interprofessional

Pain science is not a thing


Today’s post is occasioned by reading several discussions on various forums where the term “pain science” and various adjectives to describe this kind of practice. For those who don’t want to read the rest of my ramblings: no, it’s not a thing, science is an approach to understanding phenomena, and I would have thought all health professionals would use a science-based approach to treatment.

I went on to Google, as you do, to find out when this term began its rise in popularity. Google wasn’t particularly helpful but did show that it’s been around since 2004 at least, and seems to have been centred around the US, UK and Australia in roughly May 2004. I can’t grab data from earlier than this, sadly, but I think it’s interesting to take a look at the popularity peaks and troughs…

So, what does “pain science” mean to commentators? I haven’t delved in too deeply to the social media use of the term, but given I’m a social animal and have written my blog since 2007 (which is mainly on “pain science”) I’ve encountered it many times. It seems to be related to using a neurobiological explanation for pain as an experience (referring to the phenomenon and the underlying biological processes involved) rather than focusing purely on biomechanics or tissue damage/nociception as the key force. And it does seem to tie in with the emergence of “Explain pain” as one way of helping people reconceptualise their experience as something they can influence rather than something other people need to “fix”.

Commentators who aren’t in love with the “explain pain” thing have said things like “the pain science camp” or as one person put it “There’s your manual PTs, your pain science PTs, and your just load it PTs etc”

I went on to Twitter and the hashtag #painscience was paired with #BPSModel and #PT and #physicaltherapy (or variations), #chronicpain #exercise #lowbackpain – and so on.

So what do I think pain science means if it’s not a neurobiological approach to pain management? Well – pain science is a lot like cardio-respiratory science, and neurological science, and psychological science – it’s about applying a scientific approach to understanding pain. Science has been defined as “the intellectual and practical activity encompassing the systematic study of the structure and behaviour of the physical and natural world through observation and experiment.” In this instance, Google is your friend. So science is about systematically studying phenomena through observation and experimenting. If we apply this to pain – it’s the systematic study of structure and behaviour of the phenomenon we call ‘pain’ through observation and experiment. For what it’s worth, scientific study of pain has been going on since… oh at least Descartes, but probably much earlier given that pain is a ubiquitous and essential part of human experience.

To me, understanding pain involves multiple disciplines: yes to biology, and especially neurobiology because the experience (as we understand it now) involves neurobiological processing. But it’s also about psychology
the scientific study of the human mind and its functions, especially those affecting behaviour in a given context; sociology – the study of the development, structure, and functioning of human society; the humanities – the study of how people process and document the human experience; politics – the activities associated with the governance of a country or area, especially the debate between parties having power; and Anthropology –  the study of humans and human behavior and societies in the past and present. Social anthropology and cultural anthropology study the norms and values of societies. Linguistic anthropology studies how language affects social life.

So to describe an entire approach to understanding a phenomenon as if it’s a “movement” or “camp” or “dogma” or even “tribe” suggests serious  misunderstanding of both science and of an intervention.

What is “explain pain” then, or pain neurobiology education? – it’s an explanation of some of the biological elements of our nociceptive system as they combine to produce the experience we know as pain. For some people it’s the first time anyone took the trouble to explain why the pain of a papercut feels so bad compared with, for example, the pain of a sprained ankle; and why they still experience pain despite having no “damage” as visible on imaging. It’s an attempt to give people a frame of reference from which to understand their own journey towards recovering from a painful injury/disease/problem. In itself it’s not new: explanations for pain have been used in pain management programmes since the 1970’s (and earlier, if we consider that Fordyce used explanations in his behavioural approaches to pain management), and have routinely drawn on current pain research to help provide explanations that make sense to both the person and the clinician. The distinction between earlier explanations which drew heavily on the gate control theory, and this latest iteration is that the explanations are more complex, pain is considered to be an “output” that emerges from multiple interactions between brain and body, and that’s about it. Oh and it’s been picked up and enthusiastically used by physiotherapists (and other primarily body therapists) around the world.

