

Over the past 20 years or so, cognitive behavioural approaches for helping people cope with their ongoing pain have focused on reducing distress and disability by helping people reframe the problem of persistent pain as something that can be managed.  This takes the focus off trying to remove the pain, and broadens problem solving so that people begin to look at what else can help them live well.

My research is examining how people who do live well with their pain manage to do so.  While the people I’m talking with don’t say no to new treatments, they don’t seem invested in it so that their whole lives are focused on solving the problem of pain.  Instead, they seem to view pain as “just another thing” that they deal with while they get on with the real business of living life. Some have found that having chronic pain has enthused them with a new direction in life. Others have a focus on family, or community, or work.

The context of chronic pain matters.  It’s the way that the problem of chronic pain is framed that situates and generates the range of problem solving options that are considered.  If we ask a person “what’s important in your life”, and see if they’re willing to make room for having pain present while they engage in occupations or activities that allow them to live their values, we offer people a chance to live well with their persistent pain.

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model PAIN, 132 (3), 233-236 DOI: 10.1016/j.pain.2007.09.014

Eccleston, C (2011). A normal psychology of chronic pain The Psychologist, 24 (6), 422-425

little schoolhouse

The Graded Motor Imagery Handbook – a review


I love getting presents, and I love books, so what could be better than getting a book to review as a present!

Graded motor imagery (GMI) has become incredibly popular in pain management, especially for people with unilateral pain.  It’s a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence.  For those who don’t know – level B1 evidence means there are several RCT’s, and at least one meta-analysis showing support for this approach.

Back to the book.  Like all the NOI books it’s an unusual size, has groovy graphics and an easy-to-use layout. It’s a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes.  The illustrations and photographs are clear and provide excellent guidance for clinicians.  Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler’s favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment.   Each chapter can stand alone, and it’s not necessary to read from beginning to end – but of course, it does help!

This book isn’t for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain – and the translation into the “real world” – are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.

Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment.  GMI has best application in people with unilateral pain such as CRPS and phantom limb pain – although it has been extended to other pains.  These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.

Back to the book again!   I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI.  His writing is clear and provides an excellent scientific basis for the approach.  He doesn’t extend his writing into psychological aspects of pain beyond the concepts of what he calls “neurotags”, or “interconnected neurones … that produce an output”.  Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action).  I have learned these associations as just that – associations between various aspects of learning and anticipation, and have called them the neuromatrix – but NOI have used the term neurotag, and I guess it’s as good a name as any.

The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written.  While it’s possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer’s neuroscience, and Butler’s metaphors, it becomes far more flexible.  I like this.  It is a chapter that I think many clinicians will turn to regularly – but as is emphasised throughout this handbook, patients/participants should read this stuff too.

Worth getting? Yes, I think so. 

My caution lies in over-interpreting the application of GMI beyond the evidence-base.  If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her.  Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain.  Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world.  After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport – where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment.

Where to get it? Go here – and let ‘em know I sent you.