pain management

Frustration in the clinic


I’m prompted to write this post because it’s something I see in social media so often – a clinician gets frustrated. Things don’t work. The person getting treatment doesn’t respond in the way that was expected. The person doesn’t look like what the clinician usually sees. The evidence doesn’t fit with practice. All the things! So I thought today I’d write about emotions and thoughts that might turn up – and what might underlie those feelings. (For people living with pain – we also have frustration in the clinic. Things don’t work out. The therapist isn’t what we expected. I’ll write more about this soon!)

Emotions are a complex reaction pattern, involving experiential, behavioral and physiological elements (https://dictionary.apa.org/emotion). From a cognitive behavioural perspective, an event happens, we appraise it (judge it), and we experience an emotion – then we do something as a response. It’s much more complex than this, and each part interacts with the others – so we end up with a big diagram looking something like this: (from – https://www.researchgate.net/figure/Cognitive-behavioral-therapy-model-of-depression_fig1_338695579).

Instead of “depressive”, just put in “beliefs/expectations about who I am and what I can expect from myself”. This is a pretty generic model in CBT, and is well-established even if there are plenty of arguments about accuracy and adequacy!

Clinicians generally want to help. Yes, some are in it for fame or fortune (choose something else, kthx), but on the whole people enter a clinical profession because they think they can do some good, and people will “get better.” Our communities hold long-standing expectations about what seeing a health professional should entail: read Benedetti’s “The Patient’s Brain” for a much more detailed description of the historical and evolutionary basis for a therapeutic encounter.

Why does this matter? Because it sets the scene for how we think a therapeutic encounter should go.

Rules and assumptions about what “ought” to, or “should” happen often underlie emotions.

We’re happy when all the things line up and the patient does what we expect of patients while the clinician does things that work. When things don’t go to plan (ie our expectations are violated) that’s when we get some feelings, and they can be pretty big.

What do we expect from patients?

Despite moves towards person-centred care where patients are seen as people and clinicians offer options rather than dictate orders, our societies still hold expectations about the roles a patient and a clinician should play.

Patients are expected to seek help when they’re sick. They’re expected to be truthful about their symptoms, and tell clinicians everything that is relevant about their condition – AND about any other aspect of their health, even if it’s not immediately relevant to their current problem. Symptoms experienced by patients are expected to be what the clinician expects, and the disease a patient has should fit within “typical” parameters (usually based on males). Patients are also expected to follow instructions, not do things that go against instructions, and of course, to get better. Patients are meant to be grateful for their treatment, even if it’s disruptive, has unpleasant side effects, or isn’t 100% effective. Patients should do their best all the time.

As a corollary, clinicians have a huge number of expectations they take on (and are given!). Some of us have these explicitly handed to us during our training, while others find they’re an implicit set of assumptions that we adopt, perhaps in the guise of “being professional.”

What do we expect from clinicians?

Clinicians expect to be in control in the clinical encounter. We’re expected to know what to ask about, and from this, what to test for. We’re expected to have the answers, and be right. We’re also expected to be calm, caring and focused – even when our personal lives are topsy-turvy. We’re meant to know what the patient wants, and how to give that to them. We’re also expected to be up-to-date, do no harm, change our practice according to evidence (even when that evidence is contradictory, or just emerging), and to stay interested in our work even if we’ve been doing it for years.

We’re expected to know our scope of practice, but practice using a broad “whole person” framework even if we were never trained to do this. We think we should be compassionate and caring, even if we were selected for training on the basis of our academic prowess and not on emotional literacy. We must take on responsibility for outcomes, even though we’re not there to “make sure” the patient “does what they’re told” in their own time. We assume when we tell someone to do something, they’ll drop everything in their life to do it – because their health should matter most, and even when other things in their life matter more.

Clinicians can be expected to practice independently from the moment they qualify, and are either “right” or “wrong” and never shades of in between. Clinicians expect that if something goes wrong, and the person doesn’t get better, it’s either the person’s fault (they didn’t do what they should have done), or the clinician has done something wrong and made a wrong diagnosis, or chosen the wrong treatment (or the treatment was right but the intensity was wrong…. so just do it again). And clinicians shouldn’t ask for emotional help because that means they’re “too emotionally invested” or “not distanced enough.”

Expectations suck

We all have them. And the ones I’ve listed above, while not always present, often underpin the way we expect clinical encounters to go. Many of them are implicit, so we don’t even realise we hold them – until BAM! Something goes wrong.

When expectations are violated, we feel emotions and some of these can be pretty strong. Many are less strong, just little niggles, little irritations, a bit of cynicism, some disappointment, some frustration. And they go both ways: people seeking help, and people trying to help. Over time, violated expectations feel like your head hitting against a brick wall, or swimming against the tide, or just plain demoralisation or even burnout.

Ways through them

Some of us have professionally-endorsed support systems to help us. Occupational therapists and psychologists have mandatory clinical supervision with someone who is there for you, who supports your development as a clinician, who challenges your assumptions, who pokes and prods at your reactions, who encourages taking a broader view. Individual clinicians in other professions may also pick up on using supervision in this way.

Some of us don’t have that kind of support. So we seek it elsewhere – I suppose, in part, I started writing this blog those years ago to “find my tribe.” Social media is one way we get affirmation, validation and even (sometimes!) great ideas to help us shift our approach.

Some clinicians leave their profession, do something else that’s more lucrative and less emotional effort. Some move out of practice and into academia. Some use “outside work” interests to blow off steam, or give emotional space.

Some of us are a little fused with the assumptions we hold. It’s hard to create a little space around those assumptions, because they’re held so tightly (or they’re so deeply buried). When we do get a tap on the shoulder suggesting our beliefs are out of whack it can feel so terribly humiliating, so inherently WRONG that we shut off, or bite back.

Creating “wiggle room”

Slowing down is a good way to begin creating some space to feel what is showing up when we’re feeling frustration. This could be by taking one or two minutes at the end of a session to be present. Yes, a little mindfulness to notice what is present in the body. To be OK with being aware of emotions, thoughts, and body sensations. NOT TO CHANGE THEM! To simply be with them. (An explanation here: https://www.youtube.com/watch?v=v9NkUomOO_w). This helps in many ways, but it does not (and isn’t intended to) reduce them. It helps you notice that you’re having feelings. It helps you pay attention to your own state of mind. It can create a moment to ask yourself “I wonder why I feel this way?” It can help you be more present with the next person you see because you’re not carrying those feelings into the next encounter.

Reflective practice is another way to create some space to be human, feel things, be curious about why they happen, and check in with your own values. A great resource that’s freely available is Positive Professional practice: a strength-based reflective practice teaching model – it might be a ‘teaching’ model, but clinicians teach All The Time!

Taking small steps, making small changes

The first step towards making a change is knowing that it’s needed. And the second is knowing that it’s possible. The third? Knowing what to do. I hope these suggestions help a little in this seldom-discussed aspect of practice. My own preference is to question WHY do we hold these expectations? WHO made them a thing? WHAT purpose do they serve? WHEN might those expectations be a good thing – and when might they not? WHERE can we nudge just a little to make change? And preferably, as clinicians, I think it’s OUR job to make the adjustments because we’re not ill or sore or seeking help.

Some references:

Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing Clinicians’ Well-Being and Patient-Centered Care Through Mindfulness. Journal of Continuing Education in Health Professions, 36(1), 11-16. https://doi.org/10.1097/CEH.0000000000000021

Huft, J. (2022). The History and Future of the Sociology of Therapy: a Review and a Research Agenda. The American Sociologist, 53(3), 437-464. https://doi.org/10.1007/s12108-022-09534-3

McGarry, J., Aubeeluck, A., & De Oliveira, D. (2019). Evaluation of an evidence-based model of safeguarding clinical supervision within one healthcare organization in the United Kingdom. International Journal of Evidence-Based Healthcare, 17 Suppl 1, S29-S31. https://doi.org/10.1097/XEB.0000000000000180

Spencer, K. L. (2018). Transforming Patient Compliance Research in an Era of Biomedicalization. Journal of Health and Social Behavior, 59(2), 170-184. https://doi.org/10.1177/0022146518756860

Making sense: Does it help people with pain?


