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Your patient has psychosocial risk factors: what now?


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

Do you…

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

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

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

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

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

What would you do?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Making first contact: What to do with all that information! part 2


Last week I described some of the reasons for using a case formulation approach when working through initial assessment information, and today I’m going to describe one approach for organising a formulation. This is the “4 P” formulation, and it’s one that’s often used in mental health (Bolton, 2014).

In the 4 P model, there are four questions to ask yourself:

  1. Preconditions – Why is this person vulnerable to this problem?
  2. Precipitating factors – Why now? This can mean “why is this person having symptoms now?” or “why is this person presenting to this person for treatment right now?”
  3. Perpetuating factors – Why is this person still ill?
  4. Protective factors – Why is this person not more ill?

Remembering that people are whole people, and that pain is always multifactorial, this formulation approach incorporates diagnostic information (disease) alongside a person’s response to disease (illness). The two facets of “being unwell” go together – but not synchronously. We can have a disease and be oblivious to it (think of many forms of cancer, hypertension, Type 2 diabetes, osteoarthritis…and even Covid-19). Once we begin to experience symptoms and decide that this is not “normal” we call it illness. And if symptoms and signs begin to impinge on what we can and can’t do in life, we can call this disability or functional limitations. These in turn (more or less) influence participation in community life. The relationships are not straightforward, and this is partly why a formulation can be so helpful. Formulations help us explore – in collaboration with the person – why is this problem such a problem? – whether it’s simply the presence of pain, or more related to the disability and distress that pain is posing for the person.

Preconditions include biological factors such as gender, ethnicity, and age. Preconditions also include psychological factors such as previous experiences in life, prevailing beliefs, emotional reactivity, and attention. Social factors such as employment status, social connection, stigma, socio-economic status, family and living situation are all contributors to a person’s vulnerability to the problem they’re presenting with. In our pain formulations, we know about many of these preconditions that make the people we see vulnerable to having trouble with their pain.

Precipitating factors can be considered in several ways. I like to consider behavioural antecedents for seeking help – what’s been happening in the immediate weeks before a person seeks help – as well as antecedents to the onset of symptoms. For example, people might wait for some weeks before seeking help for a back pain because “it usually settles down” – and this suggests to me that their current episode hasn’t settled down, and they have some thoughts or worries about why. Others might be seeking help because of insurance or workplace requirements where, if they don’t seek help and have the problem recorded, they may not get cover for treatment if the problem reoccurs. Some might be seeking help because their partner or family member is worried, or because they read something in the media or online. I also ask about what was happening at the time the symptoms started. Sometimes this is about an unusually busy time (at work or home), a change in activity level, a new tool or piece of equipment, a new manager or coworkers, perhaps a new daily routine, or a change in living circumstances. While these factors may not be directly causal (biologically) the meaning of these events is valuable because they inform me of the person’s beliefs about their problem.

Perpetuating factors are again, multifactorial and often unrelated to the factors that precipitated the problem. There could be factors associated with disuse influencing changes to the tissues and neurobiology; there could be steps the person has taken to deal with the problem that impact on how quickly it resolves such as using NSAIDs or strapping/wrapping, wearing splints, changed movement patterns. Some of the factors are likely to be beliefs about what’s going on and what should be done about it – like “all the pain must be gone before I start back at work”, or “it’s damaged so I need surgery”. Others could be instructions from people (or held in the community at large) about what to do, like resting, moving in particular ways, or when to seek treatment. Some can be how others respond to the person, like getting irritated because the person isn’t 100% “yet”, or mollycoddling the person (wrapping them up in cottonwool and not letting them do things again). Workplace factors like policies not allowing a person back “until fully fit” or “there are no light duties” also contribute to trouble resuming normal activities.

Protective factors help explain resilience, or strengths the person has that help them maintain well being in the face of this problem. They can be attitudes and practices of the person like believing the body is good at recovering, or maintaining healthy eating and sleeping. They may be factors such as the person’s age, gender, general health. They can include the ability to get to and from treatment (and pay for it), the person’s social supports, their relationships with other health professionals, perhaps strategies they’ve used for other problems (including similar ones to this event) that they haven’t thought to use for this one.

The 4P approach has multiple variants. Some include “the Problem” and call it a 5P model. Some are explicitly tied to a theory of human behaviour (such as a CBT model, ACT model or applied behaviour analysis). Some are entirely developed from the person’s own words and experiences, while others draw on reports from other team members, or previous interactions. The over-riding themes of all of these are that a formulation is developed in collaboration with the person, and considers the whole person in their own usual context.

Next time I’ll look at another formulation approach, and discuss it in relation to teams and how they might use it to form a “team model” of pain and musculoskeletal problems.

Bolton, J. W. (2014). Case formulation after Engel—The 4P model: A philosophical case conference. Philosophy, Psychiatry, & Psychology, 21(3), 179-189.

Cox, L. A. (2021). Use of individual formulation in mental health practice. Mental Health Practice, 24(1), 33-41. https://doi.org/http://dx.doi.org/10.7748/mhp.2020.e1515

Farmer, R. F., & Chapman, A. L. (2016). Behavioral case formulation and treatment planning. In Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action (2nd ed.). (pp. 53-100). https://doi.org/10.1037/14691-003

Gilbert, P. (2016). A biopsychosocial and evolutionary approach to formulation. In Tarrier, Nicholas [Ed]; Johnson, Judith Ed Case formulation in cognitive behaviour therapy: The treatment of challenging and complex cases , 2nd ed (pp 52-89) xvii, 384 pp New York, NY, US: Routledge/Taylor & Francis Group; US (pp. 52-89).

Making the first contact


How do we begin working with someone who is asking for help with their persistent pain? In this post I’ll describe some of the considerations I have when I begin, because as Benedetti points out, the “meet the therapist moment” is one of the most potent times in the therapeutic ritual (Benedetti, 2011). It’s the time when the person’s expectations and the clinician’s empathy and competence meet, and the “meaning response” blooms.

My two clinical questions are:

  1. Why is this person presenting in this way at this time, and what’s maintaining their predicament?
  2. And what is this person’s main concern?

But before I ask these questions, I want to take a moment to think about the person and what might be going on in his or her mind.