What’s the evidence for this approach? Well, IMHO it’s not intended to be a stand-alone “treatment” for most people experiencing pain. I see giving an explanation as integral to usual practice, just as we do when we explain why it’s not a good idea to go running on a newly sprained ankle or why we’re suggesting a mindfulness to someone with a panic disorder. So far there have been a lot of studies examining variants of “explaining pain” alone or in combination with a number of other treatments including exercise. A recent systematic review and meta-analsyis of “pain neuroscience education” for chronic low back pain found eight papers (with 615 participants) showing that in the short-term, this kind of education reduces disability (by 2.28 points on the Roland-Morris Disability Questionnaire which is a 24 point scale) in the short-term and a slightly lesser effect in the long-term  (2.18). There were greater effects when this was combined with physiotherapy, though we often don’t know exactly what is included in “physiotherapy”.  There was some evidence that this kind of education helps reduce pain scores (by 1.32) but only in combination with other physiotherapy interventions. The authors pointed out that the strength of evidence for education on pain in the short term was low to moderate, but that it doesn’t have much of an impact on pain-related fear and avoidance, or on pain catastrophising (Wood & Hendrick, in press).

To compare this with another active treatment, exposure therapy for fear of movement/reinjury in chronic low back pain, de Jong, Vlaeyen, Onghena, Goossens, Geilen & Mulder (2005) performed a careful study of six individuals, using a single case experimental design. (If you’re not familiar with this approach to research – it’s extremely rigorous and useful in a clinical setting, this link takes you to a chapter discussing its use).  The aim was to establish which part of treatment “did the work” to change behaviour, but also measured pain intensity, and fear of pain and movement.  The treatments were information about pain and mechanisms, and the activities were those the person particularly wanted to be able to do. Their findings identified that explanations do little to pain intensity, avoidance or fear – but what actually worked was doing graded exposure. In other words, experiencing something different, DOING that something different in the real world, was more effective than talking about why someone shouldn’t be afraid. A much more recent replication of this study was conducted by Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski (2018) and shows the same result: doing trumps talking about doing.

When we sit down and take a cold hard look at what we do in pain management we can see that the field has to draw on a huge range of disciplines and fields of study to understand the problems people experiencing pain have. This is, in fact, why Bonica and colleagues first established the International Association for the Study of Pain, and why multidisciplinary (and now interprofessional) pain management teams and approaches were established. None of us can possibly hold all the knowledge needed to work effectively in the area. At the same time, as health professionals working with people, we do need to have some foundation knowledge about biology, disease, illness, psychology, sociology and anthropology. These areas of study inform us as we work hard to help people get their heads around their pain. Do we need to be experts in all of these fields? Yes – if you work completely in isolation. No – if you work within an extended team (whether co-located or otherwise). Pain research will continue to push our understanding ahead – and to be responsible health professionals, we must incorporate new understandings into our practice or we risk being unprofessional and irrelevant. I would go as far as to say we’re irresponsible and harming patients if we fail to incorporate what is known about pain as a multidimensional experience. It’s time to back away from temporary guruism and move towards a far more nuanced, and perhaps less flighty approach to understanding pain.

Pain science. No, it’s not a thing. Pain being examined through multiple scientific lenses: definitely a thing.

NB for the avoidance of doubt: pain is never a “thing” but examining pain through multiple scientific lenses involves many “things”. (Merriam-Webster – click)


de Jong, J. R. M., Vlaeyen, J. W. S. P., Onghena, P. P., Goossens, M. E. J. B. P., Geilen, M. P. T., & Mulder, H. O. T. (2005). Fear of Movement/(Re)injury in Chronic Low Back Pain: Education or Exposure In Vivo as Mediator to Fear Reduction? [Article]. Clinical Journal of Pain Special Topic Series: Cognitive Behavioral Treatment for Chronic Pain January/February, 21(1), 9-17.

Schemer, L., Vlaeyen, J. W., Doerr, J. M., Skoluda, N., Nater, U. M., Rief, W., & Glombiewski, J. A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Wood, L., & Hendrick, P. A. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. European Journal of Pain, 0(0). doi:doi:10.1002/ejp.1314


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Taking a peek beneath the hood


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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

What is the difference between using cognitive behavioural therapy – and using a cognitive behavioural approach?


