Dead bodies can’t feel pain, or why biomechanics and ergonomics haven’t reduced back pain
I know, it should make sense: reduce the biomechanical load on the body bits and pain/injury should reduce, right?  I mean, the maths adds up, cadaver experiments ‘prove it’, it has ‘face validity’, there is a whole industry based on the idea of  ‘safe lifting’ and injury prevention – physical ergonomics works, doesn’t it?

Well, sad to say, this very recent paper (this week’s BMJ no less!) by very respected researchers in the field has once again found that the evidence is at the most low to moderate that “physical and organisational ergonomic interventions were not more effective than no ergonomic intervention on short and long term LBP and neck pain incidence/prevalence”.

Not only does this finding fly in the face of common sense, the quality of the evidence is pretty low – and yet the amount of research has been going on for how many years?

I don’t know if many readers know, but for some years I worked as the ‘safe handling’ advisor in a large public hospital.  The whole drive of that position was intended to reduce the number of incidents of back pain (the most common ‘injury’) and the overall cost of that problem by teaching staff members that manual handling (including patient handling) needed to be carried out with thought.

Early in my career I have studied human biomechanics and I have several papers in ergonomics – but to say I haven’t been convinced that changing manual handling techniques will reduce the prevalence of back pain is understating the blindingly obvious.

So why, oh why, did I try to do this job?  Well, my main idea was that by working in that position I could begin to influence the way this organisation managed the work situation of people who developed low back pain – by supporting the person to return to work as soon as possible, by making it slightly less physically demanding for them when they did return, and to encourage staff members to support each other and to feel supported (working on the psychosocial aspects of the workplace).

I failed, not entirely miserably, but I did fail because no matter how hard I tried to show the research, very few people believed the evidence.  It simply doesn’t fit with ‘common sense’ – because ‘everyone knows’ that how you lift will affect your risk of back pain.  Not.

Why doesn’t it work?

Well, lots of reasons – one of which is pointed out in this review.  People don’t always ‘follow the rules’ when it comes to ‘safer lifting’.  This is because we don’t live in a nice, controlled environment.  While people might be taught a specific method – in the real world, the item to be moved isn’t a nice box shape, it’s a lumpy human being who squeals and flops and does the unpredictable.  In the real world, there might be little time to think and plan.  Other people might not help when needed.  The equipment might be too far away.

Oh, and maybe the assumptions of the biomechanical and physical ergonomics approach might not be correct.

You see, biomechanical equations, even sophisticated models, are still a simplistic picture of the multiple forces acting on structures – and the maths is pretty complex.

Probably more importantly, biomechanical models don’t factor in the brain – there’s a thinking, feeling, deciding, processing, dynamic neuromatrix involved in the human that is doing the moving.

Low back pain (and other musculoskeletal pains) are not a simple A + B = low back pain equation.  Researchers still haven’t narrowed down the suspects in the causal equation for low back pain.  It’s one of those delightful problems that are called ‘multifactorial’.  No single two or three or even eight factors are reliably associated with low back pain – or at least, not physical factors.  It seems that fuzzy and difficult things like attitudes, beliefs, work satisfaction, social support, supervisor interactions, peer pressure, fatigue, mood – they’re the things that seem to be associated more strongly with problems with back pain than simply the movements and forces acting on the body.

When I think of the money that is spent on training, equipment, systems and even penalties applied to reduce the physical and biomechanical demands on bodies – without addressing the brain and the person and their social setting, I despair.  Wouldn’t it be wonderful if this funding was spent on researching the psychosocial interventions that could (and do) make a difference?

Driessen MT, Proper KI, van Tulder MW, Anema JR, Bongers PM, & van der Beek AJ (2010). The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review. Occupational and environmental medicine, 67 (4), 277-85 PMID: 20360197

The ABCDEFGHI of persisting pain

There are some things in life that need repeating – the ABC’s are one of them. In this case I mean the ABC’s of persistent pain, and I’m really referring to the risk factors for chronic disability associated with pain.

Diane Jacobs, of Sherwood Physiotherapy, has summarised some of the discussion a few of us were having on SomaSimple about the so-called ‘Yellow Flags’ or psychosocial factors that are known to be associated with disability from pain. It’s available here and is a great resource freely available on the internet. Just don’t copy it without appropriate reference to her, and don’t alter it without consulting Diane or myself. The original ‘Psychosocial yellow flags’ document is available here, integrated with the NZ Acute Low Back Pain Guide.

It’s designed to be given to a patient to go through, preferably with a clinician, to help the person identify factors that might be problematic in their recovery. It can be used as a discussion pointer, and it might be an eye-opener for other clinicians too!

But does it measure what I want it to?

While there are thousands of assessment tools available for various aspects of pain and function, one of the most important things to consider is content validity – does the assessment measure what I want it to measure? Reliability is all very well, and ensures accuracy, but if the test doesn’t measure anything useful or important, then it’s not going to be very helpful!