Benedetti points out that expectancies are an important part of a response to treatment – whether that treatment has any active action, or not. Expectancies are about what a person brings to a therapeutic encounter: there are two, one is stimulus expectancies (anticipations of external events – eg that the next painful experience will be less), and the other is response expectancies (predictions of your own nonvolitional response – eg that after doing this thing, I expect to experience less pain) (Kirsch, 1985).

People who come to see a clinician, especially a clinician from a little-known profession (occupational therapy!) will hold expectancies about what that person will do, but these will likely be weaker than the expectancies a person might hold about seeing a well-known profession. The strength of an expectancy is different from the direction of an expectancy – for example, a negative experience with a physiotherapist might lead to a strongly negative expectancy about future treatments, while not having had an experience with an occupational therapist might lead to a weakly positive expectancy about what’s about to happen.

Along with expectancies, the person will likely be anxious about what’s to come. The possibility of something that might help (or not), meeting a new clinician, and living with pain are all stressors – and anxiety erodes a person’s ability to absorb lots of information, while biasing them towards remembering threatening words (Reidy & Richards, 1997).

So there’s a lot going on in the person’s mind when they attend that first session.

There’s also often a large power imbalance (Joseph-Williams, Edwards & Elwyn, 2014). This emerges from the fact that often clinicians hold a lot more information about the person we’re seeing than they do about us. Especially after we’ve asked a bunch of questions, often quite intimate in nature. For a person seeking help, this imbalance can make it hard to ask questions, to direct the conversation, to hold a sense of independence throughout the encounter.

So having set the scene for you, I’m sure you can agree that how we go about collecting information from a person is incredibly important – especially so that relationship can begin to build.

Introductions

In the introduction, I seek to give the person some information about who I am – not just as a clinician, and the kind of treatments I use, but also about who I am. I’ve drawn inspiration from tikanga Māori here, where the cultural tradition entails letting the person know where I come from and who I’m connected to. I like to let people know my childhood roots are in Turanganui a kiwa, or Gisborne. That the mountain my heart connects with is Mount Hikurangi – the first mountain in NZ to see the sun. The river I connect with is the Taruheru, flowing into the sea in Gisborne. I also let people know my whanau connections – the Lennox’s, and the Thompson’s, are my whanau (extended family), and I’m a 5th generation New Zealander. I now live in Otautahi/Christchurch. This introduction only takes a few minutes, and your culture might not value this form of introduction. For me in Aotearoa/New Zealand, it’s one way I can show respect and follow a tradition that means the person I work with knows something more about me than just my name.

I also include my profession – what I do. I’m an occupational therapist, my job is to help people do what matters in their life contexts.

I like to then let the person know that they’re brave and courageous for seeking help – it’s not easy to say you can’t do this on your own. It takes courage to tell someone that.

Questions

Then I open with a broad question about what has led this person to come to see me. I might add in something about “tell me about your pain and what you’ve done so far for it.” I’ll often ask what their theory is about their pain, what they think is going on.

Then I ask “What is your main concern today?”

Throughout this process I’m reflecting what I’ve heard, to ensure I’ve understood what the person has experienced. I’m NOT giving reinterpretations, I’m NOT giving out new information, I’m just listening.

I often spend time asking about four areas of life: relationships, fun, work, and health. Or I might ask the person to take me through a typical day, from the time they wake up.

I like to find out not just what the person has done to help themselves, but also what they’ve learned from these experiences. The messages they’ve received over time, and the things they’ve tried but perhaps didn’t like or that didn’t help.

Questionnaires

I was a big fan of questionnaires filled out ahead of time, and I am still a fan but don’t use them as much. This is mainly because so many people have filled out endless questionnaires and nobody has sat down with them to talk about what they mean! So I’m a little more selective and focus much more on listening first then choosing something that will offer me and the person some insight into what might be going on. For example, I might choose the PASS20 (McCracken & Dhingra, 2002) because it helps me figure out where to begin with reducing pain-related anxiety. It’s a good measure to use each week to track changes over time, and I’m beginning to delve into repeated measures of progress rather than a pre-post-follow-up approach that’s typical.

Observation

Covid has meant it’s not as easy to carry out observational assessments, but I’m always watching how the person sits, moves, walks, and body language. What I’m not doing is interpreting these observations without talking to the person about them! Too many clinicians make judgements about the person based on maybe one or two observations, out of context of the person’s life and environment, and without checking in with the person to work out what might be contributing to what they see. Let’s not do that – the person might be completely oblivious that they’re guarding their sore hand, or they keep shifting in the chair, or that a habitual movement like taking a jacket off might be easier to do than being asked to perform some weird movement at the command of the clinician!

Pulling it all together

Just as we wouldn’t expect to be marched in for surgery straight after our first consultation with an orthopaedic surgeon, I don’t believe it’s OK to offer something to a person on their first visit just because we feel internal pressure to do so. Having said this, I will often suggest to the person that they spend a bit of time doing some brief “noticing without judging” exercises. We’ll give it a go at this first appointment, so they’re not being expected to go do it without knowing how. The reason I start with brief noticing experiments is that it’s something we could all do more often, it gives the person a new skill (usually) to develop, and it’s often an introduction to being fully present without judging. Being fully present without judging is hard to do when you’re sore because the mind likes to anticipate how bad it’s going to be (“you’ll need to take it very quietly or you’ll pay for it”) or remember previous pains (“last time you just sat around your pain went nuts, you don’t want to risk that now do you?”).

Notes/Documentation

I write conversational notes directly to the person, going through what we’ve talked about and pulling together all the information I’ve gathered in this first meeting. I find it helps me to make sense of what’s going on, it allows me some time to reflect on what I’ve observed and heard, and I can assemble it in a case formulation that the person and I can explore if/when we meet again.

Assessment is never over. Every time I meet with a person I’ll be learning more about what’s going on. I don’t feel pressured to “find it all out” at that first session just because there are goals that must be developed. In fact, one goal I leave in for everyone is “develop goals” (well, I don’t use goal language – it’s more about directions and actions that take you there). Because seriously, how can anyone meet someone and immediately develop goals – that’s disrespectful to the person who may not have had time to think about what matters the most, and it’s disrespectful to the complexity of goal setting as a process anyway.

