Occupational therapy

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What to do with the results from the PCS


The Pain Catastrophising Scale is one of the more popular measures used in pain assessment. It’s popular because catastrophising (thinking the worst) has been identified as an especially important risk factor for slow recovery from pain (Abbott, Tyni-Lenne & Hedlund, 2010), for reporting high levels of pain intensity (Langley, 2011), and for ongoing disability (Elfving, Andersoon & Grooten, 2007). I could have cited hundreds more references to support these claims, BTW.

The problem is, once the PCS is administered and scored: what then? What difference does it make in how we go about helping a person think a little more positively about their pain, do more and feel more confident?

If you haven’t seen my earlier posts about the PCS, take a look at this, this, and this for more details.

Anyway, so someone has high scores on rumination, helplessness and magnifying – what does this mean? Let’s say we have two people attending the clinic, one has really high scores on all three subscales, while the other has low or average scores. Both have grumbly old low back pain, both have had exercises in the past, both are finding it tough to do normal daily activities right now.

For a good, general pain management approach to low back pain, and once red flags are excluded (yes, the “bio” comes first!) this is what I do. I establish what the person thinks is going on and ask if it’s OK to talk about pain neurobiology. Together we’ll generate a pain formulation, which is really a spaghetti diagram showing the experience as described by the person (I used guided discovery to develop it). I then ask the person what they’d be doing if their pain wasn’t such a problem for them, perhaps what they’re finding the most frustrating thing about their situation at the moment. Often it will be sleep, or driving or cooking dinner, or perhaps even getting clothes on (shoes and socks!). I’ll then begin with helping the person develop good relaxed breathing (for using with painful movements), and start by encouraging movement into the painful zone while remaining relaxed, and tie this in with one of the common activities (occupations) the person needs or wants to do. For example, I’ll encourage bending forward to put shoes and socks on while breathing in a relaxed and calm way. I’ll be watching and also encourage relaxing the shoulders and any other tense parts of the body. For someone who is just generally sore but doesn’t report high pain catastrophising, I will also encourage some daily movements doing something they enjoy – it might be walking, yoga, dancing, gardening, whatever they enjoy and will do regularly every day for whatever they can manage. Sometimes people need to start small so 5 minutes might be enough. I suggest being consistent, doing some relaxation afterwards, and building up only once the person has maintained four or five days of consistent activity. And doing the activity the person has been finding difficult.

If the person I’m seeing has high scores on the PCS I’ll begin in a similar way, but I’ll teach a couple of additional things, and I’ll expect to set a much lower target – and probably provide far more support. Catastrophising is often associated with having trouble disengaging from thinking about pain (ruminating), so I’ll teach the person some ways to deal with persistent thoughts that hang around.

A couple to try: mindfulness, although this practice requires practice! It’s not intended to help the person become relaxed! It’s intended to help them discipline their mind to attend to one thing without judgement and to notice and be gentle with the mind when it gets off track, which it will. I ask people to practice this at least four times a day, or whenever they’re waiting for something – like the jug to boil, or while cleaning teeth, or perhaps waiting for a traffic light.

Another is to use a “15 minutes of worry” practice. I ask the person to set a time in the evening to sit down and worry, usually from 7.00 – 7.15pm. Throughout the day I ask the person to notice when they’re ruminating on their situation. I ask them to remind themselves that they’re going to worry about that tonight and deliberately put that worry aside until their appointment with worry. Then, at 7.00pm they are asked to get a piece of paper and write ALL their worries down for a solid 15 minutes. No stopping until 15 minutes is over! It’s really hard. Then when they go to sleep, I ask them to remind themselves that they’ve now worried all their worries, and they can gently set those thoughts aside because they won’t forget their worry, it’s written down (I think worry is one way a mind tries hard to stop you from forgetting to DO something about the worry!). People can throw the paper away in the morning because then it begins all over again.

Usually people who score high on the PCS also find it hard to be realistic about their pain, they’ll use words that are really emotive and often fail to notice parts of the body that aren’t in pain. By noticing the worst, they find it tough to notice the best.  I like to guide people to notice the unloved parts of their body, the bits that don’t hurt – like the earlobes, or the belly button. I’ll offer guidance as to what to notice while we’re doing things, in particular, I like to guide people to notice those parts of the body that are moving smoothly, comfortably and that look relaxed. This is intended to support selective attention to good things – rather than only noticing pain.

Finally, I give more support to those who tend to be more worried about their pain than others. So I might set the goals a little lower – walking for five times a week, two days off for good behaviour rather than every day. Walking for five minutes rather than ten. And I’ll check in with them more often – by text, email or setting appointments closer together. It’s important for people who fear the worst to experience some success, so setting small goals that are achieved can build self efficacy – especially when I try hard to offer encouragement in terms of what the person has done despite the odds. So, if the person says they’ve had a real flare-up, I’ll try to boost confidence by acknowledging that they’ve come in to see me even though it’s a bad pain day, that they’ve tried to do something instead of nothing, that talking to me about the challenge shows guts and determination.

People who see the glass as half empty rather than half full are just people. Like you and I, they’re people who have a cognitive bias. With support, we can help people view their pain differently – and that process applies to all of us, not just those with high scores on the PCS.

 

Abbott, A. D., Tyni-Lenne, R., & Hedlund, R. (2010). The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy, 96(3), 213-221. doi:10.1016/j.physio.2009.11.013

Elfving, B., Andersson, T., & Grooten, W. J. (2007). Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing. Physiotherapy Research International, 12(1), 14-24.

Langley, P. C. (2011). The prevalence, correlates and treatment of pain in the european union. Curr Med Res Opin, 27(2), 463-480. doi:10.1185/03007995.2010.542136

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What difference does it make to know about psychosocial risk factors?


The “psychosocial yellow flags” or risk factors for developing ongoing disability after a bout of acute low back pain have been promulgated in New Zealand since 1997. Introduced as part of the Acute Low Back Pain Guidelines, the yellow flags were lauded both locally and internationally and subsequently there have been many international guidelines which have adopted this kind of integration. But what exactly do we do with that information? How does it help if we find out that someone is really afraid their pain means something awful, or if they fear their life will never be the same again, or if they truly worry about doing movements that provoke their pain?

Truth to tell, although there have been a lot of studies examining the relevance of psychosocial risk factors, the uptake among clinicians has been fairly abysmal. This is particularly so among clinicians who work either mainly with acute musculoskeletal pain, or amongst those who are mainly involved in treated the body. One physio I know said she got the impression during her training that psychosocial factors “are the things we can blame when our treatments don’t work”.

