Psychology

What does using a biopsychosocial framework mean in practice?


A good friend of mine told me that during her training (as a physiotherapist), psychosocial factors were “what you blame when your treatment doesn’t work”. It’s something I’ve heard more than once. I’ve also been asked many times “…but are you sure you’re not doing something outside your scope of practice?” when I talk about using cognitive behavioural principles and ACT (Acceptance and Commitment Therapy) and other psychological strategies. And some of you might have seen earlier posts of mine where I ask “How social is your biopsychosocial model?”

Today’s medical students are trained in using a biopsychosocial framework in their undergraduate years. They leave medical school, begin their hospital and advanced training, and I guess I wouldn’t be alone in asking “what happened to the psychosocial?” when we see them working.

So today’s post is a bit of a reflection and a musing on what I think using a BPS approach might mean in pain practice.

BPS is, I think, less of a “model” than a way of thinking. Thinking that is based on a systems approach – every factor affects and is affected by every other factor. In fact, Engel, the originator of this way of viewing human health, was strongly influenced by general systems theory which was developed by Ludwig von Bertalanffy, a biologist who lived between 1901 – 1972. General systems theory was a model describing processes thought to be common in many different fields of knowledge. General systems theory is based on these five beliefs:

(1)  There is a general tendency towards integration in the various sciences, natural and social.

(2)  Such integration seems to be centred in a general theory of systems.

(3)  Such theory may be an important means of aiming at exact theory in the nonphysical fields of science.

(4)  Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.

(5)  This can lead to a much-needed integration in scientific education.

Engel then applied this to a model of the influences on human health. At the time he wrote his seminal article (Engel, 1977), psychiatrists were being challenged by reductionism on the one hand, particularly around approaches to mental health – the distinction between “diseases” where biological causal factors are influential, such as neurological disorders, and “problems of living” such as alcoholism, where the relevance of biology was, at the time, hotly debated; and concern that psychiatrists might lose ground to nonmedical practitioners such as psychologists. It’s an argument that continues today: should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management? (For a very interesting discussion of socio-political debates about this, read Wilson, N., Pope, C., Roberts, L., & Crouch, R. (2014). Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain. Social Science & Medicine, 102(0), 138-145. doi: http://dx.doi.org/10.1016/j.socscimed.2013.11.055)

Back to the story. The broad BPS “model” can’t be tested, and to some, was never intended to be a “scientific” model but rather a discussion tool. A way of shaping a dialogue between the person seeking help, and the clinician wanting to understand what was influencing how and why this person was presenting in this way at this time. I like to think of it as a way to remember that the person seeing you is a person-in-context.

We can argue the toss about exactly which factors belong in which “bit” of a biopsychosocial approach, but broadly speaking, we want to understand biological influences on health. Some of these are genetic (a bit hard to investigate for most of us), some of these are environmental (rickets? Vit D deficiency?), some are other organisms (M. leprae and M. lepromatosis? – Leprosy to you and me). Some are associated with what people do – tripping, jumping off things; while some are associated with what people don’t do – manage diabetes, exercise. The bio part is far more readily assessed and addressed than the other messy bits and pieces, so I won’t deal with that any further.

The psychosocial, on the other hand, is messy. It’s muddled and hard to measure and changes over time and geography and culture.

To me, it means remembering that when two people get together, it’s not just about the words we use, it’s about what we both bring to the setting in terms of experience, habits, expectations, vulnerabilities. It’s about where we meet. It’s about the purpose of meeting. It’s about recognising that everything we say and do is imbued with meaning – but it’s also about not necessarily knowing what we know, or what we don’t know.

So if I’m practicing in a biopsychosocial framework, I’m going to have to know a great deal about myself and my assumptions, my attitudes, habits, how others see me, and even what I don’t know. And the same applies to my knowledge about the person I’m seeing – only because I’m usually the “treatment provider”, I need to shape my conversation so that it’s OK for that person to tell me about this stuff, and this means knowing a bit about how people tick. I especially need to know how to hear what the person coming to me is saying – and not saying.

I see much that is called “psychological” as being about how we communicate and what we know about helping people change behaviour. I’m not “doing psychology” when I teach my child how to tie shoelaces, yet I’m using psychological techniques – modeling, reinforcement, verbal instructions and so on. Likewise when I’m helping someone feel OK about driving their car when they have back pain, I’m using psychological techniques such as verbal instruction, grading the difficulty, encouraging, supporting and so on. To suggest we can’t use psychological techniques to enable normal function is unthinkable.

Using CBT or ACT or motivation interviewing simply means refining my interpersonal skills so that I can optimise the chances that the person feels heard, can understand what I’m on about, and begins to feel OK about taking steps towards the life they want and being themselves. It’s about learning ways of explaining things, learning how to show that I’m listening, learning about the right level of support and challenge that will enhance the chances of success. Most people who live with chronic pain probably don’t need to see a psychologist – they need someone to help them make sense of pain, to show they’re there as they find their way through, and celebrate when they’re doing what’s important in their lives. I think all health professionals should be doing this.

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

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How much do you really need to deal with catastrophising?


Catastrophising is a popular concept in pain management. It’s been associated with poor outcomes in major joint replacement (Riddle, Wade, Jiranek and Kong, 2010); spinal fusion (Abbott, Tyni-Lenne & Hedlund, (2010); in experimental pain modulation (Bartley & Rhudy, 2008); in cancer pain (Bishop & Warr, 2003); and influences interpersonal relationships (Buenaver, Edwards & Haythornthwaite, 2007).

I’m often asked: so, what do I do about it? Can it be treated? What does it really mean? Should I (any kind of non-psychologist) try to treat it, or should I leave it to the psychologists?

