Low back pain

look what's coming

What should we do about acute low back pain?


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

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

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

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

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

Where am I going with this?

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

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

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

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

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

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

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

 

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

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

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

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

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

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

steadfast

Using a new avoidance measure in the clinic


A new measure of avoidance is a pretty good thing. Until now we’ve used self report questionnaires (such as the Tampa Scale for Kinesiophobia, or the Pain Catastrophising Scale), often combined with a measure of disability like the Oswestry Disability Index to determine who might be unnecessarily restricting daily activities out of fear of pain or injury. These are useful instruments, but don’t give us the full picture because many people with back pain don’t see that their avoidance might be because of pain-related fear – after all, it makes sense to not do movements that hurt or could be harmful, right?

Behavioural avoidance tests (BAT) are measures developed to assess observable avoidance behaviour. They’ve been used for many years for things like OCD and phobias for both assessments and treatments. The person is asked to approach a feared stimulus in a standardised environment to generate fear-related behaviours without the biases that arise from self-report (like not wanting to look bad, or being unaware of a fear).

This new measure involves asking a person to carry out 10 repetitions of certain movements designed to provoke avoidance. The link for the full instructions for this test is this: click

Essentially, the person is shown how to carry out the movements (demonstrated by the examiner/clinician), then they are asked to do the same set of movements ten times.  Each set of movements is rated 0 = performs exactly as the clinician does; 1 = movement is performed but the client uses safety behaviours such as holding the breath, taking medication before doing the task, asking for help, or motor behaviours such as keeping the back straight (rotation and bending movements are involved); 2 = the person avoids doing the movement, and if the person performs fewer than 10 repetitions, those that are not completed are also coded 2. The range of scores obtainable are 0 – 60.

How and when would you use this test?

It’s tempting to rush in and use a new test simply because it’s new and groovy, so some caution is required.

My questions are: (1) does it help me (or the person) obtain a deeper understanding of the contributing factors to their problem? (2) Is it more reliable or more valid than other tests? (3) Is it able to be used in a clinical setting? (4) Does it help me generate better hypotheses as to what’s going on for this person? (5) I also ask about cost, time required, scoring and whether special training is required.

This test is very useful for answering question (1). It provides me with a greater opportunity to review the thoughts, beliefs and behaviours of a person in the moment. This means I can very quickly identify even the subtle safety behaviours, and obtain the “what’s going through your mind” of the person. If I record the movements, I can show the person what’s going on. NB This is NOT intended to be a test of biomechanical efficiency, or to identify “flaws” in movement patterns. This is NOT a physical performance test, it’s a test of behaviour and belief. Don’t even try to use it as a traditional performance test, or I will find you and I will kill (oops, wrong story).

It is more valid than other tests – the authors indicate it is more strongly associated with measures of disability than measures of pain-related fear and avoidance behaviour. This is expected, because it’s possible to be afraid of something but actually do it (public speaking anyone?), and measures of disability don’t consider the cause of that disability (it could be wonky knees, or a dicky ticker!).

It’s easy to do in a clinical setting – A crate of water bottles (~8 kg) and a table (heights ~68 cm) are needed to conduct the BAT-Back. The crate weighed  7.8 kg including six one-litre plastic bottles. One could argue that people might find doing this test in a clinic is less threatening than doing it in real life, and this is quite correct. The setting is contained, there’s a health professional around, the load won’t break and there’s no time pressure, so it’s not ecologically valid for many real world settings – but it’s better than doing a ROM assessment, or just asking the person!

Does it help me generate better hypotheses? Yes it certainly does, provided I take my biomechanical hat off and don’t mix up a BAT with a physical performance assessment. We know that biomechanics are important in some instances, but when it comes to low back pain it doesn’t seem to have as much influence as a person’s thoughts and beliefs – and more importantly, their tendency to just not do certain movements. This test allows me to go through the thoughts that flash through a person’s mind as they do the movement, thus helping me and the person more accurately identify what it is about the movement that’s bothering them. Then we can go on to test their belief and establish whether the consequences are, in fact, worse than the effects of avoidance.

Finally, is it cost-effective? Overall I’d say yes – with a caveat. You need to be very good at spotting safety behaviours, and you need to have a very clear understanding about the purpose of this test, and you may need training to develop these skills and the underlying conceptual understanding of behavioural analysis.

When would I use it? Any time I suspect a person is profoundly disabled as a result of their back pain, but does not present with depression, other tissue changes (limb fracture, wonky knees or ankles etc) that would influence the level of disability. If a person has elevated scores on the TSK or PCS. If they have elevated scores on measures of disability. If I think they may respond to a behavioural approach.

Oh, the authors say very clearly that one of the confounds of this test is when a person has biological factors such as bony changes to the vertebrae, shortened muscles, arthritic knees and so on. So you can put your biomechanical hat on – but remember the overall purpose of this test is to understand what’s going on in the person’s mind when they perform these movements.

Scoring and normative data has not yet been compiled. Perhaps that’s a Masters research project for someone?

Holzapfel, S., Riecke, J., Rief, W., Schneider, J., & Glombiewski, J. A. (in press). Development and validation of the behavioral avoidance test – back pain (bat-back) for patients with chronic low back pain. Clinical Journal of Pain.

 

 

tulips

Scopes, roles, boundaries, contributions: who does what in a brave new healthcare world?