I think part of the problem is the focus on assessment “technology”. There is a proliferation of questionnaires that can be used to help spot the person who’s likely to have difficulty recovering. We have STartBack, Orebro Musculoskeletal Questionnaire, Pain Catastrophising Scale, Tampa Scale of Kinesiophobia, Depression Anxiety Stress Scale, Pain Self Efficacy Scale – most of which are known by their abbreviations, so it’s like an alphabet soup! But despite knowing about these questionnaires, and perhaps even administering them to people we think might need assessment, once the results come in it’s pretty difficult to know what to do next.

So what if a person reports really high levels of catastrophising? Or that they’re very high on the Fear of Injury/Reinjury on the TSK? Or that they have the lowest ever score on the PSEQ? What on earth do you do to make an impact?

Some people are very actively engaged in “Pain Education”. It’s given to absolutely everyone because “the evidence says” it “works”. Pain reduces. People get engaged in their exercise. Life returns to normal.

Some people refer immediately on to a psychologist. Let them deal with the “difficult” patients.

Others just carry on as normal but in the back of their mind have the “out” that “Oh but they have yellow flags” – and drop their expectations accordingly.

To me that’s just not good enough, and it suggests to me that we need to learn more about what these measures mean – and what to do differently as a result.

There’s a couple of problems though:

  1. How do we choose who to give a questionnaire to? – do we rely on “intuition” or do we give them out to everyone?
  2. Which questionnaires do we use? There’s no “gold standard” – just a mix of various measures that tap into part of the picture…
  3. How much do we rely on strong RCT’s examining whole treatment packages, versus how much do we rely on principles of behaviour change and knowledge of the underlying theories relevant to pain and disability?
  4. What if our clinical reasoning models are completely silent on the work involved in supporting people who present with these risk factors – what if our clinical reasoning models suggest that this work is not all that important compared with the “real” work of tissues and muscles and movement?

Here are my thoughts on what we can do.

I think we should give screening questionnaires to everyone who comes in with an acute bout of musculoskeletal pain, and I think there are a couple that really work well – Orebro is clearly one of them, PCS or PASS are both useful, and I think it’s helpful to screen for mood problems. Why do I think everyone needs these? Well, it’s easier to give them to everyone than to rely on our terribly inaccurate intuition. The risk of failing to identify someone who needs more support is high (and the consequences of omitting this is serious). By routinely administering screening measures we can de-stigmatise the process (though there shouldn’t be any stigma associated with understanding that pain involves the whole person!). We can make the administration easy by integrating it within routine clinic entry process – and by using electronic forms of each questionnaire we can make entering and scoring them easy.

We then need to learn what the questionnaires actually measure – not just the total score, but the subscales as well. Then we need to use those subscale scores to understand what we need to ask the person when we see them face-to-face. This helps us begin to understand the person and how they came to develop these beliefs and attitudes, and in doing so we can develop greater empathy for their experience – and alter our treatments to reflect their needs.

For management, I think we have to, at this stage, step beyond the RCT for evidence. There’s a few reasons for this: one is that RCTs naturally omit individual responses to the treatment meaning we lost the detail as to who responds to which aspect of the treatment. Another is that RCTs often group patients together to ensure power is reached – but in doing this, omit important individual differences. And finally, each person we see is a unique individual with a unique interaction between the various factors influencing their presentation – and there are simply insufficient RCTs to account for these differences. Does this mean we stop using evidence? Oh no!! It just means we need to look at the principles behind many treatments – what are the guiding principles and why might they apply to this person at this time? Finally we need to monitor outcomes so we can establish whether our approach actually helped.

Finally, I think our clinical reasoning models need to include important aspects of treatment that we vary, often without being aware that we do.

For example, if we see someone who scores very high on the PCS and tends to ruminate or brood on the negative, we can’t go ahead and give that person the same set of exercises or activities we’d give someone who is quite confident. We’ll need to lower the physical demands, give really good explanations, take the time to explain and de-threaten various sensations the person may experience, we’ll probably need to move slowly through the progressions, and we’ll definitely need to take time to debrief and track progress.

These “invisible” aspects of treatment are, I think, often the most important parts – but they’re often not mentioned in clinical protocols, and perhaps our skill in titrating the challenges we give our patients is not well developed. These factors incorporate psychological techniques of behaviour change – things like reinforcement, motivational interviewing, problem solving, Socratic questioning, how to fade support, how to bolster confidence, how to vary the environment, and how to avoid pliance and tracking (or going along with things rather than truly integrating the learning). If we want to work with people and help them change their lives, we need to learn how people change behaviour. That means, I’m afraid, learning some psychology…!

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End-of-year musings


It’s my last post for the year. It has been an extraordinary year, lots of surprises, shocks and enough excitement for anyone! I’m not even going to start on the political changes, here in NZ we’ve had yet another major earthquake, excitement as ACC (our national accident insurer) sets up new pain service contracts (with a LOT of people who haven’t been involved in pain management before… there’s an experiment in the making!), and continuing road cone carnage on the streets of Christchurch.

On the pain news front, I can’t think of any incredibly ground-breaking news – although one medic advised that “Virtually all cases of low back pain can now be diagnosed definitively by criterion standard methods as to source and cause.” That same medic also argued that a paper by Maher, Underwood & Buchbinder (2016) on non-specific low back pain, published in The Lancet, represented “the views of non-evidence-based troglodytes who (a) have apparently not read any scientific papers since 1966, and (b) have vested interests in “managing” non-diagnosed patients so their practices remain busy and they reinforce each other’s views that the burden of low back pain cannot be eased.” I’ll leave the critiquing of that view to those with more time and energy than I have!

It’s also been a year in which various commentators have critiqued the “biopsychosocial model” as it’s applied in musculoskeletal pain.  Some have pointed out that this is an unscientific model, it’s not a theory that can be tested and therefore can’t point to “truth” or whatever approximation we can currently identify. Others have argued that by adopting this framework, practitioners must either be versed in “life, the universe and everything” – or perhaps become exactly what advocates of this approach decry: reductionists. I’m not sure I follow this argument, but those that raise it are intelligent, articulate and far more thoughtful than those who believe that Maher, Underwood & Buchbinder are “troglodytes” or have “vested interests”.

I continue to hold that a biopsychosocial perspective explains more, and is of practical use when we consider the various factors that might influence why this person is presenting in this way at this time, and what might be done to reduce their distress and disability. Here’s my take.