The short answer is, I think, yes we need to be aware of catastrophising, yes we can do something to help people become less likely to catastrophise, and yes I firmly believe any and all health professionals have a contribution to make to reduce the tendency to catastrophise simply because it can be so influential for distress, function and disability.

What does catastrophising really mean?

Catastrophising is, basically, the tendency to think the worst about a situation. It probably has some adaptive function in that it helps people identify all the things that can go wrong so they can do something to reduce that risk. On the other hand, it’s not such a wonderful thing when it leads to ruminating (brooding), feeling helpless, and to magnify (or emphasise) all the disasters that could happen, when the probability is really quite low (Sullivan, Bishop & Pivik, 1995).

It’s likely that most of us will have, at one time or another, anticipated the worst. Most of the time the worst doesn’t happen, and we go our way, reassured that we’ve planned for, and managed the situation more effectively than if we’d carried out regardless. But for people who tend to catastrophise about their pain, the risk is fairly high that they’ll experience more distress, depression and disability than those who don’t.

I want to point out that identifying that someone tends to catastrophise does not mean their fears should be dismissed out of hand.  The person who tends to catastrophise is likely to disagree with you, feel their concerns are being trivialised, feel rejected and less likely to talk to you about their concerns. Not the way to maintain a therapeutic relationship!

How can you tell if someone’s catastrophising?

The main assessment measure of catastrophising is Sullivan, Bishop & Pivik’s “Pain Catastrophising Scale“.  It’s not the only measure, but it’s one of the most well-known. It’s relatively brief, and has excellent psychometric properties. But if you’re not comfortable using a pen and paper measure, how else can you decide if someone’s tending to think this way?

Some good questions to ask are:

“What do you think is the most likely outcome of this [procedure/painful event]?”

“How are you feeling about this pain?”

“What can you do to help yourself when your pain is like this?”

“How much can you distract yourself from the pain?”

“What do you think this pain means? What’s your theory about this pain?”

If the person answers negatively – for example, they say they can’t even think about an outcome it’s so bad, or they don’t think it’s ever going to get better, or it’s “terrible”, or “awful”; if they say they can’t distract themselves from the pain, they keep thinking about it all the time; and if they think there’s nothing they can do to help themselves, they feel helpless or hopeless; and if they think the pain means something sinister or bad – then you’re likely to have identified someone who is appraising their situation more fearfully than is helpful.

If the person says “Oh but it really is that bad!”

Remember when you were a kid and were terrified of the dark, or bugs, or things under the toilet lid? or when you were really upset and someone said “Calm down!” – remember that flash of anger that the other person was just not aware of how terrified you were? Simply disagreeing or correcting someone is not going to reduce their anxiety.

I find that first of all it’s important to reflect to the person that you understand they are really worried by their pain. Saying something like “It seems that your pain is really bothering you, and you’re really worried about what it means now and might mean in the future. Have I understood you correctly?”

I then find it useful to unpack the specifics of what the person is really worried about. I might ask “When you say the pain is terrible, what does that mean? What do you think might happen?”

What I’m trying to do is reduce the global appraisal the “everything” is “awful”. I want to find out the details, the underlying beliefs that are underneath the fearful appraisal. So, for example, if the answer to the question above is “I feel like I’m going to die, I can’t breathe and it’s frightening” or “I think it’s never going to end, it’s going to be there all the time, forever”, I can begin to gently reality test these beliefs and also provide some skills to help the person get through them.  I firstly reflect what I’ve heard: “It sounds so scary, not to be able to breathe – no wonder you’re feeling afraid” or “I’d be worried too, if I thought my pain was going to be there all the time, forever”.

Then I might begin suggesting we work on ways to handle the emotions associated with this belief (it’s very hard to reality test if the person is very distressed). “I wonder if we could just spend a minute looking at some ways to help you deal with your feelings, so they don’t wind your nervous system up more? Even if it’s frightening, it’s hard to deal with when your body is getting very stressed, so tell me, what do you find works well to help you calm down?” I might either use what the person says, or teach some diaphragmatic breathing and mindfulness.

Then it’s often a good time to work through a nonthreatening explanation of pain. There are so many ways to present this – YouTube videos of Lorimer Moseley “explain pain”, or Mike Stewart “Know Pain”, or the 5 minute pain video by Hunter Integrated Pain Service. Or you can use your own explanations and metaphors that are meaningful to the person. A case formulation can be helpful too.

When should you refer to a psychologist?

I think most people with chronic pain are fine just learning simple skills like breathing, mindfulness and gently approaching movements that they’ve been worried about doing. Even better if this is carried out with a strong eye to what the person can do and wants to be able to do in their everyday life. Success does breed success.

But there are a percentage of people who really struggle with catastrophising. If you find that the person you’re working with can’t use breathing to calm down, finds it really difficult to stop brooding (especially if this is going on all night!), or finds it very hard to accept a different way of viewing pain, then it’s time to work together with a psychologist to develop an approach that combines what you do (restoring occupational engagement or function) with cognitive therapy or ACT (Acceptance and Commitment Therapy). I personally find it’s people who have very rigid beliefs about their pain, about how the world works, and who find it difficult to experiment and try new things that need this kind of input.

So – should we think about catastrophising in our clinical work? Definitely yes. It’s too important to omit. Should we help people who tend to think this way? Definitely yes, it’s not necessarily the remit only of a psychologist, and I’d argue that we ALL need to contribute.

 

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

Bartley, E.J., Rhudy, J.L. (2008). The influence of pain catastrophizing on experimentally induced emotion and emotional modulation of nociception. Journal of Pain, 9(5), 388-396.

Bishop, S.R., & Warr, D. (2003). Coping, catastrophizing and chronic pain in breast cancer. Journal of Behavioral Medicine, 26(3), 265-281.

Buenaver, L.F., Edwards, R.R., & Haythornthwaite, J.A. (2007). Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain. Pain, 127(3), 234-242.