I love it when my biases are challenged (seriously, I do!). And in the study I’m talking about today, my biases are sorely challenged – but perhaps not as much as I initially thought.

Lance McCracken is one of my favourite researchers investigating processes of acceptance and living a good life in the presence of chronic pain. In this paper, he collaborates with a colleague currently involved in the INPUT pain management programme established at Guy’s and St Thomas’ NHS originally by Michael Nicholas who draws on a CBT model of pain management, and now more firmly in the third wave camp of ACT (Acceptance and Commitment Therapy). The paper is ‘Making sense’ and describes a cross-sectional study of sense-making by people with chronic pain attending the INPUT programme.

Making sense is something humans do without even thinking about it. Humans are prone to (and probably for good adaptive reasons) generate patterns out of random information. We gaze at shadows at night and think we see faces or intruders, and we look at clouds and see dragons and kittens. When we’re sore we also try to make sense of what’s going on – does this ouch feel like something I’ve had before? does it feel mysterious or can I carry on? have other people I know had this same ouch and what did they do?

In the search for making sense out of pain that otherwise seems random, clinicians have, since time immemorial, generated all sorts of stories about what might be going on. The wandering uterus. The evil spirit. The slipped disc. The leg length discrepancy. Clinicians, when faced with their own uncertainty about what exactly pain represents, can encourage patients to seek diagnosis: some sort of “explanation” for the problem. When that’s insufficient, more recently we’ve seen the flourishing of explanations for pain from a neurobiological perspective, particularly “pain as an expression of threat to bodily integrity”, a decision that is “made by the brain”.

My own research, investigating the experiences of people who indicated they live well with pain, reflected this same process. They sought a name for their experience, they wanted to understand the impact of pain on daily doing – those fluctuations and variances that emerge during the days and weeks early in the journey of learning that this pain isn’t going anywhere soon (Lennox Thompson, et al., 2019). Note that the group of people I recruited had come to the point where they identified that they were living well with pain – this group of people represent a small percentage of those who live with chronic pain, and not those who are seeking treatment.

OK, so what did McCracken and Scott (2022) find?

Bear in mind that this study was designed to measure the construct of sense-making in people seeking treatment for chronic pain. Also bear in mind the authors come from a perspective of functional contextualism, or a philosophy of science that argues for “…studying the current and historical context in which behavior evolves … to develop analytic concepts and rules that are useful for predicting and changing psychological events in a variety of settings.” What this means to me is that the form of whatever behaviour we’re observing/measuring matters less that the purpose or function of that behaviour in a specific context.

OK, on with the study.

451 adults attending an interprofessional pain management programme were participants in this study, and the measures were taken before they started treatment. They completed a battery of measures including ones measuring acceptance, cognitive fusion, committed action, tolerance of uncertainty, and pain measures such as the Brief Pain Inventory, numeric rating scale.

The research aim was to investigate a way to measure not only the positives from sense-making, but also the potential adverse effects of doing so. Concurrent with developing the measure, analyses of the inflexible ways we make sense were carried out in relation to outcomes: pain interference, depression and participation.

In the results (read through the analysis, BTW, it’s beautifully detailed), women were found to overthink compared with men, older people tended to want to avoid a sense of incoherence, and more educated people also tended to overthink.

Now, a little theory: coherence can be either literal or functional. Literal coherence is like “common sense” – so if I interpret my pain as meaning something is damaged, and moving it is bad, this is literal coherence. Functional coherence might occur when I realise that I hurt whether I’m doing things, or not, and I decide “this is how it is, I might as well get on with life”. In effect, as McCracken and Scott say, “these terms reflect the difference between language, thoughts and behavior fitting together consistently, (thoughts agree with other thoughts and behavior) versus behavior and goals in life fitting together consistently (behavior patterns succeed in reaching goals even when this seems to contradict “good sense”).

In daily life, people consistently prefer to solve problems and avoid insoluble problems. Makes sense, doesn’t it? Why try to deal with things that won’t change, even if we try hard to change them? BUT then we have insoluble problems that don’t make sense: the earthquakes in Christchurch New Zealand in 2011-2013 were random and we hadn’t had earthquake activity in our city for centuries – consequently we had many crackpots coming up with “predictions” for the next swarm of earthquakes based on phases of the moon or fracking or climate change. Anything to help people feel like they had a sense of control over something that did not make sense.

Chronic pain is often an equally insoluble problem. Many times pain like this does not make sense at all. No injury precipitated my fibromyalgia. There’s no imaging or biomarker for pain intensity. Existing biomedical diagnoses based on structural or biochemical or neurological processes don’t tell us much about who might get chronic pain, how intense it might be, or the impact of that pain on a person’s life. But clinicians and people with pain earnestly seek something, something to explain what’s going on.

For both clinicians and people living with pain, constantly searching for The Thing to explain pain can be exhausting, demoralising and linked to unhelpful patterns of behaviour. Clinicians might repeat the same treatment even though it didn’t work the first time. They might refer the person for more investigations, just in case something was missed. They might refer the person to another clinician, or, worse, they may attribute the pain to “mental illness” or “psychosocial factors”. Many, many clinicians think that giving a person a book about how pain might be constructed “in the brain” will be enough for people to make sense of what’s going on. People with pain might be afraid to get on with life in case they’re doing harm, or because they’re hoping the fix might be around the corner and life can “get back to normal”. They may spend enormous sums of money, time and emotion on treatments to either diagnose the problem, or treat it. They might spend hours brooding on what it could be. Their lives often stop – people with pain have called this “the endless limbo”.

Now there is a measure of sense-making I guess we’ll find out more about this part of learning to live with pain. The three subscales identified were “avoidance of incoherence”, “overthinking”, and “functional coherence”, though the last subscale had poor psychometric properties so wasn’t included in the final analyses.

My wish, however, is that rather than applying this measure to people attempting to make sense of something outside of their experience, we might develop a measure of how rigidly clinicians stick to “coherence” in the face of puzzling pain problems. Perhaps what might be even more influential, we might develop a measure of what happens when a vulnerable person trying to make sense of their pain meets a clinician with a high level of inflexibility about “what is going on”, because despite all the research we have into people living with pain, we haven’t yet recognised the power of the clinician in perpetuating unhelpful inflexibility.

Lance M McCracken , Whitney Scott , Potential Misfortunes in ‘Making Sense’: A Cross-sectional Study in People with Chronic Pain, Journal of Pain (2022), doi: https://doi.org/10.1016/j.jpain.2022.09.008

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

“The social” – a brief look at family


Our most important relationships, the ones we learn most from, probably occur in families (Bowlby, 1978). As kids, even before we begin to speak, we observe our family members – and there’s reasonable evidence showing that how well these early relationships develop influences our experience of pain and how we express it.

I had the occasion to read a little about adolescent and children’s pain, and the influence of parents on young people as they grow up. There’s a great deal of research interest in children’s pain because children with persistent pain grow up to be adults – usually also with persistent pain. And good evidence that parents with persistent pain can, through mechanisms including depression and catastrophising, influence pain and disability in their children (Brown et al., 2022; Brown et al., 2021).

The research is fascinating. Some studies investigating predictors of chronic pain in children, some investigating disability – and a small number of studies looking at what we can do to help parents cope with the pain their children are experiencing. Not many studies (54 in a 2021 scoping review – see Lee et al., 2021). And sooooo many studies focusing exclusively, or close to, the influence of Mothers on children. Where’s Dad? Can I repeat that: where’s Dad?