I have been meaning to write a post like this for some time now, but prompted to today by two things: one is an ongoing debate about non-psychologists using “CBT” with people who are experiencing pain, and the other is a conversation with Chai Chuah, Director General of the Ministry of Health in New Zealand. Let me set the scene:

We know there are a lot of people in our communities who have relatively simple pain problems – a temporarily painful knee after walking up hills for the first time in ages, a painful back that “just happened” overnight, a rotator cuff problem that makes it difficult to get dressed or hang out washing. We know that there are some pretty simple things that will help in these situations: some reassurance that the awful thing the person is worried about isn’t likely to happen (no, you won’t end up in a wheelchair because of your back pain, and no it’s not cancer); some pain relief to help with sleeping more soundly and so we can keep doing things; and gradually returning to normal occupations including work even if the pain hasn’t completely gone.

We also know that approximately 8% of people with low back pain will ultimately end up contributing to the most enormous spend in healthcare that we know about – their pain continues, their distress increases, their disability is profound.

BUT before we put all our attention on to this small group of people, I think it’s worthwhile remembering that people in this group are also more likely to have other health conditions, they’re more likely to smoke, to be overweight, to have mental health problems; they also probably come from lower socioeconomic groups, groups including people from minority ethnicities, people who find it much harder to get work, to remain in education and perhaps even people who typically use healthcare more often than the people who get back on their feet more quickly. Data for these statements comes from the 2006 Health and Disability Survey in New Zealand and numerous studies by epidemiologists around the world  –  back pain is only one of a number of problems people in this group have to deal with. I’m also not saying everyone who gets back pain that lingers has all of these additional concerns – but there is a greater prevalence.

What does this mean?

Well, for a while I’ve been saying that people working in this area of health (musculoskeletal pain) seem to be developed a set of common skills. That is, there is more in common between me and Jason Silvernail, Mike Stewart, Paul Lagerman, Alison Sim, Lars Avemarie, Rajam Roose and many others around the world from many different health professions, than there is between me and a good chunk of people from my own profession of occupational therapy. And I don’t think I’m alone in noticing this. (ps please don’t be offended if I’ve left your name out – you KNOW I’m including you too!)

What’s common amongst us? The ability to see and work with complex, ambiguous, messy and multifactorial situations. Recognising that along with all of our individual professional skills, we also need to have

  • effective communication skills,
  • patient/person-centredness,
  • critical thinking,
  • generating a framework to work from,
  • identifying and solving the unique goals and situations the people we work with have,
  • ability to step beyond “this is my role” and into “what can be done to reduce this person’s distress and disability?”
  • And possibly the most important skill is being able to tolerate not knowing without freaking out.

That ongoing cycle of assess -> hypothesise -> test -> review -> reassess -> hypothesise -> test -> reassess ->  review

This is important because when people come to see us with a complex problem (and increasingly this seems to happen), the simple models break down. The tissue-based, the germ-based, the simple single-factor approaches do not fully explain what’s going on, and don’t provide adequate solutions.

What this means is we, ALL health professionals, will need to think about where our skills lie. Are we people who enjoy pumping through a big number of relatively simple problems? If so, that’s great! Your contribution is clear-cut, you know what you need to do, and you refine and practice your skill-set until you’re expert. I think this is awesome. Or, are we people who relish complex, who look at situations and see that it’s messy and complicated but don’t get put off? In this group we probably use skills for researching and planning, operationalising or getting things started, and we’re often the people who network furiously. We do this not because we’re social butterflies (me being the ultimate introvert), but because we know WE CAN’T DO THIS WORK ALONE!

What about clinical skills and scopes and boundaries?

You know, I am not entirely sure that anyone except the health professional him or herself cares who does what they do to help someone get better. It’s not whether a nurse or a speech language therapist or a podiatrist or a medical practitioner, it’s whether the person (or people) treats each person as unique, listens carefully, is honest and straightforward about what can and can’t be done, and knows when his or her skills are not sufficient so calls in the rest of a team for help. There is a time for working beyond your scope, and a time for calling in an expert – but to recognise when an expert is needed requires knowing enough about the problem to know that an expert might be helpful.

What this means in healthcare, I think, is adopting a framework that works across diagnosis and into the idea that people actively process what happens to them, they make their minds up about what’s needed, and they can learn to do things differently. I’d call this self-management, but I could equally call it a cognitive behavioural approach, or behaviour change, or motivational approaches or even patient-centred or person-centred care. The idea that people understand more than we often give credit, that they make sense from what happens to and around them, and that this knowledge influences what they do comes from a cognitive behavioural model of people, and fits beautifully within a biopsychosocial framework.

So, when I advocate getting skilled at cognitive behavioural skills, I could equally use the term “person-centred” or “self-management” – whatever the label, the contributions from each professional involved will ultimately influence the health experience and actions of the person we’re seeing.

Isn’t it time to be excited about opportunities to develop and to extend our skills? And if this doesn’t excite you, isn’t it great that there are a group of people who will respond to the simple and straightforward – but let’s not confuse the two situations.

 

The bad boys made us do it

How good is the TSK as a measure of “kinesiophobia”?


