healthcare

Help me solve this puzzle


The IASP definition of pain is:

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Six key notes and etymology:

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

This definition allows for “pain is always a personal experience” and that “pain and nociception are different phenomena” – supporting the idea that the association between what goes on in the tissues and our individual experience of pain is both complex, and currently unmeasurable.

So therefore, why do we have this line in the IASP diagnostic criteria for complex regional pain syndrome: “The patient has continuing pain which is disproportionate to any inciting event” – but wait, there’s more! Kosek et al, (2021) indicate that clinical criteria for nociplastic pain include “…a history of pain hypersensitivity in the region of pain” and “Evoked pain hypersensitivity phenomena can be elicited clinically in the region of pain.”
I’m puzzled.

Pain that is “disproportionate” suggests there is “proportionate” pain… AND at the same time the definition of pain says pain is “always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.” So if I experience pain in the presence of an inciting event, and report it as “OUCH” on the ouchie scale, who can tell me whether my pain is “proportionate” or “disproportionate”?

The nociplastic criteria are similarly confusing: pain hypersensitivity in the region of pain – really painful pain where I’m already experiencing pain? Or do they mean allodynia or hyperalgesia? Or…poke me where I’m sore already and the examiner can tell whether I’m more sore than I ought to be?

Underlying these diagnostic criteria lives a sneaky little beast I call “assumed normalism.” That despite all the work over the decades, some clinicians and researchers really do believe there is a reasonable relationship between nociceptive stimulation and the degree of ouch I might feel. I’m not sure about this…

I wonder if assumed normalism relies on experimental data where people volunteer to undertake nociception tests. These are things like quantitative sensory testing where individuals report the moment they experience heat, cold, pressure, and vibration (pain threshold), and when they want the experimenter to stop doing that thing NOW (pain tolerance).

Let’s think about that situation for a moment. An experimental set-up or lab. Volunteers who know what they’re going to be asked to do. Who know they can say “STOP” when they want to. Who know that no lasting harm is going to occur (ethics, don’t you know). And who volunteers for these kinds of experiments? Nuzzo (2021) pointed out that females are well-known not to volunteer for experiments where there is “an expectation of painful, unpleasant, or risky procedures” and cites research from as far back as 1976! (Rosnow & Rosenthal, 1976) – and earlier (Howe, 1960).

But more than this, Horowitz (2009) states “…QST is a subjective psychophysical test entirely dependent upon patient motivation, alertness, and concentration. Patients can willingly perform poorly, and even when not doing so, there are large intra- and interindividual variations.”

How have clinical diagnostic criteria included definitions that seem too have slid by scrutiny?

Why does it matter?

As soon as we begin thinking of “normal” “objective” “proportional” or “disproportional” in leaps human judgement. Bias. The opportunity to dismiss a person’s experience – on the basis of what we can observe, or what the person can demonstrate. We can only infer that someone else is experiencing pain on the basis of their behaviour – what a person says, does, in the presence of pain, in a particular context. And bias exists when it comes to interpreting behaviour.

As a person living with pain, should I aim to “look well” and be judged as “not suffering enough for pain to be a problem”, or “look poorly and be judged as “not using coping strategies, wanting attention”…

Because, unless all the qualitative studies I’ve read are really erroneous, bias and stigmatising from clinicians and insurers is a thing. From adolescents (Wakefield, 2021), people tapering opioids (Benintendi et al., 2021), gender (yeah, I mean women, Zhang et al., 2021) – oh the list is long….

So, perhaps we could consider an alternative way to describing these kinds of pains: I personally prefer “severe” but maybe there are other words?

Benintendi, A., Kosakowski, S., Lagisetty, P., Larochelle, M., Bohnert, A. S., & Bazzi, A. R. (2021). “I felt like I had a scarlet letter”: Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug and alcohol dependence, 222, 108664.