More recent studies indicate the number of Fathers and Mothers – yay, we’re getting an idea of how many are recruited into these studies – and yet overwhelmingly, it’s Mothers who form the majority of participants. I wonder what effect having a Dad with chronic pain might have on a kid? And it’s only recently that oh darn animal models actually include females… it’s those pesky hormones dammit!

Turning to the next most important relationship, apart from parents, there’s a good deal of research looking at partners. Again, there exists a bias towards heterosexual couples, so we’re a little biased here. There is a wealth of material to review in this area of pain, with some brilliant research designs such as repeated interviews over 18 months, followed by 22 days of repeated daily measures (eg Martire et al., 2019); investigating people with pain problems as common as knee osteoarthritis and chronic low back pain; and examining relationships between things like sleep, caregiving burden, catastrophising, relationship satisfaction, agreement about pain intensity between partners, beliefs and perceptions about pain on interactions, anger, stress. HEAPS of fascinating research to delve into.

And yet, how many clinicians, and programmes, routinely include partners? How accessible are treatment sessions for couples to attend? Who, in a pain management team consisting of largely physiotherapy plus a dollop of psychology, looks after this aspect of living with persistent pain? Waaay back in the day, like the mid-2010s, the facility I worked in had a social worker with experience in family systems and relationships – but there are few social workers working in pain management in New Zealand/Aotearoa, and unless something has changed that I don’t know about, our national insurer doesn’t recognise the value of social workers (and, for that matter, the need to include partners in therapy for chronic pain).

When I review the many studies of this part of “the social” and compare the findings from these investigations against current clinical practice, I see an enormous knowledge and skill gap. If the questions we ask people with pain about their relationship are “how is your relationship with your partner?” we’re probably going to hear “oh they’re really supportive” or “I don’t let them know how I am”. Without adequate knowledge about the kinds of factors that negatively influence the partner’s response to the person with pain we’re likely to be oblivious to the risk of partner abuse (56% of people in this study reported past partner abuse, while 29% of the respondents had been abused in the previous year – Craner et al., 2020); we might not be aware that spouses with poor sleep because their partner was sore, were more likely to be angry (Marini, et al., 2020); that 52% of partners without pain reported high-to-severe burden of having to do more both at work and home because their partner was sore (Suso-Ribera et al., 2020) – or that if a spouse without pain did not have confidence in the pain management of their partner with pain, they were more negative (Nah et al., 2020) or that when a spouse without pain thought their partner’s pain “was a mystery” they were more critical and made more invalidating responses (Burns et al., 2019).

You see, while “the social” is complex, difficult to research, and very broad – ranging from employment status, occupation, educational status, ethnicity, culture, gender, sex – it also includes the very intimate and formative relationships we have with our family. In New Zealand/Aotearoa, with our emphasis on Te Whare Tapa Whā as a model of health and for chronic pain, where relationships with whanau are vital, isn’t it time we addressed this lack?

Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Brown, D. T., Claus, B. B., Konning, A., & Wager, J. (2022, Mar). Unified multifactorial model of parental factors in community-based pediatric chronic pain. Journal of Pediatric Psychology, 47(2), 121-131. https://doi.org/doi: 10.1093/jpepsy/jsab085

Brown, D., Rosenthal, N., Konning, A., & Wager, J. (2021, Feb). Intergenerational transmission of chronic pain-related disability: The explanatory effects of depressive symptoms. Pain, 162(2), 653-662. https://doi.org/10.1097/j.pain.0000000000002066

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019, Oct). Spouse and patient beliefs and perceptions about chronic pain: Effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186. https://doi.org/https://doi.org/10.1016/j.jpain.2019.04.001

Craner, J. R., Lake, E. S., Bancroft, K. E., & Hanson, K. M. (2020, Nov). Partner abuse among treatment-seeking individuals with chronic pain: Prevalence, characteristics, and association with pain-related outcomes. Pain Medicine, 21(11), 2789-2798. https://doi.org/10.1093/pm/pnaa126

Donnelly, T. J., Palermo, T. M., & Newton-John, T. R. O. (2020, Jul). Parent cognitive, behavioural, and affective factors and their relation to child pain and functioning in pediatric chronic pain: a systematic review and meta-analysis. Pain, 161(7), 1401-1419. https://doi.org/10.1097/j.pain.0000000000001833

Lee, S., Dick, B. D., Jordan, A., & McMurtry, C. (2021, Nov). Psychological interventions for parents of youth with chronic pain: A scoping review. The Clinical Journal of Pain, 37(11), 825-844. https://doi.org/10.1097/AJP.0000000000000977

Marini, C. M., Martire, L. M., Jones, D. R., Zhaoyang, R., & Buxton, O. M. (2020, Jun). Daily links between sleep and anger among spouses of chronic pain patients. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 75(5), 927-936. https://doi.org/10.1093/geronb/gby111

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841-2847. https://doi.org/10.1097/j.pain.0000000000001673

Meredith, P., Ownsworth, T., & Strong, J. (2008, Mar). A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clinical Psychology Review, 28(3), 407-429.

Nah, S., Martire, L. M., & Zhaoyang, R. (2020, Oct). Perceived patient pain and spousal caregivers’ negative affect: The moderating role of spouse confidence in patients’ pain management. Journal of Aging and Health, 32(9), 1282-1290. https://doi.org/10.1177/0898264320919631

Suso-Ribera, C., Yakobov, E., Carriere, J. S., & Garcia-Palacios, A. (2020, Oct). The impact of chronic pain on patients and spouses: Consequences on occupational status, distribution of household chores and care-giving burden. European Journal of Pain, 24(9), 1730-1740. https://doi.org/10.1002/ejp.1616

Ways to stop good clinicians leaving pain management (ii)


I’ve been asked to amend (actually, to remove) these two posts, so I’ve altered the opening sentence – you’re reading it now. I’ve also added some comments to preface these two posts.
I’m an old hack when it comes to teamwork and pain management: I’ve worked in this field a long time. I’m familiar with reactions to both interpersonal differences within a team (and the myriad ways these can be expressed), and to the discourse that happens when posting a publicly available message. In fact, that’s why I publish on social media: so we can have open conversations rather than ones hidden behind paywalls, or in rarified academic settings. Humans are odd, and when poked – even when poked with good evidence – want to react, to bite back. The following comments are not about any specific organisation. I’ll repeat that: comments about what we do in healthcare (ie bullying – nurses call this ‘horizontal violence’, stigmatising, excluding, not supporting etc) in the two articles I’ve written so far on how to prevent good clinicians do not relate to any one organisation. They are based on personal experience (my own) and experiences I’ve read in the literature.

Last week I started a series of posts on how we can stop good clinicians leaving pain management. I began with funding because, at least in New Zealand, lack of funding is a significant part of the problem of staff retention.

Now I want to look at how we prepare clinicians to work in pain management.

One of the major barriers in New Zealand is the dominance of musculoskeletal rehabilitation in physiotherapy clinics around the country. How could direct access to musculoskeletal rehabilitation be a bad thing, you ask? Well, it’s mainly because pain management is not musculoskeletal rehabilitation – and yet most of the workforce for pain management here comes from musculoskeletal physiotherapists.

I like physiotherapists, some of them are even very good friends! And I recognise that good physiotherapists have moved a long way from the old “back school” staff sergeant approach! Many physiotherapists have developed their skills well beyond analysing pelvic tilt and using “special tests” with limited inter-rater reliability and even less predictive validity. There are good physio’s who are skilled in Acceptance and Commitment Therapy, who routinely look at values and use motivational approaches in their clinical practice.

But, how well are new graduate physiotherapists (and indeed other entry-level health professionals) prepared for chronic pain work? (remember that many clinics in NZ employ entry-level therapists because they’re inexpensive, and chronic pain management isn’t a very profitable area – and staff turnover is a thing).

Unlike acute and subacute musculoskeletal rehabilitation, regression to the mean (ie returning to a baseline level of capability) doesn’t happen much in chronic pain rehab. Natural history doesn’t happen either, not four or more years after the original onset. Most treatments for chronic pain show very small effect sizes on both pain intensity and disability.