My last post generated an enormous amount of discussion about whether clinicians who are not psychologically trained, or who haven’t completed a psychology degree, or indeed, should carry out treatments using a cognitive behavioural approach. This is my answer! But note well, these are not my words, but drawn from two of the most eminent researchers and clinicians I know. And yes, I think you can ALWAYS learn more skills – and apply them within your practice with an eye to optimising the quality of your interactions and outcomes.

The first is from Professor Turk:

Capture

This excerpt is from Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

In this paper, Turk identifies the many influences on our experience of pain, and on subsequent disability, that are amenable to “top down” approaches. As he points out in this excerpt, a cognitive behavioural approach is a way to conceptualise the person and his or her experience. The perspective is as important as the content of therapy. The best way I can put this is to show the following clip from this paper – and ask readers if they agree, based on the findings from pain science research.

assumptions of CBT approach

 

 

 

 

 

 

 

 

 

 

 

 

 

 

So, it’s clear to me anyway, that our modern view of pain as an experience that people go through in the context of their life implies that tissues and nociception are only part of the picture. Along with this is the recognition that our treatments exert their influence not just through the so-called “active ingredients” of whatever modality we choose to use. At the same time as we “treat”, the people coming to see us interpret and place expectations on what will happen in that “third space”. Their understanding of what could and should happen influences their response – and even if we don’t recognise this! What this means to me is that we have a responsibility to be mindful and thoughtful about everything that goes on between the person “treating” and the person “seeking”, because these influences are always happening. For more information on the neurobiology of treatment seeking and relief, Benedetti’s book on The Patient’s Brain should be a mandatory reference, though there are others.

Turning to whether those clinicians who primarily touch people, or advise on movements and bodies (ie physiotherapists) should adopt a cognitive behavioural approach, I’m going to snip from a paper by Harding and Williams (1995). What’s scary is that this paper was written waaaay back then, but some clinicians in this area of practice STILL don’t recognise that this is a legitimate approach for them to take. Back to the snip:

Capture1

Here’s a further snip from that same paper, explaining how and why providing accurate information, and helping people identify unhelpful ways of thinking is an important component, especially within a team environment.

“The cognitive component of a CP management programme involves teaching patients to identify thoughts and beliefs which underpin maladaptive behaviours and which adversely affect mood. There is a particular focus on anxiety and depression. Once patients can identify the very disabling cognitions, they try to use cognitive restructuring to identify and challenge longstanding beliefs and immediate judgements (Turk et al, 1983), with resultant improvement in mood and in practical coping with the pain.
Cognitive restructuring is a task that varies in complexity. Although this complexity sometimes requires the specialised skills of clinical psychologists or others with appropriate training, there are many occasions when less experienced professionals may help patients apply the principles to great effect.
One of the more disabling habits of thinking identified in many CP patients is catastrophising: expecting only the worst to happen and feeling
unable to cope with it. Research shows that patients who use catastrophising frequently cope poorly with CP (Jensen et al, 1991; Keefe et al,
1992). Team members are therefore taught to recognise catastrophising and to help patients to challenge it when it occurs, such as during exercises,
practical activities or planning.”

I know we can argue about the language used here (remember when this was published), but here’s my rationale for physically-oriented clinicians to actively use cognitive and behavioural approaches. When do you think people are likely to think those unhelpful thoughts? When is it most likely they will recall those scary images and immediately experience distress – and then avoid? Is it likely to be sitting quietly in a clinic room where the only expectation is to talk? Or is it more likely to happen when engaged in doing something that represents the thing the person is afraid of? When do you think emotions are most likely to be present? And when do you think it’s most likely that an experiment disproving the unhelpful assumption might best be carried out? I think it’s likely to be when you and the person are beginning to do some movements.

Along with cognitive aspects, there are also behavioural ones. “Changing Behavior: Providing positive consequences for learning a new behaviour such as a previously feared exercise is likely to reinforce it, particularly when the reinforcements are provided immediately and frequently for small achievements in the early stages. The focus is moved away from unhelpful behaviours, and shaping (Becker, 1989) rather than criticism is used to achieve the finally desired exercise or posture. Pain is not denied, only the pain behaviour is not reinforced.”