The Tampa Scale for Kinesiophobia is a measure commonly used to determine whether a person is afraid of moving because of beliefs about harm or damage, with a second scale assessing current avoidance behaviour. It has been a popular measure along with the pain-related fear and avoidance model and together with the model and measures of disability, catastrophising and pain-related anxiety, has become one of the mainstays within pain assessment.

There have been numerous questions raised about this measure in terms of reliability and validity, but the measure continues to be one that is widely used. The problems with reliability relate mainly to a long version (TSK-17) in which several items are reverse scored. Reverse scored items often state a negative version of one of the concepts being assessed by the measure, but pose problems to people completing the measure because it’s hard to respond to a double negative.  In terms of validity, although the measure has been used a great deal and the original studies examining the psychometric properties of the instrument showed predictive validity, the TSK’s ability to predict response to treatment hasn’t been evaluated.

Chris Gregg and colleagues from The Back Institute and CBI Health Group studied a cohort of 313 people with low back pain attending one of the rehabilitation clinics in New Zealand. Participants completed the TSK at the beginning of treatment, and again at programme completion.  Along with the TSK, participants also completed a numeric pain scale, a modified Low Back Outcome score, and indicated whether they were working or not. These latter measures were considered to be “Quality of Life” measures, although they’re not officially QoL scales.

Before I turn to the study design and statistics, I’ll take a look at the modified Low Back Outcome score. Now I don’t know if you’ve ever searched for something like this, but believe me when I say there are SO many versions of SO many different “modified” back pain questionnaires, it’s really hard to work out exactly which one is the one used in this study, nor how it was modified. I’m assuming that it’s the one mentioned in Holt, Shaw, Shetty and Greenough (2002) because it’s mentioned in the references, but I don’t know the modifications made to it.  The LBOS is a fairly brief 12 item measure looking at pain intensity “on average” over the last week, work status, functional activities, rest, treatment seeking, analgesic use, and another five broad activities (sex life, sleeping, walking, traveling and dressing). It’s been described as having good internal consistency and test-retest reliability but validity isn’t mentioned in the 2002 paper.

Now, coming to this study, overall people improved at the completion of the programme. Pain reduced by 1.84 on the NPS, m-LBOS scores increased by 10.4 (a 28% improvement), and the TSK scores also improved by 5.5. Of course, we’d hope that at the end of a programme people would be doing better – though I’d prefer to see outcomes measured at least another three to 9 months after programme completion.

The authors looked at the relationship between the TSK and initial scores – there were small  statistical relationships between these measures. They then examined the scores between pre-treatment TSK and QoL measures at the end of treatment to establish whether there was a relationship between kinesiophobia and eventual outcome. There wasn’t. At least, not much of a relationship. These authors conclude that the TSK is therefore not a good measure to employ to predict those at high risk of chronicity due to fear of movement. I was a bit disappointed to see that a subscale analysis of the TSK wasn’t carried out – so it’s not possible to know whether change was associated with reduced beliefs about fear of harm/reinjury or whether it was due to reduced avoidance, or both.

Now here’s where I get a bit tangled up. Wouldn’t you expect the underlying constructs of the TSK (fear of harm/reinjury, and avoidance) to be the targets of a back pain related treatment? Especially one that includes cognitive behavioural therapy, education and movement? If we’re using a measure I think we should USE it within our clinical reasoning, and deliberately target those factors thought to be associated with poor outcomes. If we’re successful, then we should be able to see a change in domains thought to be associated with those constructs. In this programme, given that people were given treatment based on sub-typing, including education and CBT, I would hope that pain-related fear and avoidance would be directly targeted so that people develop effective ways of dealing with unhelpful beliefs and behaviours. To establish whether that had happened I’d want to look at the association between post-treatment TSK and measures of function or disability.

And getting back to the timing of outcome assessment, given that we’re interested in people managing any residual back pain (and in this study people were left with pain scores on the NPS of 3.4 (+/- 2.4) they still had some pain), wouldn’t you be interested in how they were managing a bit further down the track? We can (almost) guarantee that people will make changes directly as an effect of attention and structured activities. Measuring what occurs immediately at the completion of a programme may not show us much about what happens once that person has carried on by him or herself for a few months. My experience with chronic pain programmes shows a typical pattern of improvement immediately at the end of a programme, then six weeks later, what can be called regression to the mean, or what we often described as “the dip” or “the slump” as reality hits the road. At a further six months down the track, results had improved a bit, and these were usually sustained (or thereabouts) at the following twelve month follow-up.

So, does this study provide us with evidence that the TSK isn’t useful as a predictive tool? I’m not so sure. I think it does show that there are improvements in TSK, pain, disability and work status immediately at the end of a programme. Unfortunately TSK scores at the end of the programme are not analysed into subscales, so we don’t know which aspects of pain-related fear and avoidance were affected – but we know that they were.

For clinicians working in chronic pain programmes, where people are referred after having remained disabled and/or distressed despite having had prior treatment, the TSK may not be the most useful tool ever. The problems I’ve had with it are that scores in the fear of injury/reinjury subscale are lower when people have been given good pain “education” – but often present with a combined high score because of very high scores on the avoidance subscale.

A lovely study by Bunzli, Smith, Watkins, Schütze and O’Sullivan (2014) looked at what people actually believe about their pain and the associated TSK items. They found that many people DO believe their pain indicates harm, and they also found that people were worried about the effect pain would have on other things – and it’s this part that I find particularly interesting. It may not be the pain that matters as much as the anticipated losses and disruption to normal life that could occur.