Howe, E. S. (1960). Quantitative motivational differences between volunteers and nonvolunteers for a psychological experiment. Journal of Applied Psychology, 44(2), 115–120. https://doi.org/10.1037/ h0045002

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

Nuzzo, J. (2021). Volunteer Bias and Female Participation in Exercise and Sports Science Research. Quest, 73(1), 82-101. https://doi.org/10.1080/00336297.2021.1875248

Rosnow, R. L., & Rosenthal, R. (1976). The volunteer subject revisited. Australian Journal of Psychology, 28(2), 97–108. https://doi.org/10.1080/00049537608255268

Wakefield, E. O., Puhl, R. M., Litt, M. D., & Zempsky, W. T. (2021). “If It Ever Really Hurts, I Try Not to Let Them Know:” The Use of Concealment as a Coping Strategy Among Adolescents With Chronic Pain. Frontiers in Psychology, 12, 1840.

Zhang, M., Zhang, Y., Li, Z., Hu, L., & Kong, Y. (2021). Sexism-related stigma affects pain perception. Neural plasticity, 2021.

Rehab Fails: What goes wrong in rehab 4


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

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

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

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

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

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

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

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

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

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

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

Cassell, E. J. (2011). Suffering, whole person care, and the goals of medicine. In T. A. E. Hutchinson (Ed.), Whole person care: A new paradigm for the 21st century (pp. 9-22). Springer. https://doi.org/10.1007/978-1-4419-9440-0

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

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

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

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

What goes wrong in pain rehabilitation (2)


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

Let me unpack this one.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Starting at the wrong intensity

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

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

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

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

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

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

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

What do we do with these thoughts?

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

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

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

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

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

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

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

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

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

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

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

Reflective practice


In occupational therapy and some other health professions, reflective practice is a vital part of professional clinical activity. In others – not so much. And the term reflective practice has a heap of assumptions attached to it, so it may mean different things to different people.

I thought I’d unpack a bit about reflective practice today because I think it needs to be part of working with people experiencing pain. It helps us get out of our own mindset (when it’s done well), and opens a space for questioning what we do and why we do it – and as you probably all know, questioning is part of who I am!

According to Wikipedia (NO! Not an academic source – but kinda handy in this instance) “Reflective practice is the ability to reflect on one’s actions so as to take a critical stance or attitude towards one’s own practice and that of one’s peers, engaging in a process of continuous adaptation and learning” (Schon, D, 1983). In other words, we take an action then step back from what we’ve done to critically appraise it. The appraisal might be simply asking “what worked, what didn’t work, what would I do differently?” or it might be a more complex process in which someone else helps us to ask these questions or compare what we’ve done against a theory or another way of working.

I will admit that I hold some skepticism about how well we do reflective practice (the “we” being us human beings in general). This is because we’re incredibly prone to cognitive errors such as anchoring, commission and omission biases, framing effects, availability bias, vested interest bias and groupthink (see Scott, et al., 2017). The sneaky thing about these biases is that they’re implicit: that is, we often are oblivious that we do them. To combat them we need to take deliberate steps, and most of us haven’t been taught how to do this. Even when we have another person to work with as a prompt, we can get caught up in biases and fail to be critical about what we think of as “normal”.

Lilienfeld & Basterfield (2020) agree with me, pointing out that reflective practice theory and practice doesn’t draw on an understanding of the difficulties using introspection to become aware of biases (because we’re not aware of these intrinsic biases), that self-assessment often omits areas in which we either feel highly confident or we’re afraid we don’t know and don’t want to admit we’re struggling, and that we often don’t learn from experience. Ooops.

Yet, there’s enough evidence to show that by employing reflective practice, people can develop meta-cognitive skills in which they check their own assumptions, identify gaps in their knowledge, seek new information to fill those gaps, then try that knowledge out in practice (Ziebart & MacDermid, 2019).

BUT how do we do it, and does it make for better outcomes for the people we hope we help?