Theme and variations

I’ve written one approach I use for learning about the person I’m trying to help. There are others – a time line, drawing a life map, mind-mapping, walking and talking, making a coffee – all of these and more can be used to explore the same information.

Let’s not call it “the subjective” – let’s call it what it is, our first “getting to know you” meeting.

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189–1202.

Joseph-Williams, N., Edwards, A., & Elwyn, G. (2014). Power imbalance prevents shared decision making. Bmj, 348.

McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research & Management, 7(1), 45-50.

Reidy, J., & Richards, A. (1997). Anxiety and memory: A recall bias for threatening words in high anxiety. Behaviour Research and Therapy, 35(6), 531-542.

Looking beyond the immediate


When I graduated as an occupational therapist, I was told that my profession was “problem-solving” and “motivation”. At the time (early 1980’s) Lela Llorens‘ problem solving process was the fundamental approach taught during our training. This approach is straightforward: identify the problem, identify solutions, select a solution, implement the solution, and review. I’m not sure if this approach is still taught but it’s stayed with me (and those memories of painstakingly completing the problem solving process documentation…).

There’s one small step that I think is either not fully articulated, or maybe gets lost in the iterative process of identifying solutions, implementing them and reviewing: and that’s the process of identifying contributors to the problem. Let me take you through a case study as an example.

Luke is in his mid-20’s with widespread pain. He’s off work, and his diagnosis is “fibromyalgia”. It started when he hurt his back working on cars (he’s a true petrol-head!) about a year ago, and now his pain dominates his life as he finds his pain has permeated his body. He doesn’t know what’s wrong with him, and thinks that his pain is because someone didn’t “fix” him when he first hurt his back.

The main thing he wants to be able to do is get back to driving and working on cars. It’s all he’s ever wanted to do, apart from play computer games, and he’s most happy at the moment when he’s watching motor racing on the net, preferably with a can of some high-sugar, high caffeine drink and a bit of weed. He otherwise doesn’t smoke tobacco, drinks on occasion, but he’s isolated and feels at a loose end.

The referral to an occupational therapist read “Luke wants to get back driving, will you assess, and provide appropriate intervention?” Implied, but not explicitly stated in the referral is that if Luke can return to driving, it will help him in his job search. Luke isn’t terribly interested in returning to work right now, because his focus is on what’s wrong with him and driving for fun.

The occupational therapist saw Luke, and assessed his ability to sit in the car, reverse the car, and drive over normal highway conditions. She thought he needed a seat insert so he was more ergonomically positioned, and she also thought that he could do with a better chair in the lounge because he usually sat slouched on the sofa playing his video games.

So she found him a suitable cushion and ergonomic backrest for his car, and he was also provided with chair raisers to lift his sofa up, and some cushions behind him so he was in a more upright position.

Luke was happy with the changes, though secretly a bit worried that his mates would think he was soft if he had a special seat cushion, and that old people used chair raisers, so he wasn’t at all keen on them in his lounge. But he took them anyway.

Job done.

Oh really? Yes, the occupational therapist addressed his seating and yes, he can now drive a bit more comfortably and even play his video games and watch TV, but did she really identify the problems?

You see, she identified the problem as “Luke can’t drive the car”, and she even dug a little deeper and identified that “Luke can’t drive the car or play his video games because he’s in pain.”

And that much is true – he was sore, told her he was sore, and pointed out that the position he used in the car and on the sofa was the same.

The problem is that – that wasn’t the problem.

There were a few more questions the therapist could have asked if her focus went beyond the immediate “problem” and she unpacked the next question which might have been “why is pain such a problem for Luke, and why is it getting in the way of Luke’s driving?” She might have added another question too – “why is Luke presenting in this way at this time, and what is maintaining his situation?”

Luke is a fictitious character, but “Luke’s” are everywhere. People who present with problems of occupational performance, but the problems contributing to those problems are the real issue. And yet, I’ve seen so many occupational therapy reports recommending “solutions” for similar problems that solve very little and probably compound the problem.

Where did our fictitious occupational therapist go wrong? Well, included in the problem solving process (and the variants developed since then) is a section called “assessment”. What exactly should be assessed in this part? Of course the assessment components will differ depending on the model of “what’s going on” held by the occupational therapist. When a simplistic biomechanical model of pain is being used, all the understanding of Luke’s values and beliefs, all the importance he places on being able to drive, the environment (his car seating, his sofa) – so much of what’s commonly included in an occupational therapy assessment might have very little to do with the problems Luke is having in daily occupation.

Leaping in to solve the problem of being able to drive focuses our minds on that as the key problem – but what if we looked at it as a symptom, or an expression of, other problems? This means, as occupational therapists, we might need to do a couple of things: firstly, we might need to assess more widely than “driving” or even “sitting” as the occupational performance problem. While referrers use this kind of approach to ask us to help, it doesn’t do much for our professional clinical reasoning. It tends to anchor us on “The Problem” as defined by someone else.

Even being person-centred, and asking Luke what he needs and wants to do may mislead us if we forget to look at the wider impact of pain on daily doing. If, as occupational therapists, we’re ignorant of the bigger picture of what’s going on when someone is disabled and distressed by their pain. If we forget that there are underlying processes we are well-equipped to deal with. If we forget the wider body of research into pain as an experience.

Perhaps occupational therapists could take some time to think about our contribution to the pain management team. I’ve been banging on about our knowledge translation skills, our awareness of context and how much daily life context differs from a gym or a clinic or an office. I’m not seeing that knowledge being demonstrated by occupational therapists in practice. What I’m seeing are stop-gap solutions that skim the surface of how pain impacts a person’s daily doing.

If occupational therapists recognised what our profession can offer a team, we might look at how someone like Luke could benefit from our in-depth assessment of what he thinks is going on, of how he communicates when he’s seeing other health professionals, of how he’s coping with his pain and how these strategies are taking him away from what matters in his life. We’d look at not just his occupational performance, but also those pain-specific factors well-established in research: his beliefs, his attitudes, his emotional responses, his social context, his habits and routines, his way of processing what he learns from others. We’d begin to look at him as a whole person. We might even look at how he’s integrating into his daily life all the things other clinicians in the team are offering.