And further: “Goal Setting: Exercises are seen as part of the ‘building blocks’ to achieve a range of patient goals, so although they may improve local biomechanics, they constitute steps to  achieving activity goals and general fitness, rather than being prescriptive on the basis of the assessment.”–  yet more“Pacing: Since patients’ exercises are learnt with pacing on a quota not pain basis, practices like ’no pain, no gain’ and ‘pushing through the pain barrier‘ are discouraged. They learn to set exercise baselines at what can easily be managed rather than the most they or the therapists think they can do. Patients are thus enabled to challenge and resolve fears (such as bending the back, or weight bearing through a chronically painful knee) rather than to be precipitated into anxiety and avoidance.”

Still more “Education: Patients need information with written back-up to make choices and help them bring about behaviour change…Education is interactive and involves practical experience, not just discussion.”

“Recording Progress: Charts and exercise sheets are used to demonstrate and reinforce a behaviour change (such as regular and increasing exercise rather than pain determined exercise). They are filled in by patients, not therapists, to reinforce patients’ improvement.”

“Challenging Thoughts and Feelings: Physiotherapists who can help patients capture and challenge unhelpful cognitions, when they are confronted with feared situations such as physical activity, are likely to catalyse big improvements in function and mood. Unhelpful cognitions about exercise may be challenged on the basis of realistic estimates of physical capacity and of risk of harm.”

Finally, “Maintenance and Self-attribution: If improvement is seen as the patient’s achievement – ‘I did it’ – right from the start, rather than ‘the physiotherapist cured/fixed me up’, they will have a greater sense of future self-management.”

Further to my post about interdisciplinary working: An inter-disciplinary team is not hierarchical but involves sharing of skills, and it is quite usual, for example, for the psychologist to address the psychological implications of the physiotherapist‘s initiatives and vice versa. The physiotherapist has a lot of patient contact, so mutual feedback with other members of the team is important both in timetabled team meetings and informally. Good team integration helps patients understand how to tackle the complex experience of CP using the techniques, and prevents mixed messages from the staff which may confuse and discourage patients. Where integration is achieved, differences apparent to patients are easily resolved.” So much for concern about scope.

While these papers are old and the language reflects this, the cognitive behavioural approach is now firmly established as a helpful way to conceptualise the experience and problems of people living with pain. As Vlaeyen and colleagues indicated in their recent book “Pain-related Fear”, the skills rather than the professional discipline is what is important. Turk and others say that by using a cognitive behavioural approach, people are able to attribute change to themselves, rather than on any mythical theory about application of hands.

As Harding and Williams state: “When improvement occurs, it is important that it is credited to patients, both my themselves and by staff. Hands-on physiotherapy is tremendously rewarding, and rapid dramatic results produce in therapists quite a buzz of pride in their skills. Patients sense this and physiotherapists will remember being told: “Oh you are wonderful, no one else has been able to help me, such healing hands…etc”. However this is not helpful to patients. The unspoken message is: “I couldn’t do without you”. Physiotherapists guidance can be acknowledged but it is patient’s hard work and the renegerative capacity of their bodies which bring about change, catalysed by professional help” (p. 686).

So, to conclude, I think clinicians of all colours and stripes should be ready to adopt a cognitive behavioural approach. It is a perspective about a person experiencing pain, not a therapeutic procedure or set of actions. It’s a way of seeing people from within a biopsychosocial perspective. All the actions you then take as a professional will naturally reflect your unique clinical scope – but as far as I know, using effective communication (eliciting a person’s understanding of their pain and situation, and reflecting what you’ve heard) and being able to think of people as active participants in their own health doesn’t constitute stepping out of anyone’s scope.

cb perspective

References

Harding, V., Williams, A., (1995). Extending physiotherapy skills using a psychological approach: Cognitive behavioural management of chronic pain. Physiotherapy, 81(11), p681 – 688.

Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

Vlaeyen, J., Morley, S., Linton, S., Boersma, K., & de Jong, J. (2012). Pain-related fear. Seattle: IASP Press.