Lilienfeld and Basterfield (2020) offer some ideas – and caution us not to accept clinician satisfaction with the process of reflective practice with evidence of effectiveness. They propose drawing on research understanding debiasing: things like “consider the opposite” or “consider the alternative” as deliberate questions clinicians can ask themselves. Asking clinicians “how might I test out an alternative hunch?” could be a useful approach. Suggesting clinicians and their supervisors/mentors take an “outsider perspective” to step back from their decision-making as ‘disinterested third-party observers’ might help break through our tendency to overlook habitual practices just because they’re familiar (and perhaps help us remain willing to be vulnerable and compassionate towards ourselves instead of defensive).

I suspect clinicians working in pain management could do well with an ongoing relationship with a supervisor. Not someone who holds themselves as the “font of all wisdom”, not a “mentor” who feels responsible for shaping therapists into something new, but more as a mirror lens on practice. A neutral but supportive partner who can ask questions like “I wonder if we could use this [novel theory] to explore what’s going on” or “what if we thought about this [opposite theory] for a while to see what we learn”.

In situations where we are utterly certain of a causal relationship between X and Y, and where this leads to treatment A being the only viable option, we possibly only need to reflect on whether we’ve done the right diagnostics. In pain coaching/rehabilitation/management we have little certainty, far less to guide us, and a person experiencing pain. This person is often in a very vulnerable position where they trust us to do the right thing by them. If we fail them by being too certain we’re right without being challenged, we can do them an enormous disservice.

Lilienfeld, S. O., & Basterfield, C. (2020). Reflective practice in clinical psychology: Reflections from basic psychological science. Clinical Psychology: Science and Practice, 27(4). https://doi.org/10.1111/cpsp.12352

Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books. ISBN978-0465068746. OCLC8709452.

Scott, I. A., Soon, J., Elshaug, A. G., & Lindner, R. (2017, May 15). Countering cognitive biases in minimising low value care. Medical Journal of Australia, 206(9), 407-411. https://doi.org/10.5694/mja16.00999

Ziebart, C., & MacDermid, J. C. (2019). Reflective Practice in Physical Therapy: A Scoping Review. Physical Therapy, 99(8), 1056+.

Skyline

Your patient has psychosocial risk factors: what now?


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

Do you…

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

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

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

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

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

What would you do?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Making first contact: What to do with all that information! Part 5


People come to see us because they have a problem. So the formulation approach I’m taking today begins from “the problem” and works back and forward. It’s called a “network” model, and is something many of us do without knowing that’s what we’re doing. The network model can also be called a functional analysis where we’re looking at what happens, and what a person does, and the ongoing consequences or loops that occur over time.

Angelina comes to see you because her neck is very sore. She’s not sure why it’s sore, or what happened to start it off, but she thinks it could be after working for a week at a new workstation where she had to look to the right to read documents, and straight ahead to work on the main monitor. It’s been there for over six months, and she’s come to see you now because she has a week of annual leave and some time to spend on herself. She’s played with changing her pillows because her neck is more uncomfortable in the morning, and it gets painful towards the end of the day just before she heads to sleep. She’s having trouble turning her head to reverse down her driveway, and looking up is almost her least favourite thing. Her sleep is OK once she’s got off to sleep, but initially it takes her a while to fall asleep because she can’t get comfortable. Her partner is getting frustrated with her because she doesn’t want to kiss him because that means she has to look up, and she doesn’t sit on the couch with him any more because he likes to rest his arm around her shoulders – and that increases her pain. She’s irritable and finds herself getting snappy at him. Angelina is in her mid-50’s, otherwise well, but has always lived with various aches and pains, most of which she ignores until they go away. She has had a painful shoulder and lateral elbow pain that lasted for over a year, but has gradually settled down – she didn’t do anything special to manage those after having only a small response to a steroid injection into her shoulder.