Occupational therapy is a profession with so much to offer AND we need to develop our confidence and knowledge about what we do and about pain. We need to step outside of the narrow focus on “finding solutions and implementing them” and extend our assessments to identify the problems contributing to occupational performance difficulties.

What do occupational therapists add to pain management?


I’ve struggled with professional identity from time to time, but after completing my PhD thesis looking at how people live well with pain, I’ve developed a new understanding of how occupational therapists add value in this area of practice.

Occupational therapists joke that “no-one knows what an occupational therapist does” – and sadly, that’s true. It’s not because what we do isn’t important, it’s because our view of people and the way we work with people differs from most health professions. Occupational therapists don’t treat disease per se, we work with people’s function and participation, with a person’s illness experience. We don’t fit inside a biomedical, disease-oriented model of humans.

This means an occupational therapist works with people using a process-oriented approach. This approach begins by understanding what a person values, what matters in their life, and how the person’s life context influences their participation. Occupational therapists are concerned with the daily minutiae of life: the way you clean your teeth, how you get to work, what you do for fun, the roles you undertake, the daily routine you follow, the things that make your life your own – not a facsimile of someone else’s.

In pain management/rehabilitation, occupational therapists are there to help people resume, or begin, a life that looks like their own. To integrate strategies into daily routines and habits. To contextualise the strategies other professionals introduce. We’re the professional who talks about the timing of exercise/movement practice – how to fit exercises into each day without compromising other important routines. The details of when and where and how exercises are done in the long term, for life, in life. We encourage people to look beyond the simple 3 x 10 and into the kinds of movement opportunities that hold meaning beyond the “it will help your pain”.

Occupational therapists translate what happens in clinic settings into the real, messy, chaotic and unpredictable worlds of the people we serve. When someone is learning to develop self compassion, occupational therapists work out what this might look like in the context of being a good father, or an efficient employee. When someone is developing effective communication skills, occupational therapists are there to review when, where and how these skills are brought into play with the kids, the uncle, the neighbour, the colleague. When someone needs to learn to down-regulate a sensitive nervous system, occupational therapists are there to help assess each setting, noticing the sensory load of a situation, problem-solving ways to remain engaged in what’s important without withdrawing or overloading.

When someone’s afraid of a movement, occupational therapists go into the real world to help that person begin to do that activity – our skills are there to titrate the level of difficulty not just around biomechanical demands, but also social, interpersonal, sensory, and cognitive loads. Ever wondered why a person can manage something really well in the clinic – but can’t do the groceries, go to a restaurant, stay with friends overnight, anywhere where the demands are different? Occupational therapists can help figure out why.

For those that don’t know, my profession has been established since the days of 1793, when Phillipe Pinel began what was then called “moral treatment and occupation”, as an approach to treating people with mental illness. In the US, a National Society for the Promotion of Occupational Therapy (NSPOT) was founded in 1917, and continued through the 1920’s and 1930’s until the Great Depression. Occupational therapy became more closely aligned with medicine as part of a rehabilitation approach to recovery with wounded soldiers, those with TB (in New Zealand especially), and those with chronic diseases. In fact, occupational therapy was a registered and protected health profession in NZ since 1945 (before psychology).

It was during the 1980’s and 1990’s that the profession began questioning the medical model – and during my training in the early 1980’s, Engel’s biopsychosocial model was promoted as an over-arching approach to viewing people. So for occupational therapists, this is our practice philosophy: to look at the whole person in context.

Occupational therapists are fully trained across both physical and mental health. Our profession is one of the very few that has retained this “whole person” model of health from its inception. The value of doing, being and becoming is at the centre of practice. The appreciation that people live in a physical and social context, and that people have biopsychosocial, cultural and spiritual aspects is central to practice.

Pain is a human experience that spans the biological, the psychological, the social, the spiritual. Pain can influence all of life. When life has lost meaning because it doesn’t look like the life a person had before pain – this is where occupational therapists practice the art and science of our work.

Why are there not more occupational therapists in pain rehabilitation?


A question I’ve asked myself many times! As a small profession with a long history (as long as physiotherapy, TBH), it does seem odd that there are many, many pain rehabilitation services where never an occupational therapist has darkened the door.

Some of the reasons lie within the profession: in general, occupational therapists are busy being clinicians and have little time for research. In New Zealand, few occupational therapists pursue higher degrees, and many avoid statistical analyses, experimental design, randomised controlled studies. In fact, some occupational therapists have argued that the tailored approach used by therapists means randomised controlled trials are impossible – our interventions too complex, too individualised.

And it is difficult to describe occupational therapy in the kind of broad terms used to describe physiotherapy (movement), psychology (mind, emotions, behaviour), medicine or nursing. Occupational therapists often deal with the everyday. Things like organising a day or a week, getting a good night’s sleep, returning to work, managing household activities. Not sexy things with technical names!

So… what does a good occupational therapist offer in pain rehabilitation? These are only some of the things I’ve contributed over the years:

  • graded exposure in daily life contexts like the shopping mall, supermarket, walking at the beach, fishing, catching a bus, driving
  • self regulation using biofeedback, hypnosis, progressive muscle relaxation in daily life contexts like getting off to sleep, at work in between clients, while doing the grocery shopping, while driving
  • effective communication with partners, children, employers, co-workers, health professionals in daily life contexts
  • guided discovery of factors that increase and reduce pain in daily life contexts like the end of a working day, over the weekend, at the rugby, in the pub, on your own, in a crowd, at home
  • information on proposed neurobiological mechanisms as they influence pain and doing/participating in daily life contexts, things like attention capture, distraction, memory, emotions, stress, excitement
  • values clarification about what is important to a person’s sense of who they are in their daily life
  • progressive meaningful movement in daily life contexts
  • goal setting, planning, managing and progressing overall activity levels in daily life
  • positive, pleasurable activities to boost mood, reduce anxiety and live a life more like the person wants

What characterises all that I offer? It’s context. One of the major challenges in all our pain rehabilitation is that people feel safe when in safe surroundings, with people who elicit feelings of safety. When things are predictable – like in a clinic setting – and when clinicians are present, people feel OK to do things they simply can’t do (or won’t do) elsewhere.

Life is complex. Contexts are highly variable, often chaotic, multiple demands on attention, priorities, values – and when a skill is developed in a controlled environment, like a clinic or office, it’s nothing like the real world. This, folks, is the unique contribution of a good occupational therapist.