Biopsychosocial model

When we look into the original biopsychosocial model, we need to understand the context in which Engel first developed it. He was a psychiatrist, and at the time psychiatry was under threat from psychologists in particular, who were strongly advocating that many mental illnesses were actually “problems of living”. Things like alcohol abuse, forms of mood disorder, relationship issues and the like were seen as disorders influenced by learning and environment rather than biology. Psychiatrists were perhaps on the way to being sidelined from the very area in which they claim expertise. Engel, influenced by general systems theory and cybernetics, proposed a way for psychiatrists to remain relevant: look at the person as part of a wider system in which each element in the system could influence and be influenced by the next. Engel used this approach as a way to frame conversations with the patients he saw – attempting to understand how and why they were seeking help, and especially, attempting to understand the person and his or her priorities. I think that’s admirable.

How the model has evolved since then is an interesting tale. I first encountered the model during my occupational therapy training, where it was a foundation to viewing people-in-context. It was presented as a bit old hat (I started training in 1979), and was replaced in my profession by Gary Kielhofner’s Model of Human Occupation. This model similarly draws on general systems theory, and argues for the relevance of volition and habits as well as capacity from a biological/performance stance to undertake occupation and of course, contexts such as environment which includes the social environment. MOHO incorporates much of what we consider to be biopsychosocial – in fact, occupational therapy as a profession is based on the idea that people actively engage in purposeful and meaningful activities (occupations) that are formed out of the affordances available to them by virtue of biology, psychology and social elements within an environmental context.

So what?

For a model, or theory, to have value it needs to offer something that existing models or theories don’t. It needs to be more parsimonious (make fewer assumptions), explain more (be more consilient), hold together with existing knowledge (cohere), and predict more (Thagard, 1978).

For a clinician, a theory must also be useful in terms of explaining why this person is presenting in this way at this time, and directing what can be done to reduce distress and disability. Why these questions? Because people actively make decisions to seek treatment. They evaluate their experience in light of their past experiences, prevailing community beliefs about the trajectory of their problem, family influences, and yes, legislative influences. These are possibly more important than the biology of their problem – because we’re not going to treat someone who doesn’t believe they have a problem!

As clinicians I think we need to ponder exactly what we consider to be “treatment”.

When my fracture is reduced and immobilised, that is “treatment” – but it’s not actually ‘healing’ my bones, it’s actually up to my body to do the work. What immobilisation does is create an environment in which my body can heal itself. But the problem of a broken bone is not “treated” just by immobilisation. Treatment has to include the rest of my recovery – and involve prevention strategies too. My recovery will need to include restoring function. And some of that restoration will be by guiding me through various movements that increase tissue tolerance as well as my confidence that my limb will support me. My recovery also has to include me understanding and learning from my experience – will I jump off that cliff again? Will I leave the toys all over the floor again? Will I walk on a slippery path again?

I think clinicians simply create an environment in which people can recover. And we need to go beyond measuring range of movement or strength to establish that recovery has occurred. Recovery isn’t just about returning to “normal” whatever that is. It’s about moving beyond this interruption and into new possibilities and new challenges. It’s really about being able to be who we really are. While that’s primarily the person’s own responsibility, our job as clinicians is to create an environment where it’s possible. While a biopsychosocial model/theory/framework makes life complex, using this approach allows us to be aware of more of the factors relevant to recovery and growth than simply looking at people as if they’re bits of meat, bone, and juice.

In the new year

I’ve been blogging since 2007. In that time I’ve written over a thousand posts all on the topic of pain. Almost all of my posts are on the theme of how we can remember that we are working with people. Other human beings who have their own thoughts, beliefs and priorities. Humans who make sense of their situation as best they can. People who, like us, hold cognitive biases, and feel emotions, and get stuck, and hold values. My real focus is on how we can integrate these things into clinical reasoning – because until we do, we’re ignoring what matters most to the people we seek to serve.

 

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

Maher, C., Underwood, M., & Buchbinder, R. (2016). Non-specific low back pain.  The Lancet. doi:10.1016/S0140-6736(16)30970-9

Thagard, P. R. (1978). The best explanation: Criteria for theory choice. The Journal of Philosophy, 75(2), 76-92.

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… a little more about Pain Catastrophising subscales


I’ve been writing about the Pain Catastrophising Scale and how to use this instrument in clinical practice these last two posts here and here because the construct of catastrophising (thinking the worst) has become one of the most useful to help identify people who may have more distress and disability when dealing with pain. Today I want to continue with this discussion, but looking this time at a large new study where the subscales magnification, rumination and hopelessness have been examined separately to understand their individual impact on pain severity and disability.

Craner, Gilliam and Sperry looked at the results of 844 patients with chronic pain prior to taking part in a group programme (a heterogeous sample, rather than a single diagnosis, so this group probably look at lot like those admitted to high intensity tertiary chronic pain management services such as Burwood Pain Management Centre here in Christchurch).  Most of the participants were female, European/white and married, and had chronic pain for an average of 10.7 years. Just over half were using opioid medication to manage their pain.

Along with the PCS, participants also completed some very common measures of disability (Westhaven-Yale Multidimensional Pain Inventory – MPI) and quality of life (SF-36), and the CES-D which is a measure of depression.

Now here comes some statistical analysis: multiple hierarchical regression! Age, sex, duration of pain and use of opioids were entered into the equation and found to account for only 2.0% variance of the pain severity subscale of the MPI – but once the PCS was added in (subscales entered separately) an additional 14% of the variance was accounted for, but the helplessness subscale was the only one to contribute significantly to the overall variance.

When Pain Interference was  entered as the dependent variable, all the same demographic variables as above contributed a meagre 1.2% of the variance, but when the Pain Severity subscale scores were added, 25.5% of the variance was explained – while the combined PCS subscales contributed 6.5% of the variance. Again, helplessness was the only subscale to contribute to Pain Interference.

Moving to quality of life – the physical subscale of the SF-36 was used as the dependent variable, and once again the demographic variables accounted for only 1.5% variance in physical QOL, with Pain Severity accounting for 23%. PCS subscales contributed only 2.6% of the variance, with only the magnification subscale being identified as a unique contributor. When the mental health subscale was used, again demographics only accounted for 1.2% of variance, with pain severity accounting for 12.4% of the variance. This time, however, the PCS subscales contributed 19.5% of the variance with both Magnification and Helplessness contributing to the variance.

Finally, examining depression, demographics contributed a small amount of variance (3.3%), with pain severity additing 9.8% of variance. The PCS subscales were then entered and contributed a total of 21% to the prediction of depression with both Magnification and Helplessness contributing to the overall depression variance.

The so what factor

What does this actually mean in clinical practice? Well first of all this is a large group of patients, so we can draw some conclusions from the calculations – but we need to be a little cautious because these participants are a group who have managed to get into a tertiary pain management facility. They’re also a group with a large percentage using opioids, and they were pretty much all European – and from North America, not New Zealand. I’m not sure they look like the people who might commonly come into a community-based facility, or one where they’d be referred directly from a GP or primary care centre.