Riddle, D.L., Wade, J.B., Jiranek, W.A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Sullivan, M.J., Bishop, S.R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7(4), 524. doi: dx.doi.org/10.1037//1040-3590.7.4.524

An allied health response to primary care for musculoskeletal aches and pains


For as long as I can remember, the joke about doctors saying “take two paracetamol and ring me in the morning” has been a pretty accurate reflection of reality – but no more perhaps?

A large review and meta-analysis of randomised placebo controlled trials of paracetamol in back pain and osteoarthritis has found that although paracetamol can provide a limited reduction in pain in osteoarthritis but not at a clinically important level, there is an elevated risk (four times) of having abnormal results on liver function tests (Machado, Maher, Ferreira, Pinheiro, Lin et al, 2015). The meaning of this elevated risk on liver function isn’t clear, but what is clear is the very minimal effect of what has been used as a mainstay drug for two of the most common complaints in the world.

Oh what are we to do? Because if the findings about paracetamol are stunning, add to it the clear evidence of harms associated with nonsteroidal anti-inflammatories, and we have a situation where the two most common front-line treatments for musculoskeletal pain are being strongly questioned. What’s a busy GP meant to do?

As a community, I think health professionals working with people who have musculoskeletal pain need to begin a concerted campaign to show the value of nonpharmacological approaches to managing life with aches and pains. We already have this beginning with some of the physiotherapy social media campaigns – see a physio first! But I think we could add “See your allied health team first”.

What would it mean to see an allied health professional first? And what would allied health professionals need to do to make this a valid option?

I think allied health professionals would need to make some changes to how we assess people presenting with pain – I wouldn’t want to ban the biomechanical, but here’s a question: how well do physiotherapists consider the psychosocial in their history taking? Luckily I don’t need to have the answer because Rob Oostendorp, Hans Elvers and colleagues have done the work for me.  In this study, therapists were observed conducting their first assessment with a new patient experiencing chronic neck or back pain. Their interviews were reviewed against the SCEBS (Somatic, Psychological (Cognition, Emotion and Behaviour) and Social dimensions of chronic pain), and given scores for how well the interviews explored these domains. Perhaps unsurprisingly, history taking for the Somatic dimension (how sore, where are you sore, what triggers etc) was excellent, with 98% including this area. BUT, and you’d expect this perhaps, Cognition was 43%, Behaviour was 38%, Emotion was 28%, and Social was 18%. What this means is that despite the clinicians themselves considering their coverage for all but the social domain as being “adequate”, in reality the only aspect that these clinicians covered well was the most basic area – “what does it feel like?”.

Challenging indeed.

Now, what would happen if we then examined what these clinicians do with that information? Because if we’re not so wonderful at collecting useful information across domains, my bet is that we’re even worse at combining this information to make sense of it – in other words, developing useful formulations.

Unfortunately I don’t have any information on how we as allied health clinicians use the information we collect, but if my experience as an educator and the very limited number of papers discussing formulations is anything to go by, I don’t think we’re doing too well. I suspect we tend to collect information then blithely continue doing what we’ve always done in terms of treatments. And I’m sorry I don’t have the evidence to support my hunch – would someone take this on for a project, please?

I think allied health professionals also need to make some changes to how we present what we do to the general public. While most people in the general public know that physiotherapists help people move, osteopaths are gentle and work with their hands, chiropractic looks after backs and necks – I’m not so sure anyone really knows what occupational therapists might offer, and I’m certain there would be some angst if psychologists were recommended as front line clinicians for musculoskeletal problems!

You see, while we’ve been concerned about a biomedical dominance in musculoskeletal pain, we haven’t been as good at helping the general public recognise that aches and pains are fairly common and often not a sign of pathology. We’ve been pretty poor at showing the value of relaxation, mindfulness and down-regulation as useful ways to deal with pain. We haven’t addressed the need to engage in occupations and activities that are fulfilling and enjoyable and enriching. In fact, I venture to say that we have almost wholly bought into the biomedical model when it comes to how to conceptualise musculoskeletal aches and pains. We are as guilty as anyone for considering an ache or pain as a sign that the person needs to be “fixed” or “mended” or “aligned” or “stabilised”.

I think a more radical approach, and one that allied health professionals can really endorse because there is evidence for it, is that living well involves being fully human beings. That means allowing ourselves to engage in what we love to do, to not only be active but also to relax, to be exuberant and to be peaceful. To think of our lives as a whole, rather than an isolated ouchy hip or knee or neck. And to look to our whole lifestyle as key to living well rather than “treating” the bit that happens to be bothering us right now.

Imagine that – an allied health workforce that puts out the message that life and wellbeing are the products of balancing all the wonderful facets of being human.

 

 

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

Oostendorp, Elvers, Mikolajewska, Laekeman, van Trijffel, Samwel, Duquet (2015). Manual physical therapists’ use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice. The Scientific World Journal, 2015, art. 170463, doi: http://dx.doi.org/10.1155/2015/170463

Chronic pain as psychiatric disorder


For years I’ve taken a stance that chronic pain is not a psychiatric disorder. Yes, it’s associated with depression, anxiety and a host of other problems, but in itself it’s not primarily a mental health problem. I was taken to task for this the other day. The argument went like this:

“Pain disorder”: chronic pain…thought to be caused by psychological stress.  I argued that I didn’t like the label, and have met more people with psychological problems after they’ve developed chronic pain, rather than chronic pain initiated through psychological stress. The International Association for the Study of Pain notes accompanying the definition of pain states:

“Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons…. pain most often has a proximate physical cause (http://www.iasp-pain.org/Taxonomy?navItemNumber=576).”

