Learning from old research (digging into history)

I recently submitted a manuscript to a journal. After the usual delay as the reviewers commented on my draft, I received the feedback – one comment stood out to me: “the references are quite old”. I scurried around to find some more recent references and resubmitted, but as I did, I started pondering this drive to continually draw on recent research even if the findings of the older references had not been superseded. There is a sense that maybe journal editors and perhaps people reading the journals think that old research has no merit.

As someone who relishes reading about the history of pain and pain management (If you haven’t yet read Melanie Thernstrom’s The Pain Chronicles or Joanna Bourke’s The Story of Pain, it’s time to do so!), and because some of the best and most revolutionary papers in pain and pain management were published in the 1980’s (Fordyce, W. E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43(4), 276-283. ; Waddell, G. (1987). 1987 volvo award in clinical sciences: A new clinical model for the treatment of low-back pain. Spine, 12(7), 632-644. ; Waddell, G., Main, C. J., Morris, E. W., Paola, M. D. I., & Gray, I. C. (1984). Chronic low-back pain, psychologic distress, and illness behavior. Spine, 9(2), 209-213.), I find it extraordinary that some of the concepts being discussed today as New! Improved! Radical! are pretty much the same as those introduced waaaay back then…

Examples? Well one is the whole notion of helping people understand something of what’s know about neurobiology of pain. The “Pain Neuro Education” or “Explain Pain” thing. I’ve read several papers touting the idea that before Lorimer Moseley and colleagues published their paper on “intensive neurophysiology education in chronic low back pain” we never included information about what we knew about distinctions between acute and chronic pain. There’s this really weird disconnect between the practice discussed in the 1970’s and 1980’s where at the very least the Gate Control Theory was integral to helping people distinguish between hurt and harm – and this New! Improved! Radical! pain ‘education’. Seriously, incorporating what’s know about pain neurobiology has been part of a cognitive behavioural approach to pain management since the 1970’s if not earlier. It was even provided to me when I first developed chronic pain, and that was the mid-1980’s.

What can we learn from old research, and why does history matter?

Well, one of the things that strikes me about learning from history is that in the general population, and possibly even more so in the health professional population, there are “legacy models” of pain hanging on. Most of us will have encountered someone we’re treating/working with who holds a really strong belief that if there’s a problem with a disc (it’s degenerated, bulging, or otherwise misbehaving), then it just needs to be removed and maybe a new one put in, and everything will be just fine. Where does that come from? And some of us will point to our orthopaedic colleagues and suggest that it’s something “they’ve” encouraged. But perhaps if we take a closer look at the things that contributed to a shift away from “oh I can live with this aching back” to “it must be fixed” we might learn something about how to help shift beliefs back towards a more accommodating and accepting view of the problem.

The history of low back pain

Gordon Waddell, orthopaedic surgeon (Sept 21 1942 – April 20 2017) was, amongst many other things, a keen historian. His fascination came from his desire to understand how it was that low back pain went from being something most people experienced but were not troubled by, to the epidemic of disability that it had become – and still is.

David Allan and Gordon Waddell wrote a paper in 1989 for Acta Orthopaedica Scandinavica, called An historical perspective on low back pain and disability.  The paper was written to try to outline the genesis of the increasing epidemic of low back disability since World War II. In it, Allan and Waddell detail historic understandings of backache from as early as 1500 BC (Egypt) through Greek times (Galen, ~150AD) when back pain was described as “one of the fleeting pains that affected joints and muscles. Treatment was symptomatic. Spas, soothing local applications and counter irritants were used.” (p. 1). Back pain was not often talked about, possibly because it was so common and settled mainly by itself. Over the period 1493 (Paracelsus) to 1642 (Baillou) back pain was gradually classified as one of the diseases of “rheumatism” – a watery discharge or evil humour which flowed from the brain to cause pain in the joints or other parts of the body. Rheumatism was thought to be caused by damp and cold but not trauma – note that well!

By 1800, said Allan and Waddell, doctors started to seek a cause of low back pain itself. Maybe it was “rheumatic phlegm” – let’s rub the area, let’s heat it, let’s blister the area, let’s use cupping… And in 1828 a doctor from Glasgow (Brown) described “spinal irritation” and the vertebral column and nervous system could be the source of low back pain. This radical notion “swept Europe and had a profound effect on medical thinking for nearly thirty years”. The exact nature of “spinal irritation” was never shown… and the specific diagnosis faded away but by then and until today the idea that a painful spine “must somehow be irritable” remains.