At the same time, while this group may not look like the people most commonly seen for pain management, they share some similar characteristics – they tend to magnify the “awfulness” of pain, and then feel helpless when their pain is bothering them. Surprisingly, I thought, ruminating or brooding on pain wasn’t a unique contributor and instead the helplessness scale contributed the most to pain severity, pain-related interference (disability associated with pain), poor mental health quality of life, and low mood, while magnification scale contributed to poorer physical health quality of life, mental health quality of life and low mood.

What this means for practice

The authors suggest that the construct measured by the helplessness subscale might be a factor underlying poor adaptation to life’s difficulties in general, leading to passivity and negative emotions. They also suggest that magnification might be a unique contributor to perceiving obstacles to doing the things we need to do every day, while hopelessness might mean people are less likely to participate in enjoyable activities and then in turn contribute to feeling low.

Importantly, the authors state: “We offer that simply collapsing the 3 dimensions of this phenomenon (ie, rumination, magnification, helplessness) may actually conceal nuanced relationships between specific dimensions of catastrophizing and outcomes that would might inform treatment approaches.” Looking at the overall scores without thinking about the subscales is going to give you less information to use for individualising your treatment.

In a clinical setting I’d be reviewing the individual subscales of the PCS alongside both disability and mood measures to see if the suggested relationships exist in the scores this person has given.

I’d be taking a look at the repertoire of coping strategies the person can identify – and more, I’d be looking at how flexibly they apply these strategies. Extending the range of strategies a person can use, and problem-solving ways to use these strategies in different activities and contexts is an important part of therapy, particularly occupational therapy and physiotherapy. Another approach you might consider is helping people return to enjoyable activities that are within their tolerance right here, right now. By building confidence that it’s possible to return to things that are fun we might counter the effects of helplessness, and help put pain back where it belongs – an experience that we can choose to respond to, or not.

I’d also be taking a look at their tendency to avoid feeling what their pain feels like, in other words I’d like to see if the person can mindfully and without judging, complete a body scan that includes the areas that are painful. This approach is intended to help people notice that alongside the painful areas are other nonpainful ones, and that they can successfully be with their pain and make room for their pain rather than attempting to block it out, or over-attend to it. The way mindfulness might work is by allowing people to experience the sensations without the judgement that the experience is bad, or indicates some terrible catastrophe. It allows people to step back from the immediate reaction “OMG that’s BAD” and to instead take time to view it as it actually is, without the emotional halo around it.

Pain catastrophising is a useful construct – but I think we need to become more nuanced in how we use the scores from the questionnaire.

Craner, J. R., Gilliam, W. P., & Sperry, J. A. (2016). Rumination, magnification, and helplessness: How do different aspects of pain catastrophizing relate to pain severity and functioning? Clinical Journal of Pain, 32(12), 1028-1035.

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What do we do with those questionnaires (ii)


In my last post I wrote about the Pain Catastrophising Scale and a little about what the results might mean. I discussed the overall score suggesting a general tendency to “think the worst”, with the three subscales of magnifying or over-estimating the risk; ruminating or brooding on the experience; and helplessness or feeling overwhelmed and that there’s nothing to be done.  At the end of the post I briefly talked about how difficult it is to find a clinical reasoning model in physiotherapy or occupational therapy where this construct is integrated – making it difficult for us to know what to do differently in a clinical setting when a person presents with elevated scores.

In this post I want to show how I might use this questionnaire in my clinical reasoning.

Alison is a woman with low back pain, she’s been getting this niggling ache for some months, but last week she was weeding her garden and when she stood up she felt a sharp pain in her lower back that hasn’t settled since. She’s a busy schoolteacher with her own two children aged 8 and 10, and doesn’t have much time for exercise after teaching a full day, and bringing children’s work home to grade at night. She’s completed the PCS and obtained an overall score of 33, with her elevated scores on the magnifying subscale contributing the most to her total score.

Her twin sister Belinda has coincidentally developed low back pain at the same time, only hers started after she had to change the tyre on her car over the weekend. She’s a busy retail manager preparing for the upcoming Christmas season, and also has two children just a bit younger than her sister’s two. She’s completed the PCS and obtained an overall score of 34, but her score on ruminating is much higher than her scores on the other two scales, and this is the main reason her overall score is high.

What difference does Belinda’s elevated score on ruminating mean for us as clinicians? What do we do when we see Alison’s overall elevated score?

Common themes

Both Alison and Belinda live busy lives, and have lots of stressors within their lives. While they both have similar presentations, we might go about helping them regain confidence in their bodies slightly differently. I’ll begin with Belinda who might, because of the elevated ruminating score, have trouble getting off to sleep and might spend more time attending to her back pain than her sister. Ruminating is that endless brainworm that keeps on dragging our attention back to the thing we’re worried about (or perhaps the problem we’re trying to solve).  Alison, on the other hand, might be more inclined to monitor her back pain and imagine all sorts of dire outcomes – perhaps that the pain will never go away, that it’s going to “cripple” her, and that it’s going to be a major problem while she’s at work.

While both sisters would benefit from learning to move with more confidence, to relax the muscle tension that occurs when back pain is present, and to return to their usual daily activities, we probably need to help Alison learn more about her back pain (for example, explain that most back pain settles down quite quickly, that it’s helped by moving again in a graduated way, and that we’ve ruled out any sinister reason for her developing her pain). During treatment sessions where we help her learn to move more normally, we might spend more time giving neutral messages about fluctuations in her pain (for example, we might let her know that it’s normal to have a temporary increase in pain when we start moving again, and that this is a good sign that she’s beginning to use her body normally). If we notice her looking anxious during a new movement or exercise we might take a moment to ask her about her concerns and provide her with neutral and clear information about what’s going on so she becomes more realistic in her judgements about what her pain means.