Someone posted an image once, on the one side was physical therapy. On the other was psychology. And the question was posed: who bridges the gap between these two professions? I say definitively that this is the occupational therapy space. We are knowledge translators. We are the bridge between clinic and daily life. It is our domain, the entire specialty area of this profession. And it has been since the professions’ inception, way back in the early 1900s.

There are occupational therapists who let us down. These are the therapists who focus exclusively on occupational participation without factoring in that we are also a rehabilitation profession. These occupational therapists provide equipment to people who are sore: the new bed, the shower stool and rails, the kitchen stool and trolley, the bed and chair raisers. Now there may be good reason for installing these gadgets – in the short term. They might keep someone safe in their environment so they can do what’s important. AT the same time they can, and do, reinforce the idea that this person cannot do, and certainly cannot change. While installing these things can mean a person is able to do – the person also learns to avoid doing these movements. This is such an important concept in pain rehabilitation – because progressively working towards being able to manage normal activities without aids is what we’re aiming for! An occupational therapist installing these things without reviewing and supporting the person to no longer need these things is just like a physiotherapist offering a person a back brace or splint and never reviewing whether it’s needed.

Why is it difficult to acknowledge occupational therapy’s contributions? Partly our rejection of a biomedical model based on diagnosing disease. Occupational therapists are about the person’s illness experience, our model is wholistic, biopsychosocial, integrative. It’s hard to articulate our contributions without using a lot of words! Or making it seem so dumbed down that people view the exterior actions (cleaning teeth, having a shower) without recognising the myriad contributing factors that influence whether this action is carried out successfully.

Occupational therapists have relied on qualitative research to examine the lived experience of people dealing with persistent pain. Rather than pointing to randomised controlled trials of broad concepts like “exercise”, we’ve tended to describe the individual and unique experiences of people as they regain their sense of self. Not something easily measured like range of movement or cardiovascular fitness, or even simple measures of disability and self efficacy. Peek behind these descriptions you’ll find synthesised strategies that integrate values, committed actions, sense of self, cognitive defusion, behavioural approaches – messy things that aren’t readily translated into simple cause and effect experiments. Multifactorial approaches that recognise that life is a contextual experience.

I contend that one of the major failings in pain rehabilitation is helping people reclaim their sense of self again. Self concept is ignored in favour of changing a person from a couch spud to a gym attender. Even psychologists can forget that when instilling new strategies, the person in front of them has to learn to integrate these new things into their world – and that means adjusting their sense of who they are. That’s the hidden work people living with persistent pain have to do, rarely supported. And yet it’s the thing people most want to resolve when they’re dealing with this experience. Who am I? Can I be me again? If I can’t be the old me, can I at least get something of what was important to me back again?

What I’d like to see are more occupational therapists being confident about what our profession offers, being willing to step up and be the resource we know is needed. We don’t need to be defensive about this – but we do need to be sure about the validity and relevance of why our contribution is so important. I think the results from research showing how short-lived positive results of pain rehabilitation really are speak for themselves. Maybe the missing link is knowledge translation into daily life contexts?

Who am I? The sense of self in chronic/persistent pain


One of the most pervasive descriptions of what it is like to live with persistent pain is the loss of sense of self. Time after time in qualitative research we read about people feeling they’re in “limbo land”, losing confidence that they can do what matters in their lives, feeling stigmatised and isolated – not themselves any more. An in-depth meta-ethnography of qualitative research showed that pain undermined participation, ability to carry out daily activities, stymied a sense of the future, and intruded on the sense of self (MacNeela, Doyle, O’Gorman, Ruane & McGuire, 2015).

To understand the idea of “self”, I poked about a little in the literature, and found a title I like “Becoming who you are” (Koole, Schlinkert, Maldei & Baumann, 2019). The theoretical propositions of this paper relate more to self-determination than self-concept – but that title “Becoming who you are” resonated strongly with me.

When I read through pain rehabilitation research and theory, especially that dealing with learning how to live well with pain, I rarely see anything written about how we might help people who feel alienated from their sense of self. Scarcely a word. Except in the psychological literature. There’s a bit about self-discrepancy theory (See E. Tory Higgins works for much more about self-discrepancy), where the “imagined self”, the “real self”, the “feared self” and the “ought self” don’t match – but not much about what to do about helping people restore a sense of self, particularly in physical and “functional” rehabilitation.

Silvia Sze Wai Kwok and colleagues (2016) argue that psychological flexibility can play a role in helping people adjust to chronic pain. They found that psychological flexibility mediated between self-discrepancy (how close is my current self to my feared or ideal self?) and pain outcomes (distress, disability and so on). In other words, the degree to which people could flexibly adjust their goals and actions to suit what they could and couldn’t do made a difference.

This seems like common sense. Kinda. As the authors put it: “recognition of self worth and self-values could be attuned through flexible (re)construction of self-concept in response to changing contexts. These adaptations and regulatory functions then in turn may predict the subjective feelings of pain interference, emotional distress and pain tolerance level perceived.”

So my question is: how often does this become openly discussed in pain rehabilitation? Particularly by occupational therapists and physiotherapists – the clinicians who most often work on goals and helping people achieve them?

Whether a person is “motivated” to pursue important goals depends on whether the goals are important to them and whether they think they’ll successfully achieve them. When someone is “non-compliant” it’s because either the rehabilitation activities are not as important as something else in the person’s life, OR they’re not at all confident they can be successful at it. An enormous part of our job as rehabilitation professionals is helping people re-examine what they want to do and helping them adjust how to achieve the underlying values, even if the particular goal isn’t possible – yet. So, for example, if a person really values being a conscientious worker but can’t sustain a full working day, we can either help them fell OK about being conscientious for fewer hours, or we can make the work less demanding. I see this as an especially valuable contribution from occupational therapists.

Should rehabilitation clinicians be involved in this kind of “self-concept” work? I think so – especially occupational therapists. Occupational therapists are about doing, being and becoming – by doing things, we express who we are, and what we choose to engage in also shapes our perceptions of ourselves. As therapists we can’t help but influence a person’s self-concept – if we’re hoping to increase self-efficacy, we’re automatically influencing self-concept. If we’re working on goals, we’re influencing self-concept. If we’re working on participation in life, we’re working on self-concept.