Some people argue that this set of statements doesn’t consider central sensitisation (it was written before there were ways to examine living brain function) – but the end result was, as intended, to equate the experience of pain with only the experience of pain, rather than nociception or tissue damage. The person who disagreed with me suggested I was denigrating those with a mental health diagnosis – I hope I’m not, because illness affects people whether it’s so-called “physical” or “mental”.

Studies have shown that some people do develop chronic pain after being exposed to workplace stress – but haven’t been able to demonstrate that this is a direct stress —> pain relationship. Instead there could be any number of mediating and moderating factors, such as genetic predisposition to chronic pain, tendency to respond to stress with fatigue and increased risk of making errors, response from within the workplace system, working faster and harder because of stress, limited attention to recovery and so on. To show a direct relationship between stress and developing chronic pain, we’d need to see clear evidence of an impact on biological systems that are involved with both stress and pain, and we’d need to see a dose-response relationship and so on. There’s some suggestion that chronic stress may influence the HPA axis, particularly during childhood development, but the main hypothesis about stress and cortisol and neuroinflammation (the glucocorticoid cascade hypothesis) doesn’t appear to have translated well from animal studies to humans (Frodl & O’Keane, 2013).  Quintner and colleagues have suggested fibromyalgia may be the outcome of long-term adaptation to stress, but this hypothesis has not yet been rigorously tested (Lyon, Cohen & Quintner, 2011).

My stance on stress and chronic pain is that having chronic pain is extremely stressful. When a person experiences pain it disrupts and interferes with usual bodily experience during movement and rest. Being unable to do what’s important in life is frustrating, and can lead to social rejection – social rejection itself activates a number of neural pathways that are very similar to those active in chronic pain (MacDonald & Leary, 2005). There’s no doubt that for some people, the demoralising effect of trying time after time for a diagnosis, and the search for effective treatment is stressful enough to produce depression and/or anxiety, and certainly a sense of hopelessness and helplessness. If you happen to be vulnerable to mood problems, or to the effects of stress on a sensitive nervous system, then I’m certain there is a relationship between the two. But not in every case, and not all the time. And the jury is still out on which came first: the mood problem or the chronic pain.

Whatever, I have other reasons for not wanting chronic pain to be labelled a psychiatric disorder. Like it or not, mental health problems are not as well accepted socially as say, breaking a leg or having the flu. Despite the vigorous efforts of many people to raise awareness about depression and anxiety, it’s not anywhere near as easy to announce to people “I’ve got depression” than it is to say “I’ve got the flu”. It’s more difficult if you have chronic pain. Not only is there a really strong belief in the general community that pain should be associated with some sort of visible tissue insult, this belief carries through to many health professionals. Hopefully that’s changing, but far too slowly. What’s worse, many insurers and much compensation law identifies that if there’s no tissue damage, or the problem can’t be imaged, then pain is not a compensable condition. This places the person experiencing pain in an incredibly difficult position – how to demonstrate to people around them that they have a problem that isn’t imaginary and can’t be shrugged off.

Now add another layer of complexity to the argument. By labeling chronic pain a psychiatric disorder, the person being thus labelled experiences a double-whammy. Their pain may be real but not acknowledged, their suffering may be acknowledged but labelled a psychiatric problem. And very often treatment for psychiatric conditions is poorly funded, with limited attention to a biopsychosocial model or to an interdisciplinary approach.

A person given a diagnosis of “somatic symptom and related disorder” (according to DSM 5) is meant to mean they have “somatic symptoms associated with significant distress and impairment.”  The diagnosis is to be made “on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms) rather than the absence of a medical explanation for somatic complaints.” (See DSM-5, p. 309.)

I wonder, what are “abnormal” thoughts, feelings and behaviours in response to pain?  How is this judged? Who does the judging? What’s normal? Simply having pain that no-one can explain is, in itself, distressing. I’d have thought this was a pretty normal response.

The American Psychiatric Association states that the DSM 5 Pain Disorder diagnosis “takes a different approach to the important clinical realm of individuals with pain”. They go on to say “In DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.”(click here for the document)

By acknowledging that it’s not possible to distinguish between pain associated with psychological, medical, injury or both, I think this category is a catch-all. I think it’s acknowledging that chronic pain is a problem that many people with mental health problems experience, and it recognises that clinicians working with those who have mental health problems need a box to tick to enable them to address the issues and be paid for it. This isn’t attacking those clinicians who use DSM V to justify their involvement with people who experience chronic pain. But I think it’s a clumsy way of addressing the underlying issue that means insurers and legislators STILL believe there has to be tissue damage, or something we can “see” before a person can have real pain.

 

Frodl, Thomas, & O’Keane, Veronica. (2013). How does the brain deal with cumulative stress? A review with focus on developmental stress, HPA axis function and hippocampal structure in humans. Neurobiology of Disease, 52(0), 24-37. doi: http://dx.doi.org/10.1016/j.nbd.2012.03.012

Lyon, Pamela, Cohen, Milton, & Quintner, John. (2011). An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome). Pain Medicine, 12(8), 1167-1178.

MacDonald, Geoff, & Leary, Mark R. (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological bulletin, 131(2), 202.

Stepping out of the glue: How to generate goals


Chronic pain has been called one of the “most powerful and insidious disruptors” of routine, habit and wellbeing (Karoly, Okun, Enders & Tennen, 2014).  When a person experiences pain, a whole range of mechanisms come into play and work together to use thinking and processing space, and especially those areas we use when we’re developing and achieving goals.  When people are first trying to make sense of their situation, they can find it hard to think about future goals and plans, and instead focus on trying to solve the problem of pain – many people call this time like being in limbo (McGowan, Luker, Creed & Chew-Graham, 2007).