Angelina’s main concern is to establish whether her neck pain is anything to worry about, or whether it’s just more of the same, like her shoulder and elbow pain. Her other focus is on getting a comfortable position to go off to sleep because she thinks this is adding to her problem.

OK, so we have a lot of information about Angelina, and we can organise this information in many different ways. Given her main concern is her prognosis and then her sleep, we need to make sure the way we organise the information offers a possible explanation – a hypothesis.

Take a look at the network diagram below to see how I’ve sketched the information out – you’ll note that at this point I’m not trying to develop a diagnosis, I’m focusing on the problem as she sees it.

The matrix I’ve used here comes from Hofmann, Hayes & Lorscheid (2021) Learning Process-based Therapy, published by Context Press, New Harbinger.

What I’ve done is summarised the processes that I think might be relevant to Angelina’s presentation, and drawn the relationships between various aspects that she’s described. You might organise this information differently – and I’d usually do this in collaboration with the person.

If you look closely at the networks, you’ll see several loops that likely will continue if something doesn’t change. One to spot is this set below:

You can see that she’s worrying about her sleep, doesn’t get comfortable as she goes off to sleep, feels fed up, has changed her pillow (in line with her self-concept of someone who is a practical person), and the whole network will likely remain winding itself up unless “something” comes to disrupt this pattern.

This set of relationships raises some factors we need to consider when we’re thinking of interventions. As someone who sees herself as a practical person who doesn’t seek healthcare often, and has had previous bouts of pain that settled without specific treatment (though she sought it for her shoulder), we could interpret this as meaning she doesn’t panic about her situation too much – but we could also wonder if, because she’s seeking help now, she’s seeing her problem as different from previous pain problems and maybe this one is worrying her more than she’s ready to acknowledge. Just to the right of the loop I’ve shown above, you’ll see a box where she says “I’ll deal with it if it doesn’t get in the way of my family and relationship”. This is important – it’s an expression of how she sees herself, an important value, and her motivation for seeking help is also framed in terms of maintaining her loving relationship. For this reason, I’d be looking for interventions that either won’t intrude on her family life and routines, or I’ll be looking for ways to frame whatever treatment suggestions I make in terms of how this will support her relationship.

By drawing a network diagram showing potential processes that might be influencing Angelina’s presentation, I’m answering my question “why is she presenting in this way at this time, and what might be maintaining her predicament” – she really wants a prognosis so she can establish a strategy to maintain her relationship with her family, keeps her “practical person” view of herself alive, and in a way that she can still fulfill her desire (and others’ expectations) to be fully productive at work.

I could analyse (or organise) Angelina’s information in lots of different ways. This is just one – and in some ways, the particular model I use to assemble her information is less important than ensuring Angelina is an equal partner in sketching out these relationships. I could have drawn the Tim Sharpe CBT model or used an ACT-based model and looked for patterns of psychological flexibility. I could have used Vlaeyen’s fear-avoidance model – and I’m sure there are plenty of others that might have been useful.
Irrespective of the model, what needs to be evident is using the information the person offers us, modifying the way we approach therapy as a result, and collaborating with the person to decide treatment priorities. This means we as clinicians need to be nimble, responsive, adaptive, and stop using treatment protocols! Any approach that suggests offering the same approach irrespective of the unique things influencing a person’s presentation is doomed to do a half-arsed job. These protocols might work for some, but they won’t work for all, and they may fail to address the real reason the person came to see us in the first place.

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

People are active processors of information and not passive reactors.

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

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

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

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

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

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

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

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

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

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

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

Making first contact: what to do with all that information! part 1


Last post I wrote I said I’d continue with a process for structuring and synthesising the information we gather from the initial contact we make with the person. This process is integral to clinical reasoning, and somewhat surprisingly, there’s not a great deal of research to give us guidance on the best way to do this – and it’s even more challenging for those of us working in an interprofessional team setting, where different professions, personalities and assumptions are part of it.