Progress towards goals is slow, and there are many – many! – flare-ups, set-backs, detours and plateaus. Because pain problems have lasted longer than expected, people have had time to worry, to be given inaccurate information, to have had poor sleep for ages, to have stopped doing the things that bring life into life, to have had several unsuccessful treatments – consequently, people with chronic pain often hold negative expectations about how effective a treatment will be.

How well do we prepare entry-level clinicians for the challenges of treatments not working? Despite the therapist “doing all the right things”?? Do we prepare them for the ambiguity and uncertainty of working without a clear diagnosis? without an algorithm? without a “simplifying process”? Chronic pain is complex!

How well do we prepare entry-level therapists not to take responsibility for a person’s outcomes? Or do we inculcate them into the idea that they must “get it right” all the time or they’ve “done something wrong”?

Do we spend so much time teaching a certain school of therapy, or set of special tests, that we forget to help them learn to listen well first? Do we teach them that mind and body are separate – and that psychological and psychosocial only come into play when “the bio” has failed to respond to treatment? Do we imply this, even inadvertently?

When do we teach entry-level therapists how to deal with therapy failure? How to work in the dark? How to revise their formulation when a treatment doesn’t have the intended effect? Where do we teach entry-level therapists how to seek and accept supervision – and how do we help them view supervision as a supportive opportunity to develop as a person and therapist?

And how well do we prepare entry-level clinicians to work well in a team, where they’ll come into contact with other clinicians seemingly “stepping into my scope”? In other words, where other clinicians have broad skills and experience, and who do what they do… Do we teach undergraduates how to be confident enough in their professional value that they stop being defensive?

Solutions, that’s right. I was going to suggest solutions.

Solutions include much more time working with other professions during training – and not just the ones handy to where they’re being trained. Solutions include ensuring the process of clinical reasoning is emphasised rather than the outcome. Solutions involve teaching undergraduates that they will carry on learning and that more experienced therapists from other professions will teach them a lot. Solutions might include ensuring that all students spend regular time with a supervisor who is not there to “correct” them, but instead to foster their self-reflection, to offer them support when they’re feeling overwhelmed, to encourage them to be OK to feel lost and not know the answers. And perhaps solutions involve recognising that chronic pain management is a specialist area of practice, and it is not musculoskeletal rehabilitation with a psychosocial twist.

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3), e663. https://doi.org/10.1097/PR9.0000000000000663

Lindblad, T. L. (2021, Jun). Ethical Considerations in Clinical Supervision: Components of Effective Clinical Supervision Across an Interprofessional Team. Behavior Analysis in Practice 14(2), 478-490. https://doi.org/10.1007/s40617-020-00514-y

O’Carroll, V., Owens, M., Sy, M., El-Awaisi, A., Xyrichis, A., Leigh, J., Nagraj, S., Huber, M., Hutchings, M., & McFadyen, A. (2021, May-Jun). Top tips for interprofessional education and collaborative practice research: a guide for students and early career researchers. J Interprof Care, 35(3), 328-333. https://doi.org/10.1080/13561820.2020.1777092

Perreault, K., Dionne, C. E., Rossignol, M., Poitras, S., & Morin, D. (2018, Jul). What are private sector physiotherapists’ perceptions regarding interprofessional and intraprofessional work for managing low back pain? Journal of Interprofessional Care, 32(4), 525-528. https://doi.org/10.1080/13561820.2018.1451829

Steuber, T. D., Andrus, M. R., Wright, B. M., Blevins, N., & Phillippe, H. M. (2021). Effect of Interprofessional Clinical Debates on Attitudes of Interprofessional Teams. PRiMER, 5, 14. https://doi.org/10.22454/PRiMER.2021.154149

Biopsychological pain management is not enough


I recently read a preprint of an editorial for Pain, the IASP journal. It was written by Prof Michael Nicholas, and the title reads “The biopsychosocial model of pain 40 years on: time for a reappraisal?” The paper outlines when and how pain became conceptualised within a biopsychosocial framework by the pioneers of interprofessional pain management: John Loeser (1982) and Gordon Waddell (1984). Nicholas points out the arguments against a biopsychosocial model with some people considering that despite it being a “holistic” framework, it often gets applied in a biomedical and psychological way. In other words, that biomedical concerns are prioritised, with the psychosocial factors relegated to second place and only after the biomedical treatments have not helped. Still others separate the relationships between “bio” “psycho” and “social” such that the interdependent nature of these factors is not recognisable.

Nicholas declares, too:

“… that cognitive behavioural therapy interventions that did not also include workplace modifications or service coordination components were not effective in helping workers with mental health conditions in RTW. That means, just like in the case of reducing time lost at school for children in pain, the treatment providers for adults in pain for whom RTW is a goal should liaise closely with the workplace. Unfortunately, as the studies from the systematic reviews examined earlier for a range of common pain therapies indicated, engaging with the workplace as part of the treatment seems to be rarely attempted.

I find this confusing. In 1999 I completed my MSc thesis looking at this very thing: pain management combined with a focus on using pain management approaches in the workplace. The programme was called “WorkAbilities” and included visits to the workplace, liaison with employers and even job seeking for those who didn’t have a job to return to. The confusion for me lies in the fact that I’ve been doing pain rehabilitation within the workplace since the mid-1980’s – and that while today’s approach for people funded by ACC is separated from pain management (more is the pity), there are many clinicians actively working in pain rehabilitation in the context of returning to work here in New Zealand.

I’m further puzzled by the complete lack of inclusion by Nicholas of occupational therapy’s contribution to “the social” aspects of learning to live well with pain. This, despite the many studies showing occupational therapists are intimately connected with social context: the things people do in their daily lives, with the people and environmental contexts in which they do them. You see, occupational therapists do this routinely. We work with the person in their own environment and this includes home, work, leisure.

For those that remain unaware of what occupational therapists offer people with pain, I put it like this: Occupational therapists provide contextualised therapy, our work is in knowledge translation or generalising the things people learn in gyms, and in clinics, and helping people do these things in their life, their way.

An example might help.

Joe (not his real name) had a sore back, he’d had it for about three months and was seeing a physiotherapist and a psychologist funded by ACC (NZ’s national insurer). Not much was changing. He remained fearful of moving especially in his workplace where he was a heavy diesel mechanic and was under pressure from a newly promoted workshop manager to get things done quickly. Joe was sore and cranky, didn’t sleep well, and his partner was getting fed up. Joe’s problems were:

  • guarding his lower back when moving
  • fear he would further hurt his back if he lifted heavy things, or worked in a bent-over position, or the usual awkward positions diesel mechanics adopt
  • avoiding said movements and positions, or doing them with gritted teeth and a lot of guarding
  • poor sleep despite the sleep hygiene his psychologist had prescribed
  • irritability
  • thoroughly enjoying the gym-based exercise programme
  • hating mindfulness and any of the CBT-based strategies the psychologist was offering him, because as he put it “I never did homework when I went to school, do you think I’m going to do it now? and this mindfulness thing doesn’t work!”

The occupational therapist visited Joe at home. She went through his daily routine and noticed that he didn’t spend any time on “fun” things or with his mates. His intimacy with his partner was scant because the medications he was on were making it hard for him to even get an erection, and his partner was scared he’d be hurt when they made love. Besides, she was fed up with all the time he had to spend going in to the gym after work when he wasn’t doing simple things around home, like mowing lawns, or helping with grocery shopping.

She went into his workplace and found it was a small four-person operation, with one workshop manager, two mechanics and one apprentice. The workshop was a health and safety hazard, messy and cramped, and open to the weather. The relationships between the team were strained with unpleasant digs at his failure to keep up the pace. The workshop manager said that he’d do his best to help Joe out – but in the end he needed to get the work out on time. The other mechanic, an old hand, meanwhile was telling Joe to suck it up and be a man, but also to watch out because Joe shouldn’t do as he’d done and shagged his back.