Back pain and trauma

Chronic low back pain was not thought due to injury until the latter half of the 19th century. In other words – not all that long ago. And we can blame the industrial revolution and railways for the development of an association between back pain and trauma. In the fear that often arises during the introduction of new technology (remember RSI in the 1980’s and 1990’s? due to all these new-fangled computers we were using… and maybe, just maybe “text neck” could go the same way…) people attributed back pain and a number of other ailments on “minor injuries and cumulative trauma” to the spine because of the speed of early railway travel. This was when trauma and back pain became firmly linked.

But wait – there’s much more to come! Next week I’ll talk about the rise of the “Dynasty of the Disc” and why orthopaedic surgeons got in on the act…


Allan, D. B., & Waddell, G. (1989). An historical perspective on low back pain and disability. Acta Orthopaedica Scandinavica, 60(sup234), 1-23.

Moseley, G., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi:http://dx.doi.org/10.1097/00002508-200409000-00007

There is nothing new under the sun

A new journal of pain has been published: The Scandinavian Journal of Pain, published by Elsevier, and contents lists available at ScienceDirect. One of the papers I flicked through today caught my eye – and it reminds me that although there is a huge amount of new information about chronic pain available now, many of the concepts are not really all that new.

Stephen Butler, a well-respected researcher and clinician in the chronic pain world, writes about his experiences learning from two of the great ‘pain pioneers’, JJ Bonica and W Fordyce. Dr John Bonica was the editor and author of the monumental ‘The Management of Pain’, which has evolved into ‘The Textbook of Pain’, he was also the founder of the International Association for the Study of Pain (IASP) in 1973 – along with around 100 researchers and clinicians, including Christchurch’s own Dr Barrie Tait. John Bonica also established one of the first authors to ‘insist’ on multidisciplinary pain evaluation and management, setting the scene for this approach to be the standard around the world.

Bill Fordyce is another pioneer in pain management – he was one of the first ‘champions’ of the application of behavioural principles to the treatment of chronic pain, and indeed incorporated these principles within the multidisciplinary pain management programmes and like John Bonica, his approaches have been and still are being used around the world. His major mark was in applying the biopsychosocial model as an explanation for disability and suffering in chronic pain.

Both of these men worked in the mid- to late- 1970’s and beyond – and what they had to offer people with chronic pain was revolutionary. At that time the prevailing models for managing pain could be separated into ‘mind’ (ie psychiatric) and ‘body’ (ie medical) – and never the twain should meet. A question to ponder today is whether this revolution has accomplished all it needs to yet.

Stephen Butler was introduced to John Bonica in 1973, on the end of a phone call at 0300, according to this article. From all account, John Bonica was a larger than life driving force who lived, ate and breathed work, particularly pain management. Bonica’s dictum was to evaluate patients with ‘at least three blocks for diagnosis’. I can hear some medics of my acquaintance rubbing their hands with glee at this! Yes, one block was placebo, one short-acting, and one long-acting. Then to move to ‘consider a series of blocks that were diagnostic, prognostic or therapeutic’. At the same time, Bonica emphasised the need for pain physicians to be physicians – to consider the whole person, to read all their medical history, but not to ‘take for granted that it is factual or complete’.

Bonica was aware that the results from diagnostic blocks were ‘confusing’ (have things changed any?). So he ‘assembled a group of experts from several fields to work with him’, meeting once a week after they had all seen the person, and discussing as a team, diagnosis and management. This team included people from several medical specialties, as well as psychology, nursing, social work and others. Part of the philosophy was for junior members of staff to learn from these discussions: an amazing experience! I can recall a similar situation happening for me at Burwood in the mid-1990’s, when the whole team was brought together to discuss (on a level playing field, no hierarchies!) the management of individual patients.

Butler goes on to describe his time with Bill Fordyce, who was a very different character from Bonica, but no less significant in impact. Fordyce worked with Butler who found the psychological insights from Fordyce enhanced his practice and especially the ‘common sense’ approach to managing pain behaviours. Butler went on to work on the pain management programme (a three week in-patient one) for the next 15 years!