The original authors of the “fear-avoidance” model, Vlaeyen and Linto (2012) reviewed the model after 12 years, and agree there is much to be done to refine assessment of pain-related fear. Self-report measures are only as good as the ability, insight and willingness of participants to complete them accurately.

So, is it time to throw the TSK out the window? I don’t think so – at least not yet. There’s more we need to do to understand pain-related fear and subsequent avoidance.

 

Chris D. Gregg, Greg McIntosh, Hamilton Hall, Heather Watson, David Williams, Chris Hoffman, The relationship between the tampa scale of kinesiophobia and low back pain rehabilitation outcomes, The Spine Journal (2015), http://dx.doi.org/doi:10.1016/j.spinee.2015.08.018.

Bunzli, S., Smith, A., Watkins, R., Schütze, R., & O’Sullivan, P. (2014). “What Do People who Score Highly on the Tampa Scale of Kinesiophobia Really Believe? A Mixed Methods Investigation in People with Chronic Non Specific Low Back Pain The Clinical Journal of Pain DOI: 10.1097/AJP.0000000000000143

Vlaeyen, J. W., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147. doi: dx.doi.org/10.1016/j.pain.2011.12.009

abandoned interior

How to spend money you don’t need to


I’m a shopper. I love to shop with a pocket full of money and buy lovely new things! I don’t even need to spend the money – just knowing I have it there to spend is enough to send me into raptures. Now one thing I have never heard in healthcare is that there’s plenty of money. Not once. I can’t recall a time when I’ve heard “Oh let’s just go and spend”. Instead I hear a lot about “Lean thinking”, and “efficiencies”, and “cost saving” – and “No, we can’t do that because it needs an up-front investment and the payback won’t be for years”.

What if I could show where there are hundreds of thousands of dollars going to waste that are also contributing to poor health outcomes and increased risk of complication?

Well, as it happens, I have just such a case. It’s when a person goes to the Emergency Department during a bout of back pain.

A group of researchers (Schlemmer, Mitchiner, Brown & Wasilevich, in press) examined the records of people attending ED for low back pain over the course of one year, from 2011 – 2012. They looked at the indications for receiving imaging for the preceding 12 months. Over 14,838 events were recorded – and of this group, 51% had no indications for imaging. This group attended ED less often, had fewer hospital stays, had lower rates of healthcare visits and had fewer appointments with specialists. BUT among this group 30% had imaging, 26% had advanced imaging (eg CT or MRI).

Overall, nearly 30% of people presenting to ED with low back pain are likely to have an Xray, and 10% will go on to have advanced imaging.

What this means is that there are a group of people who really don’t need to have imaging, according to our best evidence, but end up having it. We know that most people with back pain are not going to benefit from having X-ray, CT or MRI because these images either don’t show anything useful (no image shows pain) or show something irrelevant that might look interesting but is actually unrelated to back pain. We know this, and there have been numerous treatment guidelines and algorithms and education indicating not to give imaging for low back pain without neurological changes.

Yet this paper shows very clearly that this practice is still going on.

The authors point out why changing practice is important: unnecessary imaging increases exposure to radiation, increases the risk of getting surgery (that’s not likely to change the low back pain outcome), and costs a lot – in this case, the authors suggest $600,000 could be saved in the two years in which this study was conducted. That’s a lot of money – it might even pay for a clinician or two!

I’m interested in why this happens.

ED is a busy place. It’s set up for people to be seen urgently, where the focus is on saving lives, where every minute counts. It’s not the place for people with chronic problems, complex problems (particularly complex psychosocial problems), and it’s not the place for taking time to consider the long term implications of any action. People working in ED care enormously about their work, know they’re making a difference – but find it very difficult to deal with the complex chronic health problems of those with chronic pain. Particularly those with chronic pain and associated mental health problems.

It’s not the place to see people with chronic pain. And yet, within the top 100 “frequent attenders” to ED, most will have a mental health problem, and most will have chronic pain.

To me this suggests there are a lot of people in the community who have unmanaged chronic pain. Or poorly managed chronic pain.

It’s not that people shouldn’t get treatment – but it’s the “better, sooner, more convenient” and the “right person, right treatment, right time” that needs to be addressed.

Let’s say we employed four specialist clinicians to work in ED to help people with chronic pain. Four clinicians at roughly $80,000.  That’s $320,000.

If every person with chronic pain flare-up was seen by a clinician, connected with appropriate chronic pain services, and a management plan developed to help that person stay at home instead of venturing into ED, I volunteer that there’d be a saving. Not only a financial saving, but an emotional one – and not just for the person attending ED! But for the staff working there, the ambulance staff assisting, the family members of the person, and his or her primary care team.

Why doesn’t this happen? Well I think it’s mainly because chronic pain isn’t often given as a primary diagnosis, and certainly isn’t recorded on ED admission forms. That makes it invisible. The costs of admissions for chronic pain are therefore hidden. Chronic pain doesn’t get much airtime, and it’s not sexy. Making a change to how ED manages people with chronic pain requires an upfront investment – and every other area in health is crying out for money, usually much more loudly than chronic pain! And there’s the issue of relative power – a medical solution to chronic pain doesn’t exist, it’s mainly managed by allied health. We’re not a vocal group, we have limited political clout, and we’re poorly represented within healthcare management.  Chronic pain management also requires a team, and a team working in a way that is quite different from most teams because it’s interdisciplinary rather than multidisciplinary. Chronic pain management takes time. Results/outcomes are quite small.

