patient information

Don’t go to the internet to get good information about chronic pain
…it’s true, you know, the quality of the information about chronic pain found on the internet is poor – at least it was when this study was conducted (of course, that was before this blog got started!). ‘In December 2007, there were an estimated 1.3 billion Internet users worldwide with the usage growth increasing by 265% from 2000 to 2007’ – I don’t think that numbers will have decreased since then!
Anyway, in this study, Corcoran and colleagues developed a scoring tool to measure the quality of the material they found when searching the internet using the terms ‘chronic pain’, and using the popular search engines like Google and Yahoo. Their scoring was developed from terms from the Health on the Net code, with some modification to improve reliability.

Their search process copied the ‘typical’ searches carried out by people looking for information on the internet – that is, they used the search term ‘chronic pain’, hit the first or maybe the second page of a website and stopped there. It’s interesting to note that the patterns Corcoran and colleagues used are very typical of the patterns I see on this blog – people hit the first page and then maybe go to one other page, but then leave.

What did they find?
‘A total of 50 websites were retrieved, 10 per search engine. There were 23 websites duplicated across the search engines, leaving a total of 27 websites to be scored’

I suppose it’s a blessing that the search engines found relatively similar sites, so there doesn’t appear to be any advantage in using one search engine over another. And from the quality scoring, there wasn’t any difference in terms of quality between the different search engines. What was a bit worrying was that only two sites scoring as ‘very good’ or ‘excellent’ – and one of them is wikipedia (which as we know, is subject to frequent revision! – and may change from day-to-day…)
Just to give you an idea of the areas considered under the quality scoring:

Authors contact
Reference quantity
Reference quality
Original date
Revised updates
Total score

So, the overall quality of the sites across these headings was, on the whole, not good. In fact, combining ‘technical’ aspects (ie, did the site cover a range of interventions for each pain condition, did it identify the type of pain condition it discussed and so on), and the ‘quality’ aspects as I’ve listed above could generate a score of 22. These scores were then converted to a percentage. The authors found that ‘Only 2 out of the 27 websites we evaluated earned a grand score that ranked them as either excellent or very good. The vast majority was judged to be fair or poor.’

They also found ‘About 67% of sites had no statement of purpose, 60% were unreferenced, whereas 75% of sites mentioned drug therapy in some form, and over 30% (9 sites) omitted any mention of nondrug therapies’

So, the average web surfer looking for information on chronic pain is likely to find sites about drugs, the sites probably don’t identify why they’re published, don’t have any references to support their claims, and don’t say much about nonpharmacologic strategies. And we wonder why patients turn up with a weird and wonderful selection of ‘new’ drugs to try.

As Corcoran and colleagues point out: Patients with a chronic condition are more likely to search the Internet for healthrelated information than acute patients, and 39% of patients attending a university pain center had searched specifically for pain information on the Internet. This tendency to search for information, coupled with the poor quality of information available, increases the risk of patient misinformation which can lead to conflicting emotions. …Patients search the Internet because they feel they have not been fully informed…It is of concern that the information patients find on the Internet differs from what their doctor provides.’

What bothers me is that some health providers slate the patient for heading to the internet to find out more about their condition. Maybe it’s not the patient who should be criticised, it’s the quality of the site! How many of us write adeqautely referenced material for patients? How many public hospital services take the time to generate informative web-based material for patients, resorting instead to photocopied bits of paper (and would these bits of paper score any more highly in terms of quality than what these authors found on the web?)

This year I hope to work with Health Navigator and the NZ Pain Society to produce informative web-based material that will be accessible to patients looking to self manage their health condition. Perhaps if, in New Zealand at least, we combined forces and developed really sound material as a joint project, we might be able to ensure our patients can get good information when they go to google or bing or yahoo. If you are writing and putting your information on the internet, consider the Health on the Net code of ethics, join MedBloggers – make sure your material is accurate and of good quality. Public health promotion on the internet can be something that individuals can influence!

Corcoran TB, Haigh F, Seabrook A, & Schug SA (2009). The quality of internet-sourced information for patients with chronic pain is poor. The Clinical journal of pain, 25 (7), 617-23 PMID: 19692804

A couple of interesting podcasts

If you haven’t ever listened to a podcast, maybe today’s post will be an eye-opener.  PainAwareness was set up during the month of September which is Pain Awareness month, but has extended beyond that.  While the content is a little limited at present, there is an interesting podcast about chronic pain (three, actually!).  While it has been sponsored by Ortho-McNeil-Janssen, the emphasis is on exercise and chronic pain.  People from the US will recognise the Olympian Nikki Stone who features on the podcast and experiences chronic pain herself.  This is a good mode for providing patients with a positive message about the usefulness (and safety) of exercise despite experiencing ongoing pain. (more…)

Cognitive behaviour for pain worksheet – client information

It’s not always easy to find freely available client worksheets that reflect ‘real life’ situations, and are written for the age and reading level of the people we often see. For example, most of the people I work with are practical ‘hands-on’ people who don’t like reading or writing, and are either very visual ‘show me what to do’, or kinesthetic ‘let me do what I need to do’. So they can find some of the materials available for cognitive behavioural therapy rather unrelated to their own situation.

I thought I’d share with you a client worksheet I recently developed for a man who has always worked in very practical metal fabricating work. Although he is very intelligent and readily learns new concepts, he is not the sort of person to read a book for leisure, and he dislikes writing.

He is happy to carry out ‘missions’ (I never use the word ‘homework’ because it reminds people too much of school!), but strongly prefers them to be action-based, and if there is any recording to be done, that it be ticking boxes rather than writing sentences. Does he sound like any of your clients?!

CBT worksheet for client handout

The worksheet attached (above) has a brief explanation of what CBT is, then three pictures of activities. The ones used in this example were relevant to the person I was working with – and it’s not terribly difficult to replace these examples with ones relevant to the individual you’re working with.

If you’re using something like Microsoft Word, you can go to the clipart section on their website and there are a lot of photographs you can find showing everyday activities. If none of these fit, very inexpensive clipart CD’s are available with literally 1000’s of different photographs of people and activities that you can use.

I used these because although I would love to have taken him to his own workplace and home, in this instance I was only able to see him at the Centre, and photographs are much more able to elicit automatic thoughts (AT’s) than just talking about a situation.

I then ask him to tell me what was going through his mind, and write this down in the speech bubble beside the relevant picture. Sometimes at this point it’s helpful to work through the AT’s so you access the underlying beliefs, attitudes, or rules that are being expressed – because often you’ll elicit an exclamation like ‘Oh no!’ or a swear word, which is ‘shorthand’ for the unstated but highly relevant belief that is being elicited. The next step is to ask about the emotion that occurs as a result of the statement – and then to write that down in the thought bubble.

This then allows you to identify three separate instances when an automatic thought can be identified, as well as recording both the thought and the emotion very briefly and with graphic illustrations rather than a whole lot of writing. Even if, in the end, there is writing, the photographs seem to help reduce the ‘brain fog’ that can get induced by seeing a lot of writing all on one page.

The final part is to work through one example of an AT and its effect, look at the pro’s and con’s, perhaps work through any thinking patterns (I use this word rather than ‘maladaptive’ or ‘errors’ because it’s less demoralising to hear that it’s a pattern than a fault or error), and replace with a more helpful but equally true statement.

See what you think – and let me know how this works for you.

be careful what you say...

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