Butler then lists what he learned from both of these pioneers. I won’t list them all, but a couple from each:

  • John Bonica taught that you need to take time and listen to pain patients; you need to do a very careful examination…as part of a more comprehensive general examination;  you need to have as much information from past evaluations as possible, especially testing; you need to discuss with the patients all the findings, discussing what is not present as well as what is present is important.
  • Bill Fordyce taught – if you have something better to do, you do not hurt; hurt does not equal harm; use it or lose it; no pain, no gain; information is to behaviour change as spaghetti is to bricks  (talk therapy may not help, you need to watch them exercise, monitor daily activities – they may just ‘tell the nice doctor/therapist that he/she is working’)

And the final learning that Butler says he got from both John Bonica and Bill Fordyce is ‘treat the patient, not the diagnosis’.

Butler completes his paper with a reminder of Santayana’s curse: Those who forget the past are condemned to repeat it.  What he means is this: the reductionist view continues and affects both the bio (medical inputs) and the psychosocial.  Under the ‘bio’ aspect, loads of new research is happening – but no magic bullets.  Under the ‘psychosocial’ aspect – new therapies, but one size does not fit all, and some of the new approaches represent the older ones (fear-avoidance being one!) in new guises.  Flexible, individualised care is emphasised, but Butler warns that there is a problem with the rush to implement ‘new’ and ‘improved’ – as he puts it, ‘any ideas that are a few years old are considered passe’.  He warns that these new therapies ‘are accepted rapidly and assume importance far greater than they deserve because we do not analyse them carefully and do not look at them in light of past experience and past knowledge in the pain field.’

I don’t think I can add to that – except to quote one last sentence from this paper: ‘The modern assembly line medical clinic does little for pain patients.  We owe our patients more and they come to us as failures of modern medicine.  We should not be another failure of the system due to Santayana’s curse.’

Butler, S. (2010). A personal experience learning from two pain pioneers, J.J. Bonica and W. Fordyce: Lessons surviving four decades of pain practice Scandinavian Journal of Pain, 1 (1), 34-37 DOI: 10.1016/j.sjpain.2009.09.009

New Zealand Colonial Architecture

I love it! A cob cottage built sometime in the 1880’s or maybe earlier…


This is south-west of Gore, and I don’t know how old it is, but it’s great example of the cob cottage, built from stone and earth in a simple and timeless design.  I think it would have been warm, but not very light inside – and given the winters in Southland, those chimneys would have been well-used.

Don’t you wish the women of that time could have left us some more about their lives and dreams?  What would it have been like to leave everything to come out to New Zealand?  All the comforts of home left behind to start a new life in a brand new country?  And what a country!  Nothing like the safe haven of the UK, a much harsher place with none of the history of the Old World.  But wow – what a place to live!

Am I patriotic?  I think I am – I’ve never really waved a flag or been especially fervent about the flag or the national anthem, but I love the landscape.  I belong in this landscape, it’s something visceral to me.

The Maori have a tradition where, when they introduce themselves, they name the mountain, river and area of their birth.  I was born in Auckland, but I grew up in Gisborne.  I’ve chosen to live in Christchurch, and it’s the South Island that calls to my soul.  The hills around Gisborne are limestone and greywacke – they slip at the first sign of rain.  The mountains around the South Island tower with huge boulders that are buried in the hillsides and strewn across riverbeds and seascapes.

The river I grew up with is the Turanganui – it’s the shortest charted river in the world.  It’s the confluence of Taruheru and Waimata rivers, and flows out to Poverty Bay.  The rivers I live by now are the massive braided rivers of the Waimakariri and the Rakaia.  And of course the Avon.

And the mountains?  Hikurangi is the mountain I grew up with – first mountain to see the sun every day.  Now for me I love the Kaikoura mountains.  Wonderful to view, not so nice to climb!

And if you live in New Zealand, you’re never, ever far away from the sea.  Tangaroa, son of Rangi and Papa, (Sky and Earth).  Restless, mysterious, and never ever satisfied.  Wherever I live I hope I’m close to the sea, my real lover!

Pain cures from history

Grabbed from the internet over the past couple of days…some things have not changed. Humans seem to have a fascination with magnets, colours, electricity and traction.
First up, the Faradic Electrifier – apply the electrodes to the painful part, press a button and – hey presto! an electric shock. Not exactly sure what that did about the pain, apart from distract from it, but it sure looks cool.

The Electreat was a device that is probably the forerunner of the modern TENS – if you head over to here you’ll find the whole history of it…


The one that really got me was this specially designed treatment for men only (don’t worry ladies, we have our own treats coming right up!).