It’s not surprising, then, that when clinicians begin to work with someone who has had pain for a very long time, it can be very difficult for them to think of a “goal”. After all, not everyone sets goals anyway (I heard somewhere that it’s about 3% of people – but I can’t find the research to support it). But in pain management, funders often ask clinicians to work with the client to “set goals” for therapy from the first day as a way to ensure a client-centred programme, increase motivation, and monitor outcomes. This can be a problem in a couple of ways: first of all, if the person doesn’t have goals because they’ve been in “limbo land” for a long time, and feel pretty demoralised or their goal relates to “getting rid of the pain”; secondly, if the person has vague ideas that are difficult to set into the typical “SMART” formula (incidentally, I really don’t like that acronym!); thirdly, if the person doesn’t have strong ideas about what they want from therapy, the clinician can set the goals for them, and perhaps not those the client is really all that interested in; and finally, it’s hard to set goals without having spent some time listening to and collaborating with the client.

Pain can be experienced as a major obstacle to motivation for setting goals. Negative mood associated with pain can reduce motivation to think ahead, to dream. Morning pain in particular can make it more difficult to want to do things, unless those activities are important, there are relatively structured ways to pursue them, and they don’t need much planning.  This can influence whether a person gets out of bed to go to work, or the gym, or take the kids to school. In a daily diary study, Karoly, Okun, Mooris, Enders and Tennen (2014) found that people with relatively high overall pain over a two-week period, but not necessarily just in the morning, and who have chosen to stay working, often also carry out their “lifestyle” goals in the afternoon. They suggest this could be because goals that are further out in time, and the positive feelings associated with achieving work goals keep them motivated. But they also found that even then, on the days people had more than their usual pain in the morning, they were less inclined to do as much.

The implication of this finding by Karoly and colleagues is that people who experience a “high pain” morning might need some reminders of the pleasure they get when they achieve goals – perhaps to pay attending to people and places that support their goal achievement. Helping people develop goal planning skills might also be useful – do the thinking when you’re feeling a bit more positive and can see beyond “now”, then when pain is higher, the cognitive demanding work is already done and the reminders help to generate positive emotions to encourage doing them.

OK, so we know some ways of helping people keep motivated, but what do we do to help people set them in the first place?

People are motivated by both push and pull factors. We want to move towards things we experience as good, and away from things we don’t enjoy. When pain is present, not only does it become hard to think straight, it doesn’t feel like it will ever change. So we need to help people dream a little. One way I do this is ask “What would you be doing if pain wasn’t such a problem for you?” Note that I’m not saying pain isn’t there – but that it’s less of a problem. Sometimes I’ll use a plastic magic wand and hand it to the person, asking them to dream a little. Other times I’ll add in “What gives you joy and pleasure? What makes you lose your sense of time and place? What gives you a sense of satisfaction when it’s done?”

These questions begin to identify activities in which a person might experience “flow” – Mihaly Czikszentmihalyi.

Another way is to ask the person what they need to, or want to do, perhaps using the occupational therapy broad groups of “productivity/work”, “leisure/fun”, and “self care” as prompts.

I’ve also found that by asking “what’s important in your life” can be a good way to generate personal goals. Importance indicates that the person places value on it. Values are important and lasting beliefs or ideals shared by people about what is good or bad and desirable or undesirable. Values underpin ACT (Acceptance and Commitment Therapy), because instead of setting goals, which can be achieved, values are like a compass – things we do (actions) allow us to move closer towards important values, and we never completely achieve them. They’re directional and aspirational, and allow us to do difficult things that have short-term negative consequences, just so we can move towards a better long-term consequence (van Huet, Innes & Stancliffe, 2013).

How can you use this in therapy?

Well, if a person really values family, and being a good Dad, anything that Dad does to enable him to be a better Dad will be motivational. So you can ask “What could you do today that would take you one step closer to being a great Dad?” And use whatever that might be as the foundation for a goal. Then you can go on and use all the other great goal-setting strategies like specific, measurable, achievable, relevant, and so on.

This doesn’t mean that doing that thing will be easy – far from it! But it will make achieving it more relevant, powerful and motivating. Working with the challenges is why you are a therapist.

 

Karoly, Paul, Okun, Morris A., Enders, Craig, & Tennen, Howard. (2014). Effects of Pain Intensity on Goal Schemas and Goal Pursuit: A Daily Diary Study. Health Psychology, 33(9), 968-976.

McGowan, Linda, Luker, Karen, Creed, Francis, & Chew-Graham, Carolyn A. (2007). ‘How do you explain a pain that can’t be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle. British Journal of Health Psychology, 12(2), 261-274.

van Huet, Helen, Innes, Ev, & Stancliffe, Roger. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56-65.

…but I thought a new knee would fix my pain!


ResearchBlogging.org
Working in an orthopaedic surgery department is quite enlightening. Along with discussions about ceramic vs metal implants and cartilage regeneration (I work with a team of researchers looking at how to create replacement cartilage), the topic of what counts as a surgical success in knee surgery also comes up from time to time. Knee joint replacement isn’t as successful as hip joint replacement for a number of reasons including the complex nature of the joint, the way the joint capsule is disrupted during surgery, and the knee can apparently feel quite different from the original knee.

What this means is there can be quite a mismatch of expectations for people who believe very strongly that there should be no pain and they should have a completely normal knee joint after surgery. In fact, in the NZ National Joint Registry, the main reason recorded for knee joint revision is pain.

Naturally, the problem of pain after surgery is something surgeons and researchers are also interested in. Many studies have shown psychological factors such as catastrophising (thinking the worst) and low mood are associated with poorer outcomes (Riddle, Wade. Jiranek, & Kong, 2010; Roth, Tripp, Harrison, Sullivan & Carson, 2007; Shelby, Somers, Keefe, Pells, Dixon & Blumenthal, 2008).  The outcomes looked at so far include length of stay in hospital at the time of surgery, analgesia use during surgery, increased disability after surgery and revision rates.