And physiotherapists? Self-concept? Yep – of course. If we’re helping someone do exercise, that’s going to influence that person’s beliefs about exercise and their capabilities – that in turn is going to influence self-concept. (psst! it might be even more powerful if movements are done in the context of daily life, where feedback is real, meaningful and ever-present).

Persistent pain challenges the automatic assumptions people hold about what they can and can’t do, what they’re good at, what’s important in life, and how to engage with “the world” at large. Our job as clinicians is to be sensitive to just how confronting it is to find that what used to be effortless and meaningful is now daunting and requires more concentration and thought than we ever believed. I think that’s part of our job, irrespective of professional labels.

Koole, Sander L., Schlinkert, Caroline, Maldei, Tobias, & Baumann, Nicola. (2019). Becoming who you are: An integrative review of self-determination theory and personality systems interactions theory. Journal of Personality, 87(1), 15-36. doi: 10.1111/jopy.12380

Kwok, Silvia Sze Wai, Chan, Esther Chin Chi, Chen, Phoon Ping, & Lo, Barbara Chuen Yee. (2016). The “self” in pain: The role of psychological inflexibility in chronic pain adjustment. Journal of Behavioral Medicine, 39(5), 908-915.

MacNeela, Padraig, Doyle, Catherine, O’Gorman, David, Ruane, Nancy, & McGuire, Brian E. (2015). Experiences of chronic low back pain: a meta-ethnography of qualitative research. Health Psychology Review, 9(1), 63-82.

Knowledge translation: A home for occupational therapy?


Modern occupational therapy is involved with helping people participate in daily life in the real world. Indeed, occupational therapy has always been about “doing” – see here for a brief history of occupational therapy – but it has been difficult, in a strongly reductionist and biomedical context, to articulate the unique and particular contribution occupational therapy makes within healthcare.

In a conversation last week with Dr Mary Butler from Otago Polytechnic, we were discussing our areas of research. I mentioned that knowledge translation, or helping clinicians use research that is often locked up in peer-reviewed journals, is my passion. Something clicked and we both recognised that the process of translating from one “artificial” setting to the real world is where both of us feel completely at home. As our conversation rambled (we know how to talk!), we described the way we go about contributing to research and clinical practice: looking from the evidence-based material or research in daily life, to where this knowledge needs to be applied. Our passion is understanding the where/how/why/what that gets in the way of bringing evidence to the lived experience, whether that be researching how an older person with poor vision might avoid falls (change the lightbulbs for brighter ones – it can help!), or working out a clinical reasoning model to help therapists think broadly about pain and factors influencing disability.

Knowledge translation is an area of research and practice that bridges the gap between journal articles and implementation. It involves identifying needs in the real world (read: practice area), identifying or developing research to solve those problems, making the solutions (research) accessible, then adopting and modifying that information as it’s implemented so that it does what it needs to do.

For occupational therapists, this is work as usual. We work with the person to identify their needs: what does this person want and need to do in daily life? We then scour our knowledge bases, often assessing the person’s capabilities, understanding the context and environment, research the constraints on the person’s participation and establish the obstacles that prevent this person from participating in what they want and need to do. We then tailor the solutions to fit the unique demands of the person, the task (or occupation) and the contexts, and help the person implement the solution so they can participate.

And this is why it’s so difficult to answer that seemingly simple question: What can you offer people? Why should I refer to you? What do you do? Because my answer will almost always be “it depends …!”

Working in pain management as I do, I draw on pain research across basic science, biology, biomechanics, physiology, sociology, anthropology, psychology in many different fields. I also need to know about pharmacology, kinesiology, strength and fitness research, and yes I even have to read about surgery, physiotherapy, nursing, post-operative recovery. Because the people I work with have relationships with others, I need to understand relationship dynamics, employer/employee relations, collegial relations at work, friendships, mateships and both introversion and extraversion. I could go on – but the point is not just how many fields I need to be conversant with, it’s that the way I use this knowledge is unique to occupational therapy. Let me elaborate.

All those fields of knowledge are relevant to my work, but the area that is utterly unique to occupational therapy is understanding the interaction between this person and his/her many different participation contexts. This means that I might be working on graded exposure to the fear of bending forward. A physiotherapist may have been working on this in a gym or fitness context – but this environment is controlled, there is a therapist hovering near, the loads and positions and floor surface and lighting and number of people around and noise level is all controlled and fairly consistent. As an occupational therapist, my job is to help this person generalise the fear reduction experienced in the gym to every day life. That means loading things into the boot of the car, or over the back seat of the car, or the laundry basket, or picking up the clothes off the floordrobe in the teens bedroom, or picking up the dog pooh from the back yard, or bending to weed the garden, or bending to put the shoes and socks on, or clean the bottom of the bath or shower. I have to help the person identify where they need to bend over, and grade the demands to a level that the person can only just manage – so he or she can push towards increasing confidence in any situation.

Translating from one context to another doesn’t always happen by itself. I’m sure there are many times we’ve seen someone walking beautifully, using the painful foot with a completely correct heel-toe pattern in the clinic – then perhaps unexpectedly meeting the person in the shopping mall on a wet day when the floor is slippery only to find he or she is leaning on the shopping trolley, limping and hardly putting any weight on the foot at all.

Knowing about a strategy doesn’t mean it’s used in the real context in which it’s needed. A mindfulness meditation carried out in clinic, where it’s quiet and there are no distractions, and no children saying “what’s for dinner!” and no partner coming home after a busy day wanting to decompress by talking… is a very different experience carried out at home! And this complexity is the practice space for occupational therapists. It looks like “doing meditation” and “oh but we’ve done that in one session” – but it’s a complex balancing of priorities, establishing boundaries, caring sufficiently for oneself over others, being willing to bring the mind back repeatedly as salient thoughts and sounds intrude.

I think that many clinicians assume that what is done in treatment has carryover into daily life. I would argue that this gap between knowing and doing, discussed so much in knowledge translation about research and clinical practice, is precisely what is missing in much of our pain rehabilitation. We may not even recognise that the person hasn’t integrated the skills we’ve been focusing on: why? Because we don’t enter the person’s everyday life.