What did our erstwhile occupational therapist do? Absolutely nothing new that the physiotherapist and psychologist hadn’t taught Joe – but she worked out when, where and how Joe could USE the strategies they’d discussed in his life contexts. She went through the way he moved in the workshop and guided him to relax a little and find some new movement patterns to be able to do his work. She graded the challenges for him, and stayed with him as he experimented. She discussed alternating the tasks he did, interspersing tasks that involved bending forward with those where he could stand upright or even work above his head (in the pit). She discussed how he could use being fully present at various times during the day (mindfulness) to check in with his body and go for a brisk walk if he felt himself tensing up. She worked through communication strategies that they rehearsed and he implemented to let his manager know what he could – and could not – do.

They discussed his home life, and ways he could begin doing some of the household tasks he’d been avoiding, and she showed him how to go about this. They worked out the best time of day to do this – and to vary the exercise he did so that it wasn’t all about the gym. He started to walk over rough ground to get more confident for when he went fishing again, and he got himself a little stool to sit on from time to time. Joe and his occupational therapist talked about his relationship with his partner, and they met together with her so they could share what his back pain meant, the restrictions he had, what he could do, and how else they could be intimate. Joe was encouraged to rehearse and then tell his doctor about the effect of his meds on his sex life.

The minutiae of daily life, translating what is learned in a clinic to that person’s own world is, and always has been, the province of occupational therapy. It’s just a little sad that such a prominent researcher and author hasn’t included any of this in this editorial.

Just a small sample of research in which occupational therapists are involved in RTW.

Bardo, J., Asiello, J., & Sleight, A. (2022). Supporting Health for the Long Haul: a literature synthesis and proposed occupational therapy self-management virtual group intervention for return-to-work. World Federation of Occupational Therapists Bulletin, 1-10.

Berglund, E., Anderzén, I., Andersén, Å., Carlsson, L., Gustavsson, C., Wallman, T., & Lytsy, P. (2018). Multidisciplinary intervention and acceptance and commitment therapy for return-to-work and increased employability among patients with mental illness and/or chronic pain: a randomized controlled trial. International journal of environmental research and public health, 15(11), 2424.

Cullen K, Irvin E, Collie A, Clay F, Gensby U, Jennings P, Hogg-Johnson S, Kristman V, Laberge M, McKenzie D. Effectiveness of workplace interventions in return-to-work for musculoskeletal, pain-related and mental health conditions: an update of the evidence and messages for practitioners. J Occup Rehabil 2018;28:1–15.

Grant, M., Rees, S., Underwood, M. et al. Obstacles to returning to work with chronic pain: in-depth interviews with people who are off work due to chronic pain and employers. BMC Musculoskelet Disord 20, 486 (2019). https://doi.org/10.1186/s12891-019-2877-5

Fischer, M. R., Persson, E. B., Stålnacke, B. M., Schult, M. L., & Löfgren, M. (2019). Return to work after interdisciplinary pain rehabilitation: one-and two-year follow-up study based on the swedish quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 51(4), 281-289.

Fischer, M. R., Schults, M. L., Stålnacke, B. M., Ekholm, J., Persson, E. B., & Löfgren, M. (2020). Variability in patient characteristics and service provision of interdisciplinary pain rehabilitation: A study using? the Swedish national quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 52(11), 1-10.

Ibrahim, M.E., Weber, K., Courvoisier, D.S. et al. Recovering the capability to work among patients with chronic low Back pain after a four-week, multidisciplinary biopsychosocial rehabilitation program: 18-month follow-up study. BMC Musculoskelet Disord 20, 439 (2019). https://doi.org/10.1186/s12891-019-2831-6

Marom, B. S., Ratzon, N. Z., Carel, R. S., & Sharabi, M. (2019). Return-to-work barriers among manual workers after hand injuries: 1-year follow-up cohort study. Archives of physical medicine and rehabilitation, 100(3), 422-432.

Michel, C., Guêné, V., Michon, E., Roquelaure, Y., & Petit, A. (2018). Return to work after rehabilitation in chronic low back pain workers. Does the interprofessional collaboration work?. Journal of Interprofessional Care, 32(4), 521-524

Nicholas, M.K. (in press). The biopsychosocial model of pain 40 years on: time for a reappraisal? Pain.

Scopes, roles, interprofessional practice and person-centred healthcare


A topic that almost immediately gets my hackles up is the one of scopes and roles in pain management and rehabilitation. It’s like “Oooh but that’s MY stuff, get out of it!” and I can see Gollum saying “my preciousssss”…

I trained and graduated in 1984. As a raw newbie occupational therapist I couldn’t articulate much of what my profession brought to healthcare, except that I knew “doing”, “activities” or “occupation” was important to human wellbeing, and that I’d been trained to analyse these. I’ve learned a lot since then and got a PhD in the process. Developing as people and as clinicians is, I hope, deeply embedded in us as professionals.

Interprofessional practice is a model of healthcare recommended in pain management and rehabilitation (Oslund, et al., 2009). Interdisciplinary/interprofessional teams involve different health professionals working alongside one another using their areas of expertise, but where all use a common over-arching model such as a biopsychosocial approach. Teams meet regularly to collaborate on treatment goals and priorities (Ruan & Kaye, 2016). There is limited hierarchy and extensive communication, cooperation, and overlap between team members (Körner, 2010).

True interprofessional practice is rare. Why? Because teams on paper are not teams. Teams need time together both formally and informally, stability amongst members, a pool of common knowledge as well as an understanding of what each team member brings in to the mix. Needless to say, high trust is crucial, along with ongoing communication (Zajak et al., 2021). We can’t just use professional labels to know what another profession can offer because we [should] keep on developing.

One of the largest contributors to poor interprofessional teamwork is lack of confidence. Not just lack of confidence in the skills of the other team members, but lack of confidence in one’s own professional contribution. High trust in one another, and yourself is critical.

When you’re feeling uncertain and find it hard to articulate what you bring to a team, any encroachment on “your” turf (call it scope) will likely engender a worry that you’re unnecessary. That others are “taking over” – and in turn, this can mean you search for faults in what other team members do because this helps affirm your rights and your specialness. You might want to rigidly control who does what in a team. It boosts your sense of worth but at the expense of other team members, and more importantly, at the expense of the person the team is trying to help.

The thing is, the person with pain does not care which person in a team works with them. What they care about is that the clinician is knowledgeable, and empathic. Trustworthy. The quality of the interpersonal relationship accounted for 54.5% reduction in pain in one study by Fuentes (Fuentes et al., 2014). People with pain want to know that their individual needs have been taken into account in their treatment plan (Kinney et al., 2020).

If you’re finding it hard to work in a team, perhaps feeling vulnerable about your worth, try this:

Ask your team to meet for an hour, tops.

Ask each member of your team to say what they bring to the team – not just their profession, but what else? Consider age, humour, cultural background, additional courses, personal interests outside of work, the “social secretary”, the “librarian”…and professional skills.

Pool all of these contributions on a big piece of paper – use post-it notes of different colours for each person.

Group similar contributions together in the middle of the paper – and spread unique contributions around the outside.

Review the paper and ask each participant to add any contributions they’ve just been reminded of.

Take a good look at the common contributions and the unique ones: these are what make up your team and they’re there to use for better person-centred care.

You can add some reflective questions to this activity.

  • What are the areas of overlap? It could be goal-setting, offering information about pain, movement practices, addressing fear of pain/reinjury, helping build confidence…
  • What areas of uniqueness are there? These could be hypnosis, knowledge translation from clinic to daily life, exercise prescription, the ability to write a prescription for medications
  • What surprised you? This could be the degree of overlap, or the contribution you didn’t expect from someone, or perhaps a gap in the team’s knowledge or skills
  • What shows up in yourself as you review these contributions? These could be “yeah, right, I don’t believe you can do THAT!” or “but I can do that too!”