The history of traction as a treatment for back pain goes back far further in time than I realised.  If you thought torturers needed inspiration, I’m sure they took a look at some of these drawing for some.


But if you thought it stopped there – this is available today, for use in your own home…

I did promise you something specially for women – well, here ’tis (and it’s only one of hundreds of such potions and compounds)…


…and I haven’t even started on the rest of the ghastly herbals that were mixed together and thrown down the throat.  Perhaps that’s for another day.

If you’re new to pain management – ii

Now it’s time to turn to the details of the biopsychosocial model as it is applied to pain. There are some excellent resources available to look at this in both a simple way, and in much greater detail.

This site is written by a physiotherapist – and contains some well-written and reasonably simple information both about pain and more especially about low back pain. I’d suggest heading to this page on biopsychosocial model for a quick overview.

As far back as 1953, pain has been seen as more than simply either body or mind…
Pain is no longer considered exclusively either as a neurophysiological or a psychological phenomenon. Such a rigid dichotomy is obsolete, because pain is now recognised as the compound result of physiopsychological processes whose complexity is almost beyond comprehension.
The Management of Pain J Bonica Lea & Febiger 1953 (more…)

What should I include in my pain assessment?

With such a wide array of factors influencing a person’s pain experience, it can be difficult to decide exactly what to include in a pain assessment.

We do know that the model we use to view pain will influence the factors that are included – and although the internationally accepted model of pain is a biopsychosocial one, there are any number of versions of this model that can be adopted.

Within each domain of the biopsychosocial model the research over the past few years has exploded, meaning there are more and more factors than can be considered – and these need to be organised in a systematic way so that we can make sense of them, make good clinical decisions about interventions and then work with the person who has the pain so they can understand them and contribute.

There are a couple of fundamental things we should always have as guiding principles:

  1. No single element in the biopsychosocial model of pain is more (or less) important than any other
  2. All three domains must be assessed to fully understand the ‘four p’s’ of a pain presentation:
    1. Predisposing factors
    2. Precipitating factors
    3. Perpetuating factors
    4. Protective factors
  3. The fundamental questions to be answered through assessment are
    1. ‘What brought this person to this place with this problem today?’
    2. ‘What can be done to reduce distress and disability?’
  4. Simply asking the person with pain provides some good information, but on its own is probably inadequate.  Interviews need to be supplemented with:
    1. History – from relevant documentation (from the referrer, other health care notes, previous consultations within your facility)
    2. Observation – structured or unstructured observation from the moment the person enters your clinic, to the time they leave
    3. Clinical examination or testing – including functional performance as well as pen and paper questionnaires
    4. Other people – particularly partners or other family members
  5. Assessment only begins the process of developing a working set of hypotheses about what might be ‘true’ for this person at this time for these problems

A couple of models that can be helpful:

This one is from Robert Gatchel (Gatchel, 2004).

, American Psychologist, 59, 792–805.

Another model I like is by Tim Sharp, published in 2000, which is somewhat less complicated than Gatchel’s one, but still has a whole lot of arrows!  Dr Sharp now runs a successful consulting practice listed in my blogroll, worth a look!

Of course, no matter what model you use, under each ‘heading’ you will need to continue to update relevant research into specific factors to include (eg ‘appraisals’ would now routinely include catastrophising and pain-related anxiety, while ‘motor behaviours’ would include avoidance, safety behaviours, as well as task persistence).  And after deciding what to include, it will be just as important to determine the best way to access the information – through questionnaire, observation, history, testing or interview.

Finally, it will be important to work out a structured way to put the information collected together so it can be readily understood and used as the basis for hypothesis testing.

I’m not sure I’ve got a handle on this part yet – but I’m keen to hear what you use, or how you think this part can be structured.  I think we’ll have to draw on research from small group/teamwork literature into decision-making, and on human cognition and information processing to inform us on the best way to integrate such complex information without jumping to conclusions.

Isn’t it great the way that answering one question leads to a whole lot of new bits of research?  Can ya tell how much I love questions?!

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Gatchel, R. (2004). American Psychologist, 59, 792-805

Sharp, T. (2000). Chronic pain: A reformulation of the cognitive-behavioural model.  Behaviour Research and Therapy, 39, 787–800

Gatchel, R. J.(2004), American Psychologist, 59, 792–805