For Belinda I might be inclined to help her deal with her thoughts in a mindful way, so she can notice her thoughts and her body sensations without judging them, bringing her mind back to breathing, or to noticing the equally present but less “alerting” body sensations she may be experiencing. For example I might ask her to do a mindfulness of breath exercise where, as she notices her mind wandering off to worries or concerns, I would ask her to gently notice that this has happened, acknowledge her mind for trying to help solve an insoluble problem, and bring her attention back to her breathing. I might ask her to notice body sensations including those that are uncomfortable and around the area of her most intense pain, taking care to be aware not only of the painful sensations she’s experiencing, but also associated body responses such as breath holding, or muscle tension. I might guide her to also be aware of a neutral but generally unloved area like her left earlobe (when did you last attend to what your left earlobe felt like?), or her navel. Because at the same time as she’s noticing the painful areas of her body, she’s likely to be trying hard to avoid “going there” with the result that her mind (trying really hard to help her protect herself) actually goes there more often! (don’t believe me? Don’t think of a big fat spider crawling down your shoulder – betcha did!!). Belinda can use the same approach when she’s trying to get off to sleep – by non-judgmentally noticing her body and what’s going on, she can be aware of what it feels like – but not get hooked up in alarming appraisals of what “might” happen. In a clinic setting I might ask her to use this same mindfulness approach when we’re doing a new exercise, or returning to a new activity. She could take time to really feel the movements, to be “in” her body rather than her head, and in doing so gradually reduce the tendency for her mind to take off in new and frightening directions.

Using the PCS is not about becoming psychologists: it’s about being aware of what the person in front of us is telling us about their experience, and then tuning into that and responding appropriately while we do what we do. Our job isn’t to replace a psychologist’s contribution – but to use the results of psychometric questionnaires to augment and support the work we do in a setting where people are actively engaged in learning about their bodies. I think that’s a priceless opportunity.

Schutze, R., Slater, H., O’Sullivan, P., Thornton, J., Finlay-Jones, A., & Rees, C. S. (2014). Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Frontiers in Psychology Vol 5 Aug 2014, ArtID 839, 5.

Tsui, P., Day, M., Thorn, B., Rubin, N., Alexander, C., & Jones, R. (2012). The communal coping model of catastrophizing: Patient-health provider interactions. Pain Medicine, 13(1), 66-79.

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Clinical reasoning “think aloud”


Occupational therapists are keen on helping people return to doing the things they value – meaningful activity, or participating in valued occupations (same thing, essentially). So, a person might come to see me because they have low back pain and want to work out how to get to work.

My first step is to understand what it is about the back pain that seems to be stopping the person from doing the tasks involved in their work. I usually begin by taking a history – what does the person understand about how their back pain came on, what’s their theory as to why it’s there, what have they done to help their recovery, how are they managing the everyday things they need to do right now. I ask about sleep, sex, personal care, daily routine, and in doing so I’m finding out about the person’s beliefs and attitudes towards their pain, their ability to regulate their arousal level, their mood, their confidence, the influence of others around them (both supportive – and those more subtle influences like their response when the person does something). I’m very careful to try to understand the contexts in which the person is having trouble – and what factors in the context might be supporting change.

In my mind I’m trying to establish a set of possible reasons for this person coming to see me at this time and in this way. I’m running through the various influences I know affect a person’s ability to engage in normal daily activities. Because I have a strong psychology background, I’ll consider functional behavioural analysis, but I’m also sensitive to personal values, cultural norms, and yes, even biological factors such as strength, range of movement, and motor control.

I can try to influence two things: the demands of the tasks in the context of work, and the capabilities of the person, but I need to keep a couple of things in mind.

  1. What is the effect of my intervention in the medium to long-term, not just the short-term?
  2. What does this person need in this context right now?

Depending on my clinical formulation, and the overall theoretical model I’m using, I can approach the decision-making in many different ways. As you’ve probably guessed, I’m a fan of Acceptance and Commitment Therapy, so my end goal is to help this person develop the ability to respond flexibly to the demands of any situation. I want to keep in mind that what I do now can have a long-term influence on what they’ll do over time. Some occupational therapists may instead focus primarily on “what will solve the problem for this person right now” without always thinking about the long-term impact.  As a result, we can see some people with low back pain being given special seating, perhaps a new bed, some adaptive equipment so they can achieve the goal of “doing” – but at the same time, being unaware of the constraints this can put on the person being able to participate in other contexts.

For example, if my client is having trouble getting to work because he thinks his car’s seat should be fixed. If my focus was purely on helping him drive his car in comfort, I could consider assessing his car and giving him some cushioning to make it more supportive. There, problem fixed! But, let’s take a look at the effect of that intervention in the medium term. While he can drive to and from work, he’s learned that he “needs” a special seat or cushioning to help stop his discomfort. He’s also learned that his back pain is something he “shouldn’t” experience.

Based on what he’s learned from my intervention, what do you think can happen if he continues to experience back pain in the work setting?

His personal model of pain will have developed a couple of interesting quirks (and ones we often see in clients) – he’s learned that posture influences his back pain, and that there is a posture that “fixes” it. He’s learned that he should have his back in a particular position to be comfortable. He’s also learned that because he can influence his sitting position in the car, he “should” be able to influence his sitting position in other contexts – like, perhaps, his office desk or the seat in his digger. He might even, if his belief that his back “should” be in a particular position is especially strong, begin to try to keep his back in this position while doing other activities like walking or carrying things, or using tools. Most insidiously, he has learned that his back pain is something he should not have. It’s a sign to him that he has to “fix” his sitting position or he’s doing something wrong. But back pain is common, many factors influence it, and it often doesn’t settle completely.

If I instead want him to be able to respond flexibly to many different settings, I’ll need to think more carefully about my intervention. My underlying reasoning has to capture the workability of any suggestions I make – and workability not just in the car while driving, but at work, while doing other tasks, at other times.

I may work together with him to find out what it is about the pain in his back that particularly bothers him. Pain itself is usually not the problem – it’s what the pain represents, the effect on doing things both here and now, and in the future. In my client’s case, perhaps his back pain is particularly frustrating for him because he values getting to work and feeling ready for anything. He doesn’t want to feel like his goals are being blocked (he doesn’t want to feel exhausted and not ready for work), he doesn’t want his back pain, and his mind is telling him he needs to be “ready for anything” even though he is in the middle of a bout of back pain. In ACT terms, he’s avoiding the negative feeling of frustration, of potential failure, of feeling exhausted and his back pain, and he’s doing what all humans do – trying to control those emotions so that he doesn’t feel them! Makes perfect sense – except that the solution (giving him a cushion for his vehicle) could pose its own problems.

I can position my intervention in a couple of different ways. Honouring the value he places on being ready for anything at work, I can talk to him about how well that’s working for him right now, given he’s having a bout of back pain. Could he be willing to allow himself to be less “ready for anything” while he recovers from his back pain? I could also suggest that he could take the time to be present to his back pain, to be aware of and experience his back – and his feet, arms, shoulders and breath – while driving to work, so that he can notice the times when it’s really bothering him, and when it bothers him less, and that along with his back pain he also has areas of comfort and strength. I could provide him with a cushion – but ask him to think about what happens when he has to sit in other chairs, and ask about the workability of carrying a cushion wherever he goes.