Handling your response to what shows up to that last question is where the enormous value of this activity lies. Remember, the team is there for the person with pain, not for you as clinicians. If you think someone is claiming a contribution you can do with more skill, this only means that you can offer that person help from time to time. If you think that you’d like to contribute in an area and you didn’t add that as one of your contributions, now is the time to put it on the paper.

Take a copy of that piece of paper, and keep it close to you.

Your mission from then on, should you choose to accept it, is to review this set of contributions when you are next developing a treatment plan for a person seeking your help. Choose the combination of clinicians that offers the range of skills and knowledge, the interpersonal skills suited, and the availability of each clinician so that the person you hope to help will be seen by a team, and not just a set of individual clinicians. Oh and add in a good case formulation as well…

Remember: it’s all about the person in person-centred pain management and rehabilitation.

Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: An experimental controlled study. Physical Therapy. 94:477–89.

Kinney, M., Seider, J., Beaty, A. F., Coughlin, K., Dyal, M., & Clewley, D. (2020, Aug). The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 36(8), 886-898. https://doi.org/10.1080/09593985.2018.1516015

Körner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), 745-755. https://doi.org/10.1177/0269215510367538

Oslund, S., Robinson, R. C., Clark, T. C., Garofalo, J. P., Behnk, P., Walker, B., Walker, K. E., Gatchel, R. J., Mahaney, M., & Noe, C. E. (2009). Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Baylor University Medical Center Proceedings, 22(3), 211-214. https://doi.org/10.1080/08998280.2009.11928516

Ruan, X., & Kaye, A. D. (2016). A Call for Saving Interdisciplinary Pain Management. Journal of Orthopaedic and Sports Physical Therapy, 46(12), 1021-1023. https://doi.org/10.2519/jospt.2016.0611

Wampold, B. E. (2018). The Therapeutic Value of the Relationship for Placebo Effects and Other Healing Practices. International Review of Neurobiology, 139, 191-210. https://doi.org/10.1016/bs.irn.2018.07.019

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Frontiers in Communication, 6(6). https://doi.org/10.3389/fcomm.2021.606445

The added stress of chronic pain on life


For a minute, I’d like you to grab an ice-cube. If you don’t have one handy, try this at home or when you’re having your next gin and tonic. Hold onto that ice-cube. Keep holding onto it. Put a cloth underneath if it’s going to melt, but keep holding it. Now do your grocery shopping list. Or balance your accounts. While holding the ice-cube.*

Now add some exercises. Exercises you don’t care for, but feel like you have to do “because they’ll help you get better”.

Keep holding onto the ice-cube. Oh, it’s melted?! Fine – go grab another. Hand too cold to pick on up? Never mind, go find one and just do it. And keep doing the grocery shopping list. And the exercises.

Add in a night of not sleeping. Make that a week of not sleeping.

Add in having a new medication to take every day at night at the same time. The medication makes your mouth dry, constipates you, and you can’t wake up because it makes you feel sluggish.

Keep holding the ice-cube.

Phone your employer to say you’ll be in, but a therapist is going to visit you at work to see what you can do. Hold onto the ice-cube. The employer says OK but when are you coming back to work full time? I need you, or I’ll have to get someone else in.

Grab another ice-cube, keep holding it. Hand getting numb and sore? OK, therapy will help that! Here’s some mindfulness to do. And breathe…. and don’t forget the exercises. And that other appointment with a case manager to sign your rehabilitation plan. And do the groceries while you’re there. Keep holding that ice-cube.

And don’t be like that! Don’t get snippy with the kids, just pull yourself together! Hold onto the ice-cube. Lie awake worrying about work and how you’ll balance the accounts. Forget to take the medications, feel terrible – all sweaty and nauseous. Turn up to the employer with the therapist in tow. Hold on to the ice-cube.

The therapist says you can’t do this, or that, and you need to break your work up into chunks like this, and here’s a gadget that might help. Your employer rolls his eyes at you behind the back of the therapist. Keep holding that ice-cube.

Case manager phones saying she’s very sorry, but the paperwork for your weekly compensation hasn’t been filled out properly, you’ll have to go to the doctor to get another certificate, talk to your employer and have you done your exercises yet? Do you need to see a psychologist? Hold onto the ice-cube.

Your partner, who has been magnificent up until now, loses the plot when he gets home today. Hold onto the ice-cube, don’t let it drop. Feel that pain. Breathe. Do exercises. Take meds. Worry about job. Worry about relationship – partner comes to bed but turns the other way. Realise you missed getting a warrant of fitness for the car, think about putting that on the list for tomorrow.

…and someone said people on compensation for pain are just “non-copers”

Cry.

If you’re a therapist, remember what you ask a person to do is only one thing in a vast, unfamiliar and confusing sea of things to do. All the while holding on to an ice-cube that’s burning into your hand….

*Try this at home so you can experience what it might be like to have pain that’s present, intense, and gets in the way of life. BTW it’s not a treatment for chronic pain!!

The demise of practical pain management


Cast your mind back to the last time you decided to create a new habit. It might have been to eat more healthy food, to do daily mindfulness, to go for a walk each day. Something you chose, something you decided when, where and how you did it, something that you thought would be a great addition to your routine.

How did it go? How long did it take to become a habit you didn’t need to deliberately think about? How did you organise the rest of your life to create room for this new habit? What did other people say about you doing this?

While we all know a reasonable amount about motivation for change – importance and confidence being the two major drivers – and as clinicians most of us are in the business of helping people to make changes that we hope will become habitual, have you ever stopped to think about what we ask people with pain to do?

It’s not just “do some exercise”, it’s often “and some mindfulness”, and “you could probably eat more healthily”, and “organise your activities so you can pace them out” – and “take these medications at this and this time”, “attend these appointments”, “think about things differently”… the list continues.

Now, for a moment, cast your mind back to the last few research papers you read, maybe even a textbook of pain management, the most recent course you went on, the latest CPD.

Was there anything at all on how people with pain integrate all of these things into their life?

Lewis et al., (2019) reviewed inpatient pain management programmes over 5 decades. They found 104 studies spanning from 1970’s to 2010’s. Unsurprisingly the content, format and clinicians involved in these programmes has changed – but you might be surprised at some other changes… Lewis and colleagues found that physiotherapy (primarily exercise) remained at similar levels over time, but programmes gradually became less operant conditioning-based (ie behavioural reinforcement with a focus on changing behaviour) to become more cognitive behavioural (working with thoughts and beliefs, often without necessarily including real world behaviour change), with reduced emphasis on reducing medications and less family involvement. While the same numbers of physiotherapists, doctors and psychologists remain, nurses and occupational therapists are decreasingly involved.

What’s the problem with this? Isn’t this what the research tells us is “evidence-based”?

Let’s think for a moment about effect sizes in chronic pain. They’re small across all modalities when we look at outcomes across a group. There are some gaps in our understanding of what, and how, pain management programmes “work”. We know that movement is a good thing – but effect sizes are small. We don’t know how many people maintain their exercise programmes even six months after discharge. We also don’t know how well movements taught in a clinic transfer into daily life contexts, especially where fear and avoidance are being targeted. We don’t know who, if anyone, carries on using mindfulness, cognitive strategies such as thought reframing or reality testing, and we don’t know many people leave a programme thinking they’ve been told their pain is “in their head” (though, to be fair, this is something we’ve had problems with for at least the 30 years I’ve been doing this work!).

So while assessment might be more “holistic” and outcomes more likely to be about quality of life and disability, the minutiae of how people with persistent pain integrate and synthesise what they learn in pain management programmes into their own life contexts is invisible. It’s not even part of many pain management programmes.