But when we’re being exhorted to save money in health, I can’t see why changing practice around unnecessary imaging can’t be an effective first step.

http://www.choosingwisely.org/doctor-patient-lists/imaging-tests-for-lower-back-pain/

Schlemmer, E., Mitchiner, J., Brown, M., & Wasilevich, E. (2014). Imaging during low back pain ED visits: a claims-based descriptive analysis The American Journal of Emergency Medicine DOI: 10.1016/j.ajem.2014.12.060

symmetry and perfection

One gap to fill in pain management


There have been some great gains in pain neuroscience over the past few years – we know more about mirror neurones, cortical smudging, “placebo” and how cognitive behavioural therapy changes the brain. It’s sexy. There are also some rather unsexy areas of pain management, and one of these is about how people learn about their chronic pain.

It takes most people several years to get a definitive diagnosis for even well-known inflammatory problems like ankylosing spondylitis (Salvadorini, Bandinelli, Delle Sedie, Riente et al, 2012) – nine years is a long time to have mysterious pain that no-one seems to have a handle on. We also know that people with pain want some very specific things from their consultations: a definite diagnosis, acknowledgment of pain, acknowledgement of expert knowledge from the person with pain, to be seen as an individual rather than a diagnosis (Haugli, Strand & Finset, 2004).

My research looked at the ways to cope used by people who live well despite their pain. The first part of living well involves making sense of what is going on.

When a person first experiences pain, mostly it’s thought of as a typical acute pain problem. When the pain doesn’t settle down, or if it feels different from other experiences of pain, people will begin searching for information. Eventually, and this can take a long time (years), there’s a match between “what I feel”, “what I’ve learned” and “a label”. The label represents a lot to people living with pain. It means validation (I’m not going crazy, I’m not imagining it, I’m not being weak), it means the problem is understandable, and it means someone knows what is going on.

At the same time as getting external validation for the problem, people are trying to work out what their pain does on a day-to-day basis. Where do I hurt? What does it feel like? What’s normal? Over the past few years as apps for our devices have been developed, these are useful tools people can use to track their pain from day-to-day.  I’ve seen incredibly detailed diaries where people have written down their pain intensity, and what they’ve done for months and months in an attempt to get symptom understanding.

And then there’s the need to predict the effect of chronic pain on what needs to be done in life. And this is a gap I think we need to fill.

When people are busy learning about their pain, and at least until they have diagnostic clarity, life seems to get put on hold. It’s a recognised feature of this phase of having pain, life can become “a viscous long-lasting now”, with temporal disorganisation (Hellstrom & Carlsson, 1996; Hellstrom, 2001).  In other words, people’s sense of the future and moving towards this gets disorganised because the world that used to be predictable has become chaotic.  They’ve lost the ability to dream about what might be there for the future, because now dominates everything.

This occurs because humans make plans based on a sense of self, of who we are, what we do, our contributions and roles. When chronic pain is present, people’s sense of self (the collection of knowledge about what-it-feels-like-to-be-me) is disturbed because all the everyday things they need to do are more difficult. Pain intrudes.

I’ve looked for any systematic tools to give people so they can learn how to predict the effect of their pain on daily activities (occupations, to use the language of occupational science and occupational therapy).  I haven’t found anything yet.

The whole idea that someone might want to, or need to, develop this kind of “somatic awareness” is counterintuitive. I mean, most programmes ask people to complete questionnaires that are used by clinicians to identify their problems and what therapy should target. Much of therapy is intended to extend what people can do, to help them go beyond their existing beliefs and limitations. We do this by engaging people in physical activities such as a circuit gym or a set of exercises that gradually gets increased over time.

BUT How does knowledge drawn from a set of exercises, or a circuit gym, transfer to the daily life patterns of a 34 year old builder? Or a 28 year old bank clerk? Or a teacher? Or a retired merchant navalman?

“Somatic awareness” as a clinical need in people with chronic pain is not a new idea. Strong and Large (1995), and Large and Strong (1997) identified that people who were not seeking treatment for their low back pain used “somatic awareness” to titrate their activity levels, and this formed a large part of their coping approach. Crowe, Whitehead, Gagan, Baxter, Pankhurst and Valledor (2010) also found that people “listen to their body” so they can adjust what they expect from themselves. Fisher, Emerson, Firpo, Ptak, Wonn and Bartolacci (2007) identified that by understanding the variability of pain, people could modify their occupational engagement, as did Persson, Andersson & Eklund (2011).   There are many more.

I think an obstacle to developing this aspect of self-management might be our fear that by asking people to notice what is going on in their bodies, we are reinforcing “pain behaviour”. I’m not sure that this is in fact what happens, but it’s an area for future research. The behavioural paradigm still has a strong influence on how we think about attention and pain. And we’ve all probably seen those people who fixate on pain fluctuations to the point of obsession, and usually because they’re keen to do whatever it takes to reduce the pain.