Some of the things occupational therapists focus on so much include meaning and values, the social context, the physical environment, the cognitive and sensory environment – and at times, we can forget that we draw on foundation science in our treatment approach, so we hand out long-handled reachers for picking the clothes up from the floordrobe, forgetting that it’s possible for people to learn how to bend over without fear… and that’s a conversation for occupational therapists to have. I hope that by starting to recognise our “knowledge translation” space, we might gain more confidence to read research well outside “occupational” areas, and begin to consider how we can apply what other disciplines study to the everyday lives of the people we help.


On the problem of coping


Coping. Lots of meanings, lots of negative connotations, used widely by health professionals, rejected by others (why would you need coping skills if you can get rid of your pain?).

I’ll bet one of the problems with coping is that we don’t really know what we’re defining. Is coping the result of dealing with something? Or is it the process of dealing with something? Or is it the range of strategies used when dealing with something? What if, after having dealt with the ‘something’ that shook our world, the world doesn’t go back to the way it was? What if ‘coping’ becomes a way of living?

The reason this topic came up for me is having just written a review for Paincloud on activity patterns (Cane, Nielson & Mazmanian, 2018), I got to thinking about the way we conceptualise ‘problems’ in life.  It’s like we imagine that life is going along its merry way, then all of a sudden and out of the blue – WHAM! An event happens to stop us in our tracks and we have to deal with it.

But let’s step back for a minute: how many of us have a well-ordered, bimbling existence where life is going along without any hiccoughs?!

Back to coping. The concept of coping is defined by Lazarus and Folkman (1980) as “the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them.” It’s identified as a transactional process and one that occurs within a context where the person has both resources and constraints, and a direction in which he or she wants to go.

By contrast, if we look at the research into coping in people with persistent pain, most of the attention is on the “what the person does” and the resources he or she has (see for example Rosenstiel & Keefe, 1983; Jensen, Turner, Romano & Karoly, 1991; Snow-Turkey, Norris & Tan, 1996; and much more recently, measures of coping by Sleijswer-Koehorst, Bijker, Cuijpers, Scholten-Peeters & Coppieters, in press). There are some studies exploring the goals set by the person (Schmitz, Saile & Nilges, 1996), but few studies examine the context in which the person is coping – nor what happens once the coping efforts are successful.

Measuring coping falls into three main buckets: the repertoire (how many strategies do you have?); the variation (which ones do you use and do they match the demands?); and the fitness approach (the choice of strategy depends on the way a person appraises the situation) (Kato, 2012). Out of these three, Kato chose to develop a measure of coping flexibility. Coping flexibility refers to “the ability to discontinue an ineffective coping strategy, and produce and implement an alternative coping strategy”. The Coping Flexibility Scale aims to measure this ability, based on the idea that by appraising the situation, implementing a strategy, then appraising the effectiveness of that strategy and applying a new one, the person is more effective at dealing with the challenge.

One of the most popular measures of coping for pain is the 14-item Coping Strategies Questionnaire (Riddle & Jensen, 2013). It suggests different ways of coping, some of which are seen as helpful, while others are not. Oddly enough, and why I started writing this blog, it doesn’t include the way we go about daily activities – activity patterns. In the study by Cane, Nielson & Maxmanian (2018), two main forms of activity pattern were found: avoidant-pacing, and  overdoing (as measured by the Patterns of Activity Measure – Pain). The avoidant-pacing group used pacing for daily activity management, but did so with the intention of avoiding flare-ups. The overdoing group just did a lot of activity. After treatment, some people moved group – from the two original groups, two more emerged: avoidant-pacing, pacing, mixed and overdoing. The pacing group basically did what everyone says is a great way to manage pain: picking out the right level of activity and sticking with it, using a quote-based approach. The definition used in this study was “… preplanned strategy that involved breaking activities into smaller parts, alternating periods of activity and rest (or an alternate activity), and using predetermined time intervals (or quotas) to establish when to stop an activity. The description of activity pacing provided to patients identified the goal or function of activity pacing as facilitating the completion of activities and ultimately increasing overall activity and functioning.”

As usual there are vulnerabilities in the way this study was conducted, and the main one for me is the follow-up period is non-existent. The reason I worry about this is that in my daily life, as I’m sure happens in many of yours, my pattern of activity varies wildly from week to week. Some weeks, like the weeks just before I headed to Sunderland for Paincloud, and the weeks just after I got back, were incredibly busy. I pushed myself to get things done because there were a heap of deadlines! This week I plan to have some down-time – this afternoon, in fact, because I want to play with some silversmithing.

And it occurred to me that we expect such a lot from the people we work with who live with pain. We ask all sorts of intrusive questions about daily life and we expect people to be able to recall what they did, why they did it, and to make changes and be consistent about these until we’re satisfied they’re “coping”.

But what if coping is actually the way we live our lives? What if coping involves all the myriad self-evaluative activities we all do – like, how hungry, tired, irritable, frustrated, rushed, achey, restless, enthusiastic, apologetic we feel – and endlessly and constantly adjusting the actions and behaviours we do so we can do what, for a moment or two, we think is The Most Important thing for now.

Life is a constant flowing forward. It’s a stream, an avalanche, a train going one way only. We can’t stop the world to get off. And once we’ve “coped” with something, life doesn’t return to “normal” because we’re different. Maybe our priorities change, or our circumstances have, or we have a new insight into what we want, or we work out the goal we had is more important than we thought. What if we are expecting the people who live with pain to do something we’re not even capable of?

I suppose part of my musing is related to mindfulness. Mindfulness involves continually returning to what I want to pay attention to, and doing so without judgement, and also observing without judgement. But it always involves coming back to what I intend to attend to. On and on and on. And the lovely thing about it is that it’s endlessly gentle and forgiving. Let go of the things I forgot to do, or the rushing towards what needs doing. I wonder what would happen if we encouraged people to be mindful for brief moments throughout the day all day long. Would that encourage coping flexibility? Would it encourage using a broader repertoire of ways of dealing with things? Would it help people to be more aware of everyday choosing and prioritising and managing actions to meet what’s valued in life?