The point is that while occupational therapists can help people do the things they want and need to do, some of our efforts can constrain people’s options over time. We don’t live the lives of our clients – but sometimes we can assume the client’s priority is to solve an immediate problem, while overlooking the other competing values the person also holds dear.

I’ve included some readings that have informed this blog post – while they’re not directly referenced in my post, they help inform my clinical reasoning.

Damsgard, E., Dewar, A., Roe, C., & Hamran, T. (2011). Staying active despite pain: Pain beliefs and experiences with activity-related pain in patients with chronic musculoskeletal pain. Scandinavian Journal of Caring Sciences, 25(1), 108-116. doi: 10.1111/j.1471-6712.2010.00798.x

DeGood, Douglas E., & Cook, Andrew J. (2011). Psychosocial assessment: Comprehensive measures and measures specific to pain beliefs and coping. Turk, Dennis C [Ed], 67-97.

McCracken, Lance M., & Vowles, Kevin E. (2014). Acceptance and Commitment Therapy and Mindfulness for Chronic Pain: Model, Process, and Progress. American Psychologist, 69(2), 178-187.

Stenberg, Gunilla, Fjellman-Wiklund, Anncristine, & Ahlgren, Christina. (2014). ‘I am afraid to make the damage worse’ – fear of engaging in physical activity among patients with neck or back pain – a gender perspective. Scandinavian Journal of Caring Sciences, 28(1), 146-154. doi: 10.1111/scs.12043

Trompetter, Hester R., ten Klooster, Peter M., Schreurs, Karlein M., Fledderus, Martine, Westerhof, Gerben J., & Bohlmeijer, Ernst T. (2013). Measuring values and committed action with the Engaged Living Scale (ELS): Psychometric evaluation in a nonclinical sample and a chronic pain sample. Psychological Assessment, 25(4), 1235-1246.

van Huet, H, & Williams, D. (2007). Self-Beliefs About Pain and Occupational Performance: A Comparison of Two Measures Used in a Pain Management Program. OTJR: Occupation, Participation and Health Vol 27(1) Win 2007, 4-12.

softness

Why does “doing exercise” work?


Bless all the physiotherapists in the world, they keep us doing exercises. And exercises are good because they get us doing the things we want to do in our daily lives. But how does it work?  This is not an exposition on exercise physiology – I’m not au fait enough with physiology to do that and there are many other people out there with vast amounts of knowledge giving us the benefit of their wisdom who have written at length about exercise and why it’s important. Instead I want to talk about some observations – and maybe pose some critical questions too.

For many years I’ve worked in a chronic pain management centre where people with chronic pain attend a three week intensive pain management programme. Staff members from outside the Pain Management Centre (we were located as an outpatient facility on the grounds of a rehabilitation hospital) always told us they could spot a person with pain the moment they saw them wandering from our building to the main cafeteria: people walking slowly, sometimes limping, but often just walking very slowly towards the cafe.

Over the course of the three weeks, this group of people would go from this slow amble to walking briskly and attending the hydrotherapy sessions, doing a daily exercise session (circuit-style); and in the final week of the programme, catching a bus to the shopping centre, purchasing food, coming back and preparing a shared barbecue for friends and family. What a turn-around!

Now, I said I wasn’t going to talk about physiology and I won’t, but I WILL point out that three weeks is not a long time. It’s so little time that it’s impossible for muscle length and strength to change significantly. And yet movements (measured using the six minute walking test and timed up and go) were quicker. Postures changed. People looked more alert and took more notice of the world around them. The question of how it is that this group of people could go from being recognisably “pain patients” to people who could do everyday activities has to be asked.

There are a couple of points to make before I do my thing. Firstly, while the people attending the programme were undeniably uncomfortable, clearly slow in their movements, and most definitely disabled, they weren’t, by usual measures “deconditioned”. In other words, they were of pretty average fitness – and indeed, many had been attending daily gym sessions at the behest of a case manager and under the supervision of a physiotherapist for months! At the same time they were not DOING much and felt extremely limited in their capabilities.

The second point is that although the programme had two “exercise” sessions each day, these were not high intensity sessions! The aim in most cases was to help people establish a baseline – or a reliable, consistent quota of exercise that they could do irrespective of their pain intensity. Most of the work within the exercise sessions was to help people become aware of their approach to activity, to modify this approach, and to then maintain it. Movement quality rather than quantity was the aim.

Here’s where I want to propose some of the mechanisms that might be involved.

  1. Humans like to, and almost need to, compare their performance with other people. It’s not something we choose to do, it’s an innate social bonding mechanism and whether we then modify what we do to match others – or deliberately try to do the opposite to mark out our own stance – we’ve based our behaviour on having observed what’s “normal” around us. And this applies even when people develop disability (Dunn, 2010), but perhaps more importantly, may well be fundamental to how we experience our world – and ourselves (Santiago Delefosse, 2011). When a group of people meet, their behaviour rapidly becomes more similar – similar gestures, similar body positions, and similar facial expressions. I wonder if one of the mechanisms involved in change within a group of people who live with chronic pain is this tendency to mirror one another’s behaviour.
  2. Having proposed that mirroring is one mechanism of change, why don’t groups of people with chronic pain ALL remain slowed and showing pain behaviour? Well, another mechanism involved in behaviour change is operant conditioning. When a group is performing exercise under the supervision of a “wise and caring authority” (ie a physiotherapist), many reinforcements are present. There’s the “no, that’s not quite the right movement” response, and the “oh you did it!” response. The “you can do it, just push a bit more” response, and the “if you can do that, how about another?” At the same time people are set quota or “the number of repetitions” to complete within a timeframe. Simply recording what is happening is sufficient to change behaviour – just ask someone who is on a diet to record their food intake for a week and you’ll likely see some changes! But add to this a very potent response from the wise and caring physiotherapist, and you’ll get warm fuzzies for doing more, and possibly cold pricklies if you don’t try.
  3. And finally, and possibly the most powerful of all, is the process of confronting feared movements – and doing them. Doing them without “safety behaviour” and doing them to specifically confront the thing that makes them scary. And doing them in many, many different settings, so as to alter the tendency to avoid them because they’re scary. A recently published systematic review and meta-analysis of graded activity (usually based on operant conditioning principles, and perhaps on cardiovascular fitness training principles) compared with graded exposure (deliberately confronting feared and avoided movements in a whole range of different contexts) found that graded exposure more effectively reduces catastrophising than just doing graded activation. This shouldn’t surprise us – one of the mechanisms involved in disability associated with nonspecific low back pain is avoiding doing things because people are fearful either of further injury, or of being unable to handle the effects of pain.