Somatic awareness, making sense, symptom understanding and occupational existing are tools used by people who are naive to pain management. Maybe in our efforts to help those who have a great deal of trouble with their pain, we’ve forgotten to build on the strengths used by those who cope well.

 

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

Crowe, M., Whitehead, L., Gagan, M. J., Baxter, G. D., Pankhurst, A., & Valledor, V. (2010). Listening to the body and talking to myself – the impact of chronic lower back pain: a qualitative study. International Journal of Nursing Studies, 47(5), 586-592. doi: 10.1016/j.ijnurstu.2009.09.012

Fisher, G. S., Emerson, L., Firpo, C., Ptak, J., Wonn, J., & Bartolacci, G. (2007). Chronic pain and occupation: an exploration of the lived experience. American Journal of Occupational Therapy, 61(3), 290-302.

Haugli, Liv, Strand, Elin, & Finset, Arnstein. (2004). How do patients with rheumatic disease experience their relationship with their doctors? A qualitative study of experiences of stress and support in the doctor-patient relationship. Patient Education and Counseling, 52(2), 169-174. doi: http://dx.doi.org/10.1016/S0738-3991%2803%2900023-5

Hellstrom, Christina. (2001). Affecting the future: Chronic pain and perceived agency in a clinical setting. Time & Society, 10(1), 77-92. doi: http://dx.doi.org/10.1177/0961463X01010001005

Hellstrom, Christina, & Carlsson, Sven G. (1996). The long-lasting now: Disorganization in subjective time in long-standing pain. Scandinavian Journal of Psychology, 37(4), 416-423. doi: 10.1111/j.1467-9450.1996.tb00673.x

Large, Robert, & Strong, Jenny. (1997). The personal constructs of coping with chronic low back pain: is coping a necessary evil? Pain, 73(2), 245-252. doi: http://dx.doi.org/10.1016/S0304-3959(97)00100-0

Persson, Dennis, Andersson, Ingemar, & Eklund, Mona. (2011). Defying aches and revaluating daily doing: occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188-197. doi: http://dx.doi.org/10.3109/11038128.2010.509810

Salvadorini, G., Bandinelli, F., Delle Sedie, A., Riente, L., Candelieri, A., Generini, S., . . . Matucci-Cerinic, M. (2012). Ankylosing spondylitis: how diagnostic and therapeutic delay have changed over the last six decades. Clinical & Experimental Rheumatology, 30(4), 561-565.

Strong, J., & Large, R. (1995). Coping with Chronic Low Back Pain: An Idiographic Exploration Through Focus Groups. The International Journal of Psychiatry in Medicine, 25(4), 371-387. doi: 10.2190/H4P9-U5NB-2KJU-4TBN

Yealands Winery

Sticky back beliefs


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

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

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

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

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

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

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

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

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

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

You want a piece of me

Around and around and around we go – or…back to the beginning again


ResearchBlogging.orgIn the early days of non-medical chronic pain management, operant models of behavioural learning were used by Prof W Fordyce.  At the time, this was a revolutionary approach to helping people with chronic pain reduce their disability, distress and depression by altering the reinforcement schedules operating on pain behaviour.  It was such an innovation because it moved the focus from pain intensity to disability associated with pain, and in doing so, it offered hope to the many people who were otherwise thought unlikely to ever “get better”.

Operant models gradually fell out of favour as cognitive behavioural approaches for managing pain became popular over the 1990’s and later.  Refinements to behavioural approaches have been incorporated into ACT (Acceptance and Commitment Therapy) and graded exposure treatments for pain-related anxiety and avoidance – but this hasn’t been extended to operant conditioning.

What exactly is operant conditioning? The simplest way to think of it is to remember “operant” conditioning “operates” on the environment with behaviour maintained by what occurs afterward – so we need to think about rewards, punishments, and positive and negative conditioning.  In other words, the chance I’ll reach for a certain brand of chocolate bar will go UP if I receive some sort of reward for doing so, while the chance of my watching the Rugby World Cup will go DOWN if the people around me groan in unison whenever a game comes on the TV.  But this depends on whether I want the reward offered by the chocolate manufacturer – or I’m bothered by people groaning when I have the TV on!

In a really interesting study by researchers from Eastern Michigan University and University of Washington (Seattle), three hypotheses were tested: fear-avoidance, operant, and pain models, and their ability to predict activity levels.

To recap, the so-called fear-avoidant (pain-related anxiety and avoidance) model involves anticipatory anxiety, or specific fear of movement/reinjury and the resultant avoidance of activity and is usually associated with a classical conditioning process.  A person moves and simultaneously experiences pain or the fear of pain/reinjury, and therefore movement becomes associated with pain.  It doesn’t take long before the person avoids movement because it hurts, and because of the meaning of the hurt.

The operant model involves the person’s behaviour “operating on” the environment (usually involving people’s responses to the behaviour) which serves to increase or reduce the likelihood the person will do that particular behaviour again.  Think of someone coming home with a headache, looking poorly, maybe lying down, and the partner offering comfort – chances are, if the person liked this response, he or she will do the same thing next time a headache comes to visit!

In the pain model, it’s believed that the experience of pain itself dictates the degree of disability an individual has.  So, the person may have a neurobiological vulnerability leading to a greater sensitivity to painful input, and an augmented experience of pain.