To summarise: currently coping is measured using a “catalogue” of actions, often out of the context of daily decision-making and activity management. Activity management can vary from day to day, hour to hour, month to month. Being flexible with how we go about life seems, at least to me, to depend on my being aware of what’s important to me, what my energy is like, and the context in which I life. How well do we measure these constructs in pain management?

Cane, D., Nielson, W. R., & Mazmanian, D. (2018). Patterns of pain-related activity: replicability, treatment-related changes, and relationship to functioning. Pain, 159(12), 2522-2529.

Folkman, S., & Lazarus, R. S. (1980). An Analysis of Coping in a Middle-Aged Community Sample. Journal of Health and Social Behavior, 21(3), 219-239. doi:10.2307/2136617

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of the literature. Pain, 47(3), 249-283. doi:http://dx.doi.org/10.1016/0304-3959%2891%2990216-K

Kato, T. (2012). Development of the Coping Flexibility Scale: Evidence for the coping flexibility hypothesis. Journal of counseling psychology, 59(2), 262-273.

Riddle, D.L &  Jensen, M.P. (2013). Construct and criterion-based validity of brief pain coping scales in persons with chronic knee osteoarthritis pain. Pain Medicine 14(2):265-275. doi:10.1111/pmc.12007

Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain, 17(1), 33-44.

Schmitz, U., Saile, H., & Nilges, P. (1996). Coping with chronic pain: flexible goal adjustment as an interactive buffer against pain-related distress. Pain, 67(1), 41-51.

Sleijser-Koehorst, M. L. S., Bijker, L., Cuijpers, p., Scholten-Peeters, G. G. M., & Coppieters, M. Preferred self-administered questionnaires to assess fear of movement, coping, self-efficacy and catastrophizing in patients with musculoskeletal pain – A modified Delphi study. Pain. in press

Snow-Turek, A. L., Norris, M. P., & Tan, G. (1996). Active and passive coping strategies in chronic pain patients. Pain, 64(3), 455-462. doi:10.1016/0304-3959(95)00190-5

Wandering back from the IASP World Congress


Meetings, meanderings, mind-expansions

I’ve been away for abut 10 days, attending the World Congress of the International Association for the Study of Pain. It was a time of meetings with wonderful people I’ve met via the interwebs, with researchers and clinicians, and most importantly, with people living with pain.

It was also a time for meanderings – around the very walkable city of Boston, embracing history and looking towards the future, and mind meanderings as well.

And because it was a conference, it was also mind-expanding. New ideas, new ways of investigating this human experience of pain, new discoveries, and new applications.

… and expanding the way we help people who live with pain.

What struck me between the eyeballs?

Good things: for the first time, people living with pain were included in the proceedings. I’m reminded of the old saying from the disabilities movement “Nothing about us without us” – well, it’s finally arrived at the World Congress! There are some concerns about this move amongst clinicians, and there’s no doubt that some of the people I’ve seen for whom the experience of being seen about their pain has been disheartening, stigmatising and frustrating, are very angry. I think, though, that continuing to avoid meeting with people who are in this space serves only to fuel their rage, and perhaps it’s time for us as clinicians to learn what it is about their experiences that we can learn from.

Professor Fiona Blyth talking about the Global Burden of Disability – 21%

Another “between the eyeballs” moment was when Professor Fiona Blyth discussed the knowledge that 21% of the total global burden of disability, and that this is increasing more quickly in developing countries because of the rapidly increasing percentage of older people (with multiple MSK comorbidities) – but here’s the kicker: There has been little-to-no change in funding policies to reflect this increasing burden of disease. You read that right. Funding goes to diseases that can kill you – but very little goes to the diseases that simply leave you disabled for the rest of your days.

Not so good things: Well, much of the research shows that change is incremental and that while strategies like exercise have reasonably good research support what actually matters is that exercise gets done: the form of exercise for persistent pain is a whole lot less more important than issues of adherence (Professor Kathleen Sluka’s plenary lecture showed this).

There was a good focus on behavioural science and pain, disability and response to treatment. And plenty of emphasis on sharing the responsibility for using psychologically-informed treatments with all health professionals, not just psychologists.

Why have I included this in my “not so good things”? Because a very recent Twitter discussion suggests that there continues to be a misperception that by using a psychologically-informed treatment, the aetiology of a pain problem is therefore assumed to be psychological.

There continues to be tussling over whether a biopsychosocial (or sociopsychobiological) model has sufficient emphasis on “the bio”, along with misinterpreting the historic origins of Engel’s thinking. Various people argue that “all is bio” or “but it’s reductionist” – yet readers of Engel’s original writings will recognise an interactional systems approach, where an effect in one factor will likely have flow-on effects everywhere else.

The final “not so good” for me was the dearth of discussion about occupational therapy’s historic and ongoing involvement in pain and pain management. There were at least 20 occupational therapists at the meeting, and despite Fordyce including occupational therapists in his original behavioural approach to disability (Fordyce, Fowler & Delateur, 1968), scant evidence of occupational therapy’s important contribution to this field over the years.

This is important because occupational therapy is one of the few professions to have adopted, retained and integrated a sociopsychobiological approach to healthcare. If you’re ever thinking about asking “how does one profession use the BPS model?” maybe talking with an occupational therapist will help you.

I was lucky to have a chance to offer a piece of research conducted by Brian Rutledge and me, looking at the function of an online discussion group (yes! Facebook!). The purpose was to establish whether the group Exploring Pain Science functions as a “Community of Practice“. The answer is a resounding Yes! and you can review the poster here – click

There will be a paper forthcoming, and some further analysis of the processes used in this group.

…Why look at Facebook groups?

Well, one reason is that there was a resounding call for knowledge translation – and all manner of ways thought to be useful in this pursuit. But as far as I am aware, using Facebook groups (especially ones that have emerged “organically”) is both a popular strategy – and one that has been under-examined in pain research – for people trying to implement what they’ve read or heard from research into their daily practice.

Hope this very brief tour through just a couple of the things I’ve been pondering since this World Congress will encourage YOU and others to join IASP. It truly represents the only global organisation that is transprofessional, wedded to a biopsychosocial model of pain, and one that is progressing our understanding of pain so much.


Fordyce, W. E., Fowler, R. S., & Delateur, B. (1968). An Application of Behavior Modification Technique to a Problem of Chronic Pain. Behaviour Research and Therapy, 6(1), 105-107.