Where am I going with this post? Well, despite the face validity of exercise for reducing pain and disability, it’s not the physiological effects that first produce results. It can’t be because tissues do not adapt that quickly. What does appear to happen are a range of social-psychological processes that influence whether a person will (or won’t) do something. What this means is two things:

  • Physiotherapists, and indeed anyone who helps people do movements to reduce disability, really need to know their psychological processes because they’re inherent in the work done.
  • Becoming expert at analysing what a person wants and needs to do, and in being able to analyse then carefully titrate exposure to the contexts in which things need to be done is vital. That’s fundamental to occupational therapy theory, training and expertise.

 

 

Dunn, D. S. (2010). The social psychology of disability. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology, (2 ed., pp. 379-390). Washington , DC: American Psychological Association

Lopez-de-Uralde-Villanueva, I., Munoz-Garcia, D., Gil-Martinez, A., Pardo-Montero, J., Munoz-Plata, R., Angulo-Diaz-Parreno, S., . . . La Touche, R. (2015). A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. doi:10.1111/pme.12882

Santiago Delefosse, M. (2011). An embodied-socio-psychological perspective in health psychology? Social and Personality Psychology Compass, 5(5), 220-230.

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.

jewels

Waitangi Day – or how to live together in unity


Today is New Zealand’s Waitangi Day ‘Mondayisation’ – the actual day was Saturday 6th Feb. It’s an important day in New Zealand because it’s the day when two completely different nations signed a treaty allowing certain rights between them – and allowed my ancestors to travel from Ireland and England to settle in the country I call my home. Unlike many country’s celebrations of nationhood, Waitangi Day is almost always a time of turbulence, dissension and debate. This is not a bad thing because over the years I think the way in which Maori (Tangata Whenua, or original settlers) and non-Maori settlers (Tangata Tiriti) relate in our country is a fantastic example of living together well. Not perfectly – but certainly in a more integrated way than many other countries where two completely different cultures blend.

Thinking of Waitangi Day, I’m reminded of the way in which the multidimensional model of pain attempts to integrate biological, psychological and social factors to help explain this experience and how such a primitive response to threat can ultimately lead to adaptation and learning – in most cases – or the most profound misery and disability in others.

Like the treaty relationship in New Zealand, there’s much room for discussion and debate as to the relative weight to place on various components of the model.  And like the treaty relationship, there are times when each part is accused of dominating and not giving the other/s due credit. Truth, at least to me, is, we need all of us (and all the factors) to integrate – not to become some bland nothing, but to express the components fully.

Just last week I was astonished to find that a clinician thought that I believed low back pain is “psychological”. Absolutely astonished because this has never been my position! While this blog and much of my teaching and reading is around psychological and more recently social factors influencing pain and disability, my position has never been to elevate the influence of these factors over the biological. I suppose I shouldn’t be surprised – it’s hard to deal with the state of play in our understanding of low back pain which finds that many of the assumed causal mechanisms (like disc prolapses, poor “core” muscles, the biomechanics of lifting and so on) just don’t apply. It’s also really difficult to know that so far there are no particular exercise treatments that work more effectively than any other. Cognitive dissonance anyone? Just because these factors are less relevant than presumed does not mean that (a) I think low back pain is psychological and (b) that all biological factors are irrelevant. What it does mean is that we don’t know. I’ll say that again. We. Don’t. Know. Most back pain falls into this “nonspecific” group – and by calling it “nonspecific” we are actually admitting that We. Don’t. Know.

How do people assume that because I point out that we don’t know the causal mechanisms of low back pain but we DO know the critical importance of psychosocial factors on disability associated with low back pain – and the treatments that can mitigate these factors – that I believe back pain is psychological? I think it’s a simple fallacy – some people believe that because a person responds to psychosocial interventions this therefore means their problem is psychological. This is not true – and here are some examples. Exercise (a physical modality) is shown to be an effective treatment for depression. Does this mean depression is a purely biological disorder? Biofeedback provides visual or auditory information related to physical aspects of the body like blood pressure, heart rate, and muscle tension – does this mean that blood pressure is “psychological”? Diabetes management often includes learning to resist the urge, or “urge surf” the impulse to eat foods that increase blood sugar levels – does this mean diabetes is psychological?

Here’s my real position on nonspecific low back pain, which is let me remind you, the most common form of low back pain.

Causes – not known (Golob & Wipf, 2014), risk factors for onset are mainly equivocal but one study found the major predictor of an onset was – prior history of low back pain, with “limited evidence that the combination of postural risk factors and job strain is associated with the onset of LBP” (Janwantanakul, Sitthipornvorakul,  & Paksaichol, 2012), exercise may prevent recurrence but mechanisms of LBP remain unclear (Macedo, Bostick and Maher, 2013), while subgroup analysis carried out by therapists were “underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting” (Mistry, Patel, Wan Hee, Stallard & Underwood, 2014).

My take from this brief review? The mechanisms presumed to be involved in nonspecific low back pain are unknown.

Treatments – mainly ineffective but self-management provides small effects on pain and disability (moderate quality) (Oliveira, Ferreira, Maher, Pinto, Refshauge & Ferreira, 2012), “the evidence on acupuncture for acute LBP is sparse despite our comprehensive literature search” (Lee, Choi, Lee, Lee, Shin & Lee, 2013), no definitive evidence supports the use of orthoses for spine pain (Zarghooni, Beyer, Siewe & Eysel, 2013), acetaminophen is not effective for pain relief (Machado, Maher, Ferreira, Pinheiro, Lin, Day et al, 2015), and no specific exercises are better than any other for either pain relief or recovery – not even motor control exercises (Saragiotto, Maher, Yamato, Costa et al, 2016).

My take from this set of references is that movement is good – any movement, but no particular form of exercise is better than any other. In fact, the main limitation to exercise is adherence (or actually continuing exercising after the pain has settled).

The factors known to predict poor recovery are pretty clear – catastrophising, or thinking the worst (Kim, Cho, Kang, Chang, Lee, & Yeom, 2015), avoidance (usually arising from unhelpful beliefs about the problem – see commentary by Schofferman, 2015), low mood – which has also been found to predict reporting or treatment seeking of low back pain (see this post from Body in Mind, and this one).

What can I take from all of this? Well, my view is that because psychosocial factors exert their influence at multiple levels including our nervous system (see Borkum, 2010), but also our community understanding of what is and isn’t “illness” (Jutel, 2011) and who to see and what to do about it, the problem of nonspecific low back pain is one of the purest forms of an integrated biopsychosocial and multifactorial health concern in human life. I therefore rest my case: nonspecific low back pain is not psychological, but neither is it biomechanical or biological only. It is a biopsychosocial multifactorial experience to which humans are prone.