In this experiment, 20 patients with chronic low back pain attending a tertiary pain management centre were asked to complete a range of questionnaires, and then were tested with a pressure algometer to determine the pressure at which they experienced pain.  This is thought to help identify the degree of “pain sensitivity” people may have and in this experiment was used to test the pain model.

Then patients were asked to wear an accelerometer to determine their activity level over five days – except when in water (showering, bathing, swimming).

Working some awesome statistical analyses (that, as usual, I won’t go into! Read the paper itself for more details), the researchers found that “the operant model emerged as the only model accounting for a statistically significant amount of the variance in physical activity”.  While the other two models were also relevant, and did contribute to the level of activity people carried out, family and/or spouse responses that were less solicitous, less punishing, and more distracting predicted higher activity levels.

The researchers concluded that“significant others’ responses account for a significant amount of the variance in physical activity, confirming that reinforcement of behavior is a powerful mechanism for behavior change”.  In a sense, this is not news – the response of family and others has always been thought to be important.  What is news is that when the other two models were tested concurrently, the factor that had the most impact on activity level was that of family and partners.

Here’s a question: how often do we

(a) assess the responses of these important people in behavioural terms?  While we might ask about the impact of pain on relationships, I think we need to examine what people do when the person is experiencing pain, and we also need to know how the person demonstrates or displays their pain – what the significant other is responding to, and

(b) specifically address how the person with pain can manage the responses of other people to their pain behaviour? Do we tell the person to communicate effectively about their pain to help them let other people know what they would like them to do when they’re sore?  It can be a very delicate process to negotiate how to ask the partner not to take over the activities the person with pain is beginning to do again! and finally

(c) include the family and partner in our treatments, goal setting and pain “education” so they are more fully informed about what their family member is trying to do, and so they can know what their best options for offering support might be?

It’s almost like deja vu – operant conditioning is coming back in from the cold.  I’d love to know your take on how we can do this within our usual practice. 

Alschuler, K., Hoodin, F., Murphy, S., Rice, J., & Geisser, M. (2011). Factors contributing to physical activity in a chronic low back pain clinical sample: A comprehensive analysis using continuous ambulatory monitoring PAIN DOI: 10.1016/j.pain.2011.07.017

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A brief review of cognitive behavioural approaches for pain management


ResearchBlogging.org
Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems.  While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health.  In fact it has only been in the last few years that research into the process of change in pain management have been conducted.

What defines a cognitive behavioural approach?

  • The assumption that people can learn to accept their chronic pain
  • That people can broaden their self-concept beyond being “a patient” into being “a person with pain”
  • That people can learn or re-explore skills to deal more effectively with their pain (Morley, Biggs & Shapiro)
  • Managing or living well despite pain
  • Pain behaviour that limits living well becomes the target
  • CBT provides the skills to (ultimately) change behaviour
  • Provided by any/all members of the interdisciplinary team (common treatment model)

What are the goals of this approach? (NB in no particular order!)

  • To reduce pain intensity
  • Increase functional activity, including work
  • Reduce/rationalise use of health care
  • Reduce distress
  • Improve quality of life

One of the main aims of this approach is to ultimately help the person with pain become his or her own therapist – to effectively self manage pain.

How do we do this?

The exact combination of strategies and approaches that “do the trick” in this kind of approach is not yet known.  It could even be that the specific techniques that people learn may not, in themselves, be all that important.  Maybe it’s the emphasis throughout treatment that there is hope for a life even if pain is present that helps patients become people again.  Research simply doesn’t tell us this yet.

Certainly, in the years that I’ve been working in pain management, the core elements have changed little, with perhaps, the addition of graded exposure and the mirrorbox and laterality work for certain problems.

How do we begin with this approach?

  • Assessing what the person with pain considers to be the main problem (the problem/s that pain “causes”, rather than pain alone)
  • Asking why he or she is looking for help right now (what were the triggers? It could be the person, or someone else who has initiated the treatment-seeking)
  • Identifying the changes he or she wants to see (how will the person know treatment has been successful?)
  • Listing the behavioural difficulties the person is currently having

Some of the ways I do this are to ask the person “what would you be doing now if pain was less of a problem?”

There’s a reason I use that phrase “less of a problem”, because I pretty much don’t refer to pain intensity again.  Pain is likely to be present and to fluctuate throughout treatment and afterwards.  I want to model that it’s the fear of pain, rather than the pain itself that is most disabling.  Even when pain is intense, it’s more helpful to relax and go “with” the pain than be fearful and tense the body to resist it.

A first step is often to introduce a model of pain and how it affects the individual.  This is a personalised model of pain, individualised for this person – but based on what we currently know about pain from research.  Various explanations can be used, but I draw from what the person tells me about their experience of pain to generate their specific model.

Most times, it seems to help people to discuss a current neurobiological model of pain – and this is often where “Explain Pain” or similar descriptions can be really helpful.  Taken at a pace that people can manage, and using their own examples, helps people to quickly grasp information that many medical students only begin to learn in 3rd and 4th year of study.

How does this step help?

Cognitive behavioural theory suggests that people appraise or judge situations very quickly, on the basis of past learning, current arousal state, and future predictions.  Automatic thoughts then generate an emotional response.  This emotional response influences behaviour.  The relationships between these four factors can be bidirectional.