We could turn to the qualitative literature for some insights. Mathias et al., (2014) interviewed people two weeks after completing a programme. Munday et al., (2021) selected people toward the end of a three week programme. Farr et al., (2021) talked to people up to 24 months after a programme – but in the context of a peer-led support group (which, by the way, I think are marvellous!), Penney et al., (2019) interviewed veterans to identify outcomes, barriers and facilitators to ongoing pain management – but don’t indicate how long after a programme their participants were interviewed. So we don’t know what pain management strategies “stick” and remain in use, integrated into daily life.

So many questions come up for me! Do pain questionnaires measure what matters to people? Can a 0 – 10 response on an item of the Pain Self Efficacy Questionnaire (Nicholas, 2007) represent how someone draws on, and uses, coping strategies to do what matters? Does a response on the 0 – 10 Pain Disability Index (Tait, Chibnall & Krause, 1990) adequately capture how a person does their daily life? If we help people “do exercise” but they don’t continue with these exercises once they resume their own life – what is the point? Why are family members not included any more? How does this fit with New Zealand’s Te Whare Tapa Whā model of health?

The problem/s?

The health profession that entirely focuses on helping people do what matters in their life (occupational therapists use occupation or daily doing as both therapy and outcome) has had trouble describing our contribution. We don’t, as a profession, fit well into a medical model of health. We focus almost exclusively on the “Function” and “Participation” parts of the ICF – and we focus on daily life contexts. Researching our contribution using RCTs is difficult because we offer unique solutions that help this person and their whanau in their own context, and no-one’s daily life looks the same as another’s. We are about meaning, expressing individuality and self concept through the way we do our lives. This doesn’t lend itself to a clinic-based practice, or a hospital, or a standardised treatment, or treatment algorithms. Our contribution has been eroded over time. Very few pain management programmes incorporate occupational therapy – most are physiotherapy + psychology. This is especially noticeable in NZs ACC community pain management programmes.

Pain management is often based on the assumption that if a person is told what to do, perhaps gets to do it in a clinic with a therapist, this is sufficient. And for some people, especially those who view themselves in the same way as therapists (ie, individual responsibility), and people with the psychological flexibility and internal resources to just do it, they may do quite well. BUT consider the people we know who don’t. People from different cultures, lower socio-economic living, neurodiverse, those with competing values, lack of confidence, lack of personal agency – these are the people who don’t do as well in all of our healthcare, and especially those programmes relying on “self-management”.

Programmes also assume that what is done in a clinic can readily transfer to daily life. Clinics are contained, often purpose-built, usually regulated, and have a therapist handy. People are there for the one purpose. Daily life, on the other hand, is highly variable, holds multiple competing demands, other people question what you’re doing and why, is quite chaotic and messy. And there is no therapist. How does a person decide what to do, when, how, and why?

Remember your challenges with developing one new habit. How you had to stake a claim in your own life to create space for this new activity. How you sometimes forgot. How a change in one part of your life undermined you doing this new thing. How this was only one change. Only one. And what do we ask people with pain to do? And we don’t even bother to find out what is still being done 12 months down the track.

Practical pain management is about helping someone work out how to organise their week so they can add in this new exercise programme that might help, alongside having time and energy to be a good Mum, pick the kids up from school, sort the washing, do the groceries, oh and the car needs a new warrant, and I need a new prescription for my meds.

It’s about working out the best time of day to do some mindfulness – when will it do the most good? when can I fit it in? how do I deal with my partner wanting to get out and start the day while I’m meditating?

It’s about communicating to my boss, my colleagues and my customers that I need to get up and walk around – and maybe say no to some new projects at the moment. Perhaps I need to be more assertive about my own needs. Perhaps I’m worried I’ll lose my job because I need to make these changes….

In the rush to streamline pain management to the bare bones, I wonder if we have forgotten who it is all about. He tangata, he tangata, he tangata – it is people, it is people, it is people. Let’s remember that coping strategies and exercise and all the psychological approaches need to be continued for months, and even years. And this means helping people work out what our suggestions look like in their own life. Let’s not omit the profession that puts people and what their daily life looks like as its reason for being.

Tait, R. C., Chibnall, J. T., & Krause, S. (1990). The pain disability index: psychometric properties. Pain, 40(2), 171-182.

Farr, M., Brant, H., Patel, R., Linton, M. J., Ambler, N., Vyas, S., Wedge, H., Watkins, S., & Horwood, J. (2021, Dec 11). Experiences of Patient-Led Chronic Pain Peer Support Groups After Pain Management Programs: A Qualitative Study. Pain Medicine, 22(12), 2884-2895. https://doi.org/10.1093/pm/pnab189

Lewis, G. N., Bean, D., & Mowat, R. (2019, Sep). How Have Chronic Pain Management Programs Progressed? A Mapping Review. Pain Practice, 19(7), 767-784. https://doi.org/10.1111/papr.12805

Mathias, B., Parry-Jones, B., & Huws, J. C. (2014). Individual experiences of an acceptance-based pain management programme: An interpretative phenomenological analysis. Psychology & Health, 29(3), 279-296. https://doi.org/10.1080/08870446.2013.845667

Nicholas, M. K. (2007, Feb). The pain self-efficacy questionnaire: Taking pain into account. European Journal of Pain, 11(2), 153-163. https://doi.org/http://dx.doi.org/10.1016/j.ejpain.2005.12.008

Penney, L. S., & Haro, E. (2019). Qualitative evaluation of an interdisciplinary chronic pain intervention: outcomes and barriers and facilitators to ongoing pain management. Journal of Pain Research, 12, 865-878. https://doi.org/10.2147/JPR.S185652

Women, partner violence and pain


As the potential for greater repression of women’s autonomy grows (Afghanistan, United States, Mexico), along with racist and misogynist statements from business leaders (DGL CEO Simon Henry) it’s timely to look at pain in women. We already know that more women than men present with persistent pain (Blyth, n.d.), while women who are seen for their pain are more often misdiagnosed, offered psychiatric medication or psychological intervention only and have their experiences dismissed as “hysterical, fabricated, or nonexistent” (Samulowitz, et al., 2018). My daughter, when attending Emergency Department was offered a paracetamol and told “there’s no cure for being a woman” when seeking help for an ovarian cyst. Period pain is considered “normal” (Drabble et al., 2021). Pain in women is not a sexy topic.

Intimate partner violence is common among women. 27% of women who have had a partner report violence perpetrated against them. 24% of young women aged between 15 – 19 years report violence. Low-income countries reporting higher levels of intimate partner violence, and while data was not available for the past two years of covid-19 disruption, it’s expected that higher levels of violence are probable (Sardinha et al., 2022).

What about the intersection between partner violence and persistent pain? (BTW violence is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship and includes stalking, psychological aggression such as coercion, as well as physical and sexual violence).

Persistent pain is one of the most commonly reported health consequences of intimate partner violence (Walker, 2022), and women are more likely to be the recipients of partner abuse than men. Yet – open conversations about violence and persistent pain in women, recognising the signs and symptoms of partner violence in people seeking help for persistent pain, and adequate approaches to treatment are rare. Women may not disclose their situation for fear of being stigmatised, labelled unfairly, or having their pain – and their situation – trivialised.

Walker and colleagues (2022) carried out a systematic review of studies exploring the types of pain women experienced in association with partner violence, the severity of that pain, and the impact of pain on the person. They found that while pelvic pain was common amongst women who had been sexually abused, women also reported chest pain, back pain, neck pain, arthritis, and stiffness in joint or muscles, more frequent headaches, and more back pain – furthermore, women who had experienced partner violence reports higher pain severity, with 75% of women indicating moderate to severe pain, and the longer a women had been in an abusive relationship, the more likely they were to report higher intensity pain.

Interestingly, disability from persistent pain wasn’t measured often – only two studies from 12 included in the final review – but women with persistent pain from partner violence reported higher pain-related disability. They also reported worse impact on their mental health – more PTSD, anxiety and depression, with depression being one of the key mediator between a history of partner violence and ongoing pain.