Now, one solution to this problem could be simply not performing joint replacement surgery in people who are depressed and tend to think the worst. The problem is that two of the strongest predictors for looking for treatment are – you guessed it: low mood and catastrophising (and disability). Another solution is to provide intervention after surgery to target the people who tend to become fearful – perhaps an enhanced level of physiotherapy for this group, while the less vulnerable may even require less. Some studies have also looked at giving better education about what the surgery entails and the expected outcomes, and doing this before the person undergoes surgery, while another study has looked at providing a pain coping skills training course prior to surgery (Riddle, Wade, Jiranek & Kong, 2011). The outcomes from this last approach were promising, although it was a very small sample size, and the follow-up was for only two months.

There are a number of problems with implementing any of these approaches in clinical practice, at least in the system I’m most familiar with (NZ):

  1. Many orthopaedic surgeons still discount the importance of psychological factors, and consider the information they provide completely adequate for presurgical preparation
  2. It’s difficult to give someone different or special treatment based on psychological factors within a usual clinical setting without also inadvertently giving people a label that may change how they are responded to
  3. Any additional intervention will have an up-front cost (not good for cost accountants!)
  4. These treatments need specially trained clinicians who understand the measures being used, the rationale for treatment, and the type of treatment needed – and because these are psychological factors and surgery is conducted in a “physical” hospital, this is unfamiliar territory for many
  5. Patients may not be very comfortable with a treatment that focuses on thoughts, emotions and pain

It seems to me, and from the results from a recent study looking at analgesic use after surgery, that an argument simply based on the cost of failing to go ahead with effective management of psychosocial factors would make sense. Here’s the detail:

Fuzier, Serres, Bourrel, Palmaro, Montastruc and Lapeyre-Mestre (2014) conducted a large study of patients in the Midi-Pyrenees region of France. They examined the medical records of all 1939 patients who had knee arthroplasty, and compared the drug use (what was dispensed) at four times – 12 months before surgery, 2 months before surgery, and 10 months before and after the knee surgery.  What they found was an increase in analgesic, antineuropathic and opioid drug use in the 12 months after surgery. The actual percentage of patients requiring more medication is astonishing: 47% of people needed more analgesia, 8.6% needed more antineuropathic medications, and 5.6% needed more opioids. That’s a whole lot of drugs!

These researchers also analysed a number of other variables associated with the medication changes, and made some more understandable findings:

  • people having total knee replacement surgery were at a greater risk of using more medication than those having unicompartmental surgery (half a joint)
  • people with high levels of preoperative pain along with “psychiatric vulnerability” were at greater risk of having increased neuropathic medications prescribed
  • but older people were less likely to be prescribed additional medications

Unfortunately, this study didn’t identify the particular “psychiatric vulnerabilities” of the patients who participated – from the paper it looks like data was extracted from clinical records, so psychiatric disorders such as depression, anxiety and so on are the likely culprits. We don’t therefore know whether catastrophising contributed to the medication use – but given the results from at least 20 studies I have in my database, I think it’s probably likely.

Medications are not cheap. While they’re quick to prescribe, dispense and take, they cost not only in fiscal terms (which is a serious consideration, nevertheless), but also in side effects – and more importantly, in loss of personal locus of control. What I mean by this is that these are people who haven’t been given the opportunity to develop pain self management skills. They will continue to catastrophise, and perhaps even more so after surgery because their fears have been confirmed. Maybe it’s cheaper and more humane to bite the bullet and begin giving people appropriate psychosocial treatment before, during and after surgery.

Fuzier, R., Serres, I., Bourrel, R., Palmaro, A., Montastruc, J., & Lapeyre-Mestre, M. (2014). Analgesic drug consumption increases after knee arthroplasty: A pharmacoepidemiological study investigating postoperative pain PAIN®, 155 (7), 1339-1345 DOI: 10.1016/j.pain.2014.04.010

Riddle, D. L., Keefe, F. J., Nay, W. T., McKee, D., Attarian, D. E., & Jensen, M. P. (2011). Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Archives of Physical Medicine & Rehabilitation, 92(6), 859-865.

Riddle, D. L., Wade, J. B., Jiranek, W. A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Roth, M. L., Tripp, D. A., Harrison, M. H., Sullivan, M., & Carson, P. (2007). Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Research & Management, 12(3), 185-194.

Shelby, Rebecca A., Somers, Tamara J., Keefe, Francis J., Pells, Jennifer J., Dixon, Kim E., & Blumenthal, James A. (2008). Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients. Journal of Pain, 9(10), 912-919.

Widespread pain, aka fibromyalgia – does it really belong in rheumatology?


ResearchBlogging.org
I’ve asked it before, and I’ll probably ask it again, but does widespread pain really belong with the rheumatologists? I think the answer is rapidly becoming “No”.
The “so what” question begs: does it really matter who looks after people with widespread pain? I think the answer is “yes”, only because it’s becoming clear that helping unravel the problem of fibromyalgia (widespread pain) is going to take a different tack from looking at peripheral mechanisms alone. In fact, it could be that peripheral mechanisms are by and large irrelevant to this enigmatic disorder.

What is fibromyalgia?

Good question: there are clear diagnostic criteria for the disorder, but developed mainly for research purposes. In clinical terms, fibromyalgia is a little more tricky. Essentially, if a person says “I hurt all over”, and they also report unrefreshing sleep, foggy thinking, fatigue and sensitivity to multiple sensory modalities, chances are the person has fibromyalgia, especially if the usual diagnostic tests fail to show anything else out of order. The American College of Rheumatology released revised criteria in 2010 (Wolfe, Clauw, Fitzcharles, et al., 2010) and now doesn’t require the presence of tender points.