By giving people a more accurate and more realistic view of their pain – as something that can be understood (at least in part), and managed, and isn’t signalling harm – people can be far less distressed by it.  You can think of how your knowledge that a flu jab is a helpful way to prevent getting the flu and how this helps you cope with the sting of the needle, and compare it with how you would interpret and respond to being stuck with a dirty needle wielded by a hoodlum in a dark alley! The thoughts and beliefs we hold about sensations influence emotions and behaviour.

Eliciting an individual’s automatic thoughts about pain, and helping them recognise that the way they view their pain may be accurate-but-unhelpful, is one part of the cognitive behavioural approach to pain management that all members of the team need to reinforce.

The remainder of a cognitive behavioural approach to managing pain is focused on helping people engage with activities they value, and doing so in a way that (1) is manageable for now and (2) recognises the sensitive nervous system can be stirred up quickly by things other than physical activity.  Skills are developed to set goals, manage gradual increases, problem solve ways around obstacles, manage arousal levels, and work with thoughts and beliefs that become stirred up by doing things differently.

What about people who are really, really fearful of moving and avoid things? Take a look at that reference below – it’s a review of the approaches that have been used for people in this situation.  More on it very soon…

Bailey, K. M., Carleton, R., Vlaeyen, J. W., & Asmundson, G. J. (2010). Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review. Cognitive Behaviour Therapy, 39 (1) DOI: 10.1080/16506070902980711

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Catastrophising and Pain (ii)


ResearchBlogging.org
What are some of the indications that someone tends to catastrophise about their pain? How do we know? Do we have to use a questionnaire? Is it really my job to know about this if I’m not a psychologist – and what do I do about it?

These are the kinds of questions that have been posed to me as I’ve explored the topic of catastrophising, and I propose to answer the last question in my next post (sorry to keep stringing you along like this – I think many may know my take on that already!).

I work in a wonderful interdisciplinary team setting, in a centre where everyone who attends the Centre gets to complete a set of psychometrically sound questionnaires that all of the team are encouraged to use and interpret, so any of the team can be confident about identifying and working with a patient who catastrophises. BUT I know that many clinicians work alone, or work in a team that functions in a multidisciplinary way, and where patients don’t routinely complete questionnaires.

So, what can solo, primary care clinicians do?

As I mentioned before, questionnaires are not X-rays of the mind – they simply organise how information is obtained, and allow us to compare the responses from one person with the responses from many others so we can decide how similar or different this one person is. In other words, using a questionnaire is just another strategy to help assess where a person is at.

It’s possible and sometimes really helpful to just ask
. With some proviso’s of course – asking the right questions and not just asking but also observing behaviour and putting this information together in some form of clinical reasoning about what is going on, and what this might mean for treatment.

Even if you decide to use a questionnaire (and maybe the Pain Catastrophising Scale is a useful choice), it’s important to decide who to give it to, when to give it, and most importantly, how to interpret it because numbers just don’t mean anything on their own – not even percentage change over time tells us very much if we don’t know the meaning of the domains they are representing.

Here’s another Healthskills Advice for NonPsychologists list on questionnaires and catastrophising!

  1. Some indications for considering the use of a measure of catastrophising are people who present as highly anxious or distressed about their pain, who describe their pain in dramatic metaphors or say things like “my back will snap” or “my bones and nerves are being ground away”, who say things like “I can’t stand it any more” or “it’s terrible and it can’t go on”, or who are fearful they will “end up in a wheelchair” for example.  Particularly people who believe that moving will “do damage”, and those who seem completely helpless when they have pain “there’s nothing I can do when I have pain”.
  2. It’s probably not so helpful to administer a questionnaire for catastrophising in someone who is seeing you with acute pain (first episode, within the first two or three weeks), but more useful to give it to someone who has had their pain for six weeks or more (sub-acute), who has had episodes of pain that have lasted more than six weeks before and had a slow recovery.
  3. In primary care settings most people won’t demonstrate catastrophising – but there is some research that suggests up to 25% of people with acute pain hold catastrophic beliefs (Ciccone, Chandler & Kline, 2010), and this finding was in young, fit military people!  Clearly not everyone who has catastrophic beliefs when they have acute pain go on to develop long-term disability, but the risks are higher, so a screening assessment like the Orebro Musculoskeletal Pain Questionnaire might be useful for routine administration in acute, primary care settings.
  4. It’s not very useful to use an English language questionnaire with someone who doesn’t speak English well – see if there is a questionnaire in that person’s language instead.  Be wary of using a translator to help someone answer a questionnaire, because this can lead to unintended errors and invalidate scoring.  The same applies if the person has limited comprehension.
  5. Make sure you read and understand the questionnaire, what it measures, how it’s interpreted, what the reference or normative group is, and how to score it.  If you don’t know these things, you’d be far better off not to use the questionnaire! Kthx.
  6. If you’re going to ask about catastrophising, you can ask things like
    • What goes through your mind when your pain gets bad?
    • What do you think is happening then?
    • What images go through your mind when you’re really sore?
    • What can you do to help yourself when your pain is really bad?
    • What do you think will happen in the future if your pain gets bad?
    • What do you think is going on in your body when you’re really sore?
    • What can you do to get by when your pain is bad?

Can you tell that this post is not the last in this series? But wait, there’s more!  Come on back for more, and don’t forget to comment (they’re always welcome).
Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336