The authors of this study (Walker et al., 2022) point out that it’s likely that women who have sustained partner violence and experience persistent pain are “not being adequately identified and responded to in clinical settings” – and that the fear of not being believed and the stigma of being on the receiving end of partner violence likely limits how many women openly discuss their situation.

Isn’t it time to get women’s pain prioritised? To get political about systems and processes that fail women? Isn’t it time to shift the narrative around women’s menstrual pain? To acknowledge that women are not mini men?

Finally, when we consider pain rehabilitation, we need to not only recognise that women have different priorities and goals for their lives than men, we also need to understand that doing rehabilitation is more complex for women than men – women report more difficulty prioritising their own rehabilitation over other responsibilities in their life (Côté & Coutu, 2010). Women may not even be referred for rehabilitation as often as men (Stålnacke et al., 2015). It’s time to prioritise understanding the lived experience of women as they pursue help for their persistent painand then do something different.

Blyth, F. (n.d.). Chronic pain in Australia: A prevalence study. Retrieved May 12, 2019, from http://www.ncbi.nlm.nih.gov/ pubmed/11166468

Daniel Côté & Marie-France Coutu(2010)A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?,Disability and Rehabilitation,32:2,87-102,DOI: 10.3109/09638280903026572

Drabble, S. J., Long, J., Alele, B., & O’Cathain, A. (2021). Constellations of pain: a qualitative study of the complexity of women’s endometriosis-related pain. British Journal of Pain, 15(3), 345-356.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018. https://doi.org/10.1155/2018/6358624

Sardinha, L., Maheu-Giroux, M., Stöckl, H., Meyer, S. R., & García-Moreno, C. (2022). Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. The Lancet, 399(10327), 803-813.

Stålnacke, B., Haukenes, I., Lehti, A., Wiklund, A., Wiklund, M. et al. (2015)
Is there a gender bias in recommendations for further rehabilitation in primary care of patients
with chronic pain after an interdisciplinary team assessment?.
Journal of Rehabilitation Medicine, 47(4): 365-371
http://dx.doi.org/10.2340/16501977-1936

Walker, N., Beek, K., Chen, H., Shang, J., Stevenson, S., Williams, K., Herzog, H., Ahmed, J., & Cullen, P. (2022). The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review. Trauma Violence Abuse, 23(2), 490-505. https://doi.org/10.1177/1524838020957989

Rehab Fails: What goes wrong in rehab 4


It’s not hard to choose rehab fails, the problem is more about when to stop! I tell a lie, it’s more about how to make changes so these things don’t happen.

Today’s #rehabfail is all about attempting to carve bits of a person off so each profession gets “their” bit to do with what they will. Oh boy, this is a doozy, and it comes to me off the back of seeing the return of the age-old argument about whether pain is “all about the bio” or whether the person gets a look-in. Cuz if it’s all bio then we just treat that bio and be done with it, right? It’s a question that also arises when we begin to ask questions about what the person understands about their pain and disability, when they <gasp!> show that they’re frustrated, demoralised, maybe sad or grieving for what they can’t do….

If I had a dollar for every time I’ve heard someone say “oh but I’m stepping out of scope” – usually in response to a suggestion that they incorporate cognitive behavioural principles in their work, or when someone says it might be a good idea to look into psychosocial factors – I would be wealthy and retired. I cannot believe how often therapists with a primarily physical orientation seem to think that asking someone how they’re feeling about their situation, what they understand might be going on, what they prefer, how they’re sleeping, how they’re getting on with their family… ALL these things is “out of scope!”

Seriously folks. Since when did being a human communicating to another human about how they are in the face of pain and disability turn into a “OOooh but I’m not a psychologist” kind of fear? Who else is going to be able to guide someone to a psychologist unless it’s the insightful clinician who is sensitive to when someone is feeling pretty rotten?

Another part of this chasm between “mind” and “body” is the idea that psychosocial factors are only relevant if or when the person “fails” therapy. Who failed, huh? And where did the idea that psychosocial factors are all negative come from? We all have psychosocial factors in our lives: our temperament, memories, assumptions, relationships, goals, routines, job, choices are all psychosocial, and some of them are even pretty positive!

The siloing of professions particularly in musculoskeletal pain rehabilitation is one of the least helpful things I’ve seen in health. The second is to have a “team on paper” where the “team” members do exactly the same things they do when working as a solo practitioner. Serial monotherapy does nothing for people living with pain. What I mean by this is every doing their therapy concurrently but failing to talk to one another, failing to modify what they do to suit the overall needs of the person, failing to have a common understanding of what one another do, and failing to support one another. How confusing is that for the person getting treatment?

Now I am not suggesting that psychologists should become physiotherapists, or occupational therapists become pharmacists, or even a full transprofessional approach (though this is something our NZ health ministry is aiming for over time). I am simply suggesting these things:

  1. Know that whole people are seeking help, not a knee or a belly pain or a back. Pains are experienced by people.
  2. Be human and listen to (and ask about) human things like: how is your job going? what’s your sleep like at the moment? what do you think is going on with your pain, what is your theory? how are you feeling in yourself at the moment? Open-ended questions about human experiences and habits – and follow up with more open-ended questions, and lots of reflective statements. Do this from day one. For everyone.
  3. Take some time to sit in with someone from a different profession. Make friends with them. Go have a coffee with them. See how they work with someone in common. Let them know this isn’t so you can be them, but so you can help your patients/clients understand a bit more about what seeing them might look like.
  4. Read about “whole person rehabilitation.” Matt Erb and Arlene Schmid’s book is awesome (and not just because I wrote a chapter in it! So did a heap of people! – click.)
  5. Dip your toe into understanding your patient’s life. Ask questions that help you understand how they’ve made the decisions they have. Nobody gets up in the morning to do dumb things that might hurt them: there are logical reasons – to them – for why they do what they do. We just need to get our heads around their reasons to begin to tease out the assumptions they hold (and we hold) that have influenced their choices. Remember we all do this.
  6. Never, ever think that you’re treating a back, or a knee, or a headache or a belly pain. You are always working with a person who is experiencing pain in a part of their body, and that pain has enough meaning for them to decide to ask for help. That’s what we’re actually working with.

Here are some readings discussing how we might build teamwork and whole person rehabilitation:

Bashir, U., & Siddiqui, A. S. (2021). Teamwork in chronic pain management and the way forward in low and middle-income countries. Anaesthesia, Pain & Intensive Care, 25(2). https://doi.org/10.35975/apic.v25i2.1477

Cartmill, C., Soklaridis, S., & David Cassidy, J. (2011, Mar). Transdisciplinary teamwork: the experience of clinicians at a functional restoration program. J Occup Rehabil, 21(1), 1-8. https://doi.org/10.1007/s10926-010-9247-3

Cassell, E. J. (2011). Suffering, whole person care, and the goals of medicine. In T. A. E. Hutchinson (Ed.), Whole person care: A new paradigm for the 21st century (pp. 9-22). Springer. https://doi.org/10.1007/978-1-4419-9440-0

Gordon, D. B., Watt-Watson, J., & Hogans, B. B. (2018). Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports, 3(3), e663. https://doi.org/10.1097/PR9.0000000000000663

Griffin, H., & Hay-Smith, E. J. C. (2019). Characteristics of a well-functioning chronic pain team: A systematic review. New Zealand Journal of Physiotherapy, 47(1). https://doi.org/https://doi.org/10.15619/NZJP/47.1.02

Maynard, M. T., & Gilson, L. L. (2021). Getting to know you: The importance of familiarity in virtual teams. Organizational Dynamics, 50(1). https://doi.org/10.1016/j.orgdyn.2021.100844

Mallick-Searle, T., Sharma, K., Toal, P., & Gutman, A. (2021). Pain and Function in Chronic Musculoskeletal Pain-Treating the Whole Person. J Multidiscip Healthc, 14, 335-347. https://doi.org/10.2147/JMDH.S288401