And this is why I don’t think it’s necessary for people to be diagnosed by a rheumatologist: there are too many people who experience this range of symptoms for diagnosis to remain the province of a single specialty. At the same time, it seems quite evident that hunting for mysterious explanations for the problem by undertaking multiple investigations is also not the answer – instead, a GP using good clinical techniques can make a diagnosis and then focus on helping the person to manage his or her symptoms quickly and without fuss.

A recent paper by Fitzcharles, Ste-Marie & Pereira (2013) argues this point, saying that “the diagnosis is made on the basis of a composite of symptoms, centred on chronic widespread pain and absence of physical findings that would indicate another condition”, and “a physical examination is required for all patients, and findings may be completely within normal limits”, and “only limited laboratory testing should be conducted for most patients” (p. E646).

What about the neurobiology?

Here’s where the situation gets a little murky, and it’s going to take a while before we really begin to understand the problem.

Neurophysiologic studies show abnormal pain processing at various levels of the nervous system, and no single unique change associated with fibromyalgia. I use the term “pain” advisedly here, because while nociception may be involved, it is not obligatory, so what we are left with is the experience of pain and some really weird abnormalities that are associated with the experience. Remember, people have pain, it’s an experience, it’s formed by the interaction of biological, psychological and social elements, and we only know about it because people do something about it – look for help.

Studies show peripheral sensitisation of the primary somatosensory neuron, central sensitisation at the dorsal horn, changes at the thalamus and gray matter of the brain, impairment or reduced functioning of the descending noxious inhibitory control mechanisms, not to mention alteration of endogenous opioid uptake. Treatments are, therefore, focused primarily on reducing the ascending information and increasing the descending inhibitory mechanisms, or working to alter the way this information is managed or prioritised by the cortex.

This means that for most people with this kind of pain, some sort of neuromodulatory drug is part of the mix – something to reduce the “reactivity” of the neural circuitry involved in processing this kind of information.  Anticonvulsants such as gabapentin or pregabalin seem to do something useful, while tricyclic antidepressants or SNRI’s are also helpful, together or separately from the anticonvulsants. BUT medications really don’t alter the pain terribly much for many people with FM. I’m one of those who fail to respond to medications. What I, and many others with fibromyalgia are left with, is learning to use the most powerful of mechanisms in the world – our fabulous cortex.

A teeny bit more neurobiology

In a paper that is in preprint right now, a group of Spanish researchers have been l0oking not just at one part of the brain, but more at the connectivity and subtle interplay between various parts of the brain while a person with fibromyalgia experiences pain. The usual culprits involved in processing nociception such as the periaqueductal gray, anterior insula, pariental operculum/secondary somatosensory cortex (SII), and the primary somatosensory cortext.

Normally, there is activity between the perietal operculum/SII and the various sensory cortices such as the auditory, visual, primary somatosensory cortex and posteria insula. This is called the “default mode” and seems to provide support for Melzack’s “neuromatrix” theory where this network is assumed to monitor and maintain “normal representation” of the body. In people with fibromyalgia, there is reduced functional connectivity between these regions.  Interestingly, there were increased functional connections between the parietal operculum/SII and the posterior cingulate cortext, precuneus, ventral putamen and ventral insula. Subjective pain ratings were positively correlated with measures of functional connectivity between the parietal operculum and PCC, ACC, left angular gyrus (also parts of the default mode network), and the left prefrontal cortex.

The authors conclude that “Overall the data suggest a strong association of clinical pain with a general weakening of sensory integration in fibromyalgia.” They point out that the amgydala and the insula are two major parts of the descending limbic input to the PAG – suggesting down-regulation of the cerebral influence on the PAG. Normally the PAG provides a “brake” on ascending sensory information – if, in people with FM, this is not working properly, it provides some explanation for the poor sensory filtering in people with fibromyalgia.

What the authors argue is that because non-nociceptive information is downregulated, it provides an opportunity for more nociceptive information to reach various parts of the brain – and this occurs not just in pain, but also in other sensory modalities such as scent, sound and vision. A bit like migraineurs perhaps? Anyway, these researchers argue that “spontaneous pain may be a consequence of partial damage in the nociceptive system with a subsequent nociceptive system hyperexcitability and a secondary inhibition of the transmission of tactile signals.”

What does this mean for treatment?

Some treatments are based on providing competing information between nociceptive and non-nociceptive input – things like peripheral nerve stimulation, whole-body vibration therapy, heated water body stimulation – and probably far closer to my heart, whole body movement, body awareness and cognitive behavioural therapy. These provide opportunities for people with FM to develop (refine, enhance) discrimination between various body states and sensory inputs. By learning to be more aware of what is really happening in the body, paying mindful attention to what is, rather than what has happened or might happen, and by carefully structuring these experiences to grade the complexity and psychosocial variables associated with them including the emotions associated with them, people with FM may begin to “retune” the out of sync central mechanisms involved in sensory processing.

To me this means we need to go beyond a biomedical approach to managing fibromyalgia, or widespread pain. We need to incorporate occupational therapists, who have specific training in analysing occupations (activities) and can grade the complexity of these occupations to titrate the level of input to where the individual needs it. We need physiotherapists to guide movements and grade complexity of movement patterns. We need to work as a team to help people understand and reconceptualise their role in managing fibromyalgia – and overall, we need to help people with FM learn to live well despite their pain. My question is: should this be the province of a single speciality in medicine? I don’t think so, I think it belongs to us all, and especially to people living with the problem.

Fitzcharles, Mary-Ann, Ste-Marie, Peter A., Pereira, John X., & Iglar, Karl. (2013). Fibromyalgia: evolving concepts over the past 2 decades. Canadian Medical Association Journal. doi: 10.1503/cmaj.121414

Pujol, J., Macià, D., Garcia-Fontanals, A., Blanco-Hinojo, L., López-Solà, M., Garcia-Blanco, S., Poca-Dias, V., Harrison, B., Contreras-Rodríguez, O., Monfort, J., Garcia-Fructuoso, F., & Deus, J. (2014). The contribution of sensory system functional connectivity reduction to clinical pain in fibromyalgia PAIN® DOI: 10.1016/j.pain.2014.04.028

Wolfe, F., Clauw, DJ., Fitzcharles, M-A., et al. (2010). The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Research (Hoboken), 62, 600-610.