The best we can do with our current knowledge base is (1) limit and avoid the use of nocebic language and attempts to explain low back pain via biomechanical or muscle control mechanisms, (2) be honest about the likelihood of low back pain recurring and our treatments essentially doing very little, and (3) encourage return to normal activity by doing normal activity including exercise. Being honest about the state of play in our knowledge is a good starting point for better understanding – sounds a lot like race relations, doesn’t it?

 

Borkum, J. M. (2010). Maladaptive cognitions and chronic pain: Epidemiology, neurobiology, and treatment. Journal of Rational-Emotive & Cognitive Behavior Therapy, 28(1), 4-24. doi:http://dx.doi.org/10.1007/s10942-010-0109-x

Golob, A. L., & Wipf, J. E. (2014). Low back pain. Medical Clinics of North America, 98(3), 405-428.

Janwantanakul, P., Sitthipornvorakul, E., & Paksaichol, A. (2012). Risk factors for the onset of nonspecific low back pain in office workers: A systematic review of prospective cohort studies. Journal of Manipulative & Physiological Therapeutics, 35(7), 568-577.

Jutel, A. (2011). Classification, disease, and diagnosis. Perspectives in Biology & Medicine, 54(2), 189-205.

Kim, H.-J., Cho, C.-H., Kang, K.-T., Chang, B.-S., Lee, C.-K., & Yeom, J. S. (2015). The significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 238-246. doi:http://dx.doi.org/10.1016/j.spinee.2014.09.002

Lee, J. H., Choi, T. Y., Lee, M. S., Lee, H., Shin, B. C., & Lee, H. (2013). Acupuncture for acute low back pain: A systematic review. Clinical Journal of Pain, 29(2), 172-185.

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. BMJ, 350, h1225.

Mistry, D., Patel, S., Hee, S. W., Stallard, N., & Underwood, M. (2014). Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: A systematic review. Spine, 39(7), 618-629.

Oliveira, V. C., Ferreira, P. H., Maher, C. G., Pinto, R. Z., Refshauge, K. M., & Ferreira, M. L. (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64(11), 1739-1748.

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).

Schofferman, J. A. (2015). Commentary on the significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: Mediation analysis with bootstrapping. The Spine Journal, 15(2), 247-248. doi:http://dx.doi.org/10.1016/j.spinee.2014.11.003

Zarghooni, K., Beyer, F., Siewe, J., & Eysel, P. (2013). The orthotic treatment of acute and chronic disease of the cervical and lumbar spine. Deutsches Arzteblatt International, 110(44), 737-742.

Brandywine Falls

Who can do Cognitive Behavioural Therapy for Rehabilitation?


I have heard many discussions about scopes of practice: the main concern as far as I can see is of people who are trained to work mainly with the body perhaps stepping out of scope to work with thoughts, beliefs, and emotions. There are risks from stepping too far away from what you’re trained to do, I acknowledge this, though I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge.  And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance.

When I read about a post-surgical rehabilitation approach for people who had spine surgery, I was immediately interested and not because of the surgery! This study compared “cognitive-behavioural based physical therapy” with an education programme six weeks after laminectomy for a lumbar degenerative condition. People were included in the study if they reported high fear of movement using the Tampa Scale for Kinesiophobia. Assessments were completed before treatment, after treatment and at a 3 month follow-up, and included the Brief Pain Inventory, Oswestry Disability Index, SF-12, and three performance tests (5-chair stand, timed up and go, and 10 metre walk).

There was no discussion about the physical rehabilitation, but the CBT and education sessions were conducted by phone and participants also received a workbook to take home and follow. Sessions took 30 minutes, except the first session which was for one hour. The main components of the programme are reported as education on the mind-body connection, activity levels, graded activity plan (graded hierarchy) and weekly activity and walking goals. A cognitive or behavioural strategy was introduced in each session, with the therapist helping patients identify enjoyable activities, replace negative thinking with positive thoughts, find a balance between rest and activity, and manage setbacks by recognising high-risk situations and negative thoughts.

The education sessions included the usual contents delivered by a physiotherapist, and featured biomechanics, daily exercise, and ways to promote healing. Information on stress reduction, sleep hygiene, energy management, communicating with health providers and preventing future injury were also provided.

What did they find?

Firstly, only 68% of those eligible for the study agreed to take part, which in itself is interesting. A number of other factors influenced the total number of people entered into the programme – not being treated for a degenerative lumbar condition, not having high enough scores on the TSK were the main reasons. Dropout rates for both programmes were quite low – 7 – 5%, and both programmes had good follow-up outcomes (not too many people missed the follow-up).

Now here’s a thing: 91% of participants also received clinic-based physiotherapy during the treatment phase (roughly 8 visits), and right up until the three-month follow-up (about 6 – 7 visits). No real difference between the groups here.

What did differ was the long-term improvement in the cognitive behavioural group – in terms of back and leg pain, pain interference and disability. The education group still improved in their leg pain and disability, but back pain and pain interference stayed the same. Similarly, the CBT group continued to improve on measures of physical and mental health over time, while the education group’s physical scores improved but mental health scores stayed pretty much the same. The CBT group’s scores improved more than the education group on almost all the measures including the physical performance tests.

What does this mean?

Well, interestingly, the authors of this study suggest that they obtained large and clinically relevant changes because of the specific focus they had on decreasing barriers to functional activity and walking rather than focusing solely on resolving pain symptoms. I think this is very interesting indeed. Although this study used physiotherapists, the clinician was naive to using CBT and was trained specifically for this study. Participants received concurrent physiotherapy in a clinic – the CBT (and education sessions) were additional to what was delivered in the clinic setting. To me the results suggest that the occupational therapy focus on creating opportunities for people to do more within their own environment might be a potent tool in post-operative rehabilitation.

Once again, it also suggests that the professional discipline of the clinician delivering a CBT approach is far less important than the fact that the CBT approach is tailored to the concerns of the patient, and that the treatment targets factors within the real-world context.

Important points to note: these patients were selected on the basis of high levels of pain-related fear and avoidance. I don’t think the outcomes would be nearly as fabulous in a general or undifferentiated group. This approach, while relatively inexpensive to implement, is an added cost – though if we look at the effect on patient outcomes, I would argue that the financial cost is far outweighed by the positive human results.

Finally, I think this study also shows that addressing thoughts, beliefs and emotions is a part of what every health professional should be doing: it’s unethical not to learn to do this well.

Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips S, George SZ, McGirt ML, Spengler DM, Aaronson OS, Cheng JS, Wegener ST, Cognitive-behavioral based physical therapy
for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.09.013.