If we work backwards from the end point, we might get some clues about what to do. Our end point is to help this person do what matters in their life. All our efforts are pitched towards this end. Because people are unique, what matters to them in their context is likely to be unique, and because pain and disability are multifactorial, there will be many paths to help that person get to where they want to be. Algorithms are designed to make the task of clinical reasoning a lot simpler, but there are some enormous assumptions associated with using an algorithmic approach: that we know the important factors associated with change; that we can address those factors successfully; that each person has the same set of factors evident in their presentation… and frankly, I don’t think I’ve seen strong evidence of any of these when it comes to pain.

Clinical reasoning is about a series of cause and effect assumptions. We have limited certainty about much of pain and the relationships between factors we think influence pain and disability. We’ve also been holding on to some outdated and inaccurate assumptions about the way grouped data applies to the one person in front of us. Prof Steven Hayes points out that as early as the 1940’s (perhaps earlier) we knew that there was no such thing as “the average man” (or woman!). This emerged in human factors/ergonomic design, where using the average/median of all the anthropomorphic measures we have does not help us design a workstation or control panel that will work for all people. Instead, we have to design to suit the minimum and maximum clearances and reach, and add adjustability so that everyone can make their workstation work for them. The assumptions used in early application of anthropometrics were that everyone is essentially similar: it’s ergodic theory (https://en.wikipedia.org/wiki/Ergodic_theory). Ergodic theory holds two assumptions that don’t work well for people: all the events in ergodic theory must be stationary, and all elements in the mathematical model must obey they same rules.

When we work with people, we know their presentation is a series of responses that continue to move over time. Their presentation is dynamic, changing all the time but exhibiting similarities in terms of processes. And we also know that different factors influencing a person’s presentation don’t always follow the same patterns. There are things like legislation, unexpected events like trauma or earthquakes, biases and stigma – and these don’t affect everyone equally.

One solution is to acknowledge this and instead look to the particular, applying to this person at this time – idiographic, or as Hayes calls it “idionomic.” A network diagram, showing the dynamic hypothesised relationships between contributing factors can help us generate ways to influence change. And the diagram should “make sense”, or explain, what’s going on to all the team members including the person with pain.

I’ve used a cognitive behavioural formulation model for many years now (see here and here – and use the search bar for “case formulation” for a list of the posts I’ve made over the years). The assumptions in this approach are that directly influencing the thoughts a person has about their pain will have flow-on effects on pain, emotions, actions and physiological arousal. And to a certain extent this is true – plus, there are some things we cannot readily change, such as family responses or previous trauma. But the flexibility of a formulation approach is that we can include anything that’s relevant including strategies the person has used in response to those things that can’t be changed.

The biggest assumption that I make is that pain on its own isn’t the main problem. It’s how we respond to pain, what we think is going on, how we react to the things we do in response to pain (or things we don’t do but think we should), and how the people around us influence us, that help determine how much pain bothers us. There is plenty of research showing that people willingly do painful things if they do so for important reasons. Some everyday examples include ritual tattoos, endurance sports, boxing and martial arts, eating very spicy chilli. Of course, these aren’t examples of persistent pain – and yet, people with persistent pain started with acute pain. There are some highly influential factors that are present from the outset and these do have an impact on how we respond to pain, especially as time goes on.

The second assumption I make is that everyone is able to learn how to do things differently, and in doing these, we can develop a different relationship with pain and become less distressed and disabled by our experience. This doesn’t mean (a) that we should just give up and be resigned to a life of pain and not seek treatment to reduce pain; or (b) that we should just ignore pain and grit teeth and bear it. It also doesn’t mean that we will feel happy about pain, or that life goes on as normal. But it does mean that we can make some room for pain to be present, and move towards doing what matters rather than having pain become some invisible barrier to a life worth living.

Exactly what we include, and how the relationships between each factor play out is the topic for next weeks’ blog – stay in touch!