How occupational engagement might work in pain management


ResearchBlogging.org
Intuitively, most of us know that when we’re actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst – or pain.  In the very early years of occupational therapy, this “distracting” factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars.  Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation’s sake was often left behind.

More recently we’ve begun to learn more about how occupation might be a good thing.  First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing.

Then we found that through positive psychology studies that the state of  “flow” popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance.

Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management.  This is interesting to me for several reasons – firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004).  Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual.

Let me explain: usually it’s recommended to maintain a consistent level of activity.  Sometimes this is called activity pacing.  Yet there are times when it’s appropriate to suspend the use of pacing – when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours).  We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam.

Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity.  Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues.  Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus.  Two different colours were used, one of which had been associated with a painful stimulus.  Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing.

To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud.  If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made.  This was the “nonpain task goal”, or activity/occupation.

The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted.  In other words, they were not as quick to respond to things that they had previously viewed as a potential threat.

This is a really interesting finding – while it’s a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat.

Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used.  Their findings were that “engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. ”

It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management.

Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025

Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227.

Bradshaw, D.,Chapman, CR., Jacobson, RC.,  and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain.

When patients think their problem is mysterious


ResearchBlogging.orgThis post is sparked off by a Facebook discussion where someone (you know who you are!) asked what to do when patients hold entrenched beliefs about the uniqueness or mysteriousness of their situation.  They might say things like “I don’t think anyone know what to do with me”, or “I think because my situation is atypical, I don’t expect to respond normally”, or “herniated discs don’t usually shoot ALL the way to the foot”.  Does anyone else recognise this pattern?

The person who asked about this said the main problem was in trying to tell the person that his or her symptoms are not unique or weird, without taking away their “specialness”.  Sometimes, in trying to give accurate information, and pointing out that others have similar symptoms, the person can react as if they’re offended.  On the one hand, this person said, we are all unique and deserve to be treated as individuals and on the other hand there is a commonness in suffering that we should take comfort in.

In musing about this, I thought about some of the reasons people seek treatment.  While it’s almost a given that people are looking for alleviation of their suffering, there are a complex range of reasons that people come in to see a health provider, and not all of the reasons are evident even to the patient!

As an aside, I think it’s incredibly difficult to help some clinicians see that people think they’re logical and know the reasons for their actions, when in fact we are all influenced by an array of factors that are implicit and thus we’re not aware of their effect – more on this later.

Why do people seek treatment?

In a meta-analytic study by Ferreira, Machado, Latimer et al. (2010), the main determinants of care-seeking in back pain were

  • being female (OR: 1.67; 95% CI: 1.49, 1.88),
  • having had a bout of back pain before(OR: 1.45; 95% CI: 1.12, 1.86),
  • having higher levels of disability (OR: 1.92; 95% CI: 1.33, 2.78),
  • externalized beliefs regarding pain management (OR: 3.6; 95% CI: 2.1–6.0),
  • fear of future job impairment (OR: 3.07; 95% CI: 2.33, 4.04),
  • limited social functioning (OR: 3.07; 95% CI: 2.33, 4.04),
  • or those engaged in sports activities (OR: 1.3; 95% CI: 1.0, 1.7)

What does this tell us?

The authors suggest that “individuals seek care based on an interaction that includes their predisposition to use health care, the available resources and their recognition for the need of care”.  They add “disability, and not pain, is the strongest determinant of care-seeking behavior in people with back pain”, and suggest that interventions need to aim at matching expectations and reducing disability rather than focusing on reducing pain.

So, what to do when a person says their pain is mysterious.

If we consider that people who seek treatment are inclined to do so as part of their belief that treatment is important, as well as tendency to look for treatment (almost like a habit), maybe we need to look at what health providers (us!) do to maintain this habit.

By saying “my pain is different”, the person may well be doing what he or she has learned before – maybe they haven’t responded as expected with another provider, and been told their pain is “different”. Maybe they’re worried that you won’t be able to help them either.  Remember that intermittent reinforcement has a powerful training effect and may be influencing the expectancy of this person – they’re anxious to let you know they are hanging hopes on doing “something”.

I suggested reflecting the “meta-message” the person is telling you. What about saying “It sounds like you’ve had some trouble getting help with your pain. From all the things people have told you about what’s going on, what do you make of it? What’s your theory?”.  At this time it’s also helpful to ask them “what does that mean for you? Where does that leave you?”.

If the person describes a belief that doesn’t sound plausible, or has some catastrophic interpretation of what might be going on (like the “herniated discs don’t usually shoot all the way to the foot”), I’d ask if it’s OK to tell them what I understand might be happening.  I then ask the person if they’d be prepared to work with me on a series of mini experiments to help us work out what is going on.

It’s worth checking in with our beliefs about why people seek help for their pain.  And establishing whether there are things we can do to help people remain active and engaged with their own health management.

Ferreira, Machado, Latimer et al (2010) concluded that “values and attitudes that individuals have about health and the use of health services can be viewed as the bridge between social structure and the perceived need for health care; it is how the status of a person in the community, or the individual’s ability to cope with presenting problems, can modify his or her perception for the need to seek care.”
Ferreira, M., Machado, G., Latimer, J., Maher, C., Ferreira, P., & Smeets, R. (2010). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys European Journal of Pain, 14 (7), 7470-2147483647 DOI: 10.1016/j.ejpain.2009.11.005

Which comes first: Doing or knowing?


ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.