This article, published in 2006, is one of the few that seeks to conduct a qualitative evaluation of the content of several questionnaires but base it on a reasonably sound theoretical framework with relatively solid methodology to ensure other researchers can conduct the same process. So far, however, I haven’t found much to compare it with – but it’s a helpful study in terms of helping clinicians define exactly what they want to include in an assessment battery, even if it concludes that there are gaps in the existing repertoire!

Sigl, Cieza, Brockow, Chatterji, Kostanjsek, and Stucki set about comparing three very common low back pain measures using the the International Classification of Functioning, Disability and Health (ICF) approved by the World Health Assembly in May 2001. Their intention was twofold: to review whether three common instruments cover the areas in the ICF, and whether the ICF can function as a somewhat atheoretical framework for comparing different instruments.

Just to review the ICF, the ICF is a multipurpose classification belonging to the WHO family of international health classifications. Part 1 covers functioning and disability and includes the components ‘‘body functions’’ (b) and ‘‘structure’’(s) and ‘‘activities and participation’’ (d). Part 2 covers contextual factors and includes the components ‘‘environmental factors’’ (e) and ‘‘personal factors.’’

To quote directly from the WHO, ‘The ICF puts the notions of ‘health’ and ‘disability’ in a new light. It acknowledges that every human being can experience a decrement in health and therheby experience some degree of disability. Disability is not something that only happens to a minority of humanity. The ICF thus ‘mainstreams’ the experience of disability and recognises it as a universal human experience. [my emphasis – BFT] By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability. Furthermore ICF takes into account the social aspects of disability and does not see disability only as ‘medical’ or ‘biological’ dysfunction. By including Contextual Factors, in which environmental factors are listed, ICF allows to record the impact of the environment on the person’s functioning.

I quite like the ideal of ‘everyone’ having both limitations and abilities, and especially the idea that limitations are contextual. I’m not sure that this model has yet had an impact on the systems in which we usually work, however! I use the idea that everyone has abilities and everyone has limitations when working with people experiencing chronic pain – it has the effect of encouraging people to focus on their abilities rather than defining themselves by their limitations. The flow from conceptual ideals to measurement and implementation of these ideas takes time, and because it’s a nonmedical concept, unlikely to have a significant impact on health delivery systems for many years yet.

Back to the article…
The methodology is well-described in the article – three clinicians already trained in the ICF were used. Two reviewed the content, and linked the items in the questionnaire to a content area in the ICF, applying 10 different linking rules to the items, and then compared the identified concepts and selected ICF categories to establish a Kappa statistic. If disagreement existed occurred, a third person trained in the ICF and in the linking rules was consulted, and independently determined how the item should be classified.

Clear guidelines on how linkages were to be developed, although these are not provided in the article itself – several examples, however, demonstrate how different items were allocated categories, for example, ‘If an item of a measure contains more than one concept, each concept has to be linked separately. For example, in the item of the ODI ‘‘Pain doesn’t prevent me from walking any distance,’’ the concepts ‘‘pain’’ and ‘‘walking’’ were linked to ‘‘b28013 pain in back’’ and ‘‘d450 walking,’’ respectively. The response options of an item are linked to the ICF if they refer to concepts other than those contained in the corresponding item. For example, in the item 14 ‘‘sleeping’’ of the NASS, in which two of the response categories of the item are ‘‘I sleep well’’ and ‘‘pain interrupts my sleep,’’ the concept ‘‘sleeping’’ was linked to the ICF category ‘‘b134 sleep functions,’’ the concept ‘‘sleep well’’ to ‘‘b1343 quality of sleep,’’ and the concept ‘‘interrupts my sleep’’ to ‘‘b1342 maintenance of sleep.’’ If an item/concept is not contained in the ICF classification, it is labeled ‘‘nc’’ (not covered by the ICF). ‘‘nc’’ does not differentiate between concepts relating to function not covered by the ICF, concepts relating to personal factors for which no categories currently exist, and other concepts relating to aspects like time and space.’

Although this sounds tedious to read here, I’m certain that the process ensures precision and enables the majority of items to be appropriately categorised.

Well the first thing to establish is whether the two (and occasionally three) clinicians agreed on the categories in which they allocated items. The Kappa statistics, with adjustment made for the skewdness of the sample (from high Kappa values and small sample size) by using a bootstrapping technique of sampling from percentiles based on the observed data, was used to determine agreement. The results showed that the range of agreement was from 0.67 at the broadest level of category through to 1.0 (or total agreement) at the fourth level. To illustrate this, an example selected from the component ‘‘body functions’’ is presented below:
b2: Sensory functions and pain (first level) – at this level there was a small level of disagreement
b280: Sensation of pain (second level)
b2801: Pain in body part (third level)
b28013: Pain in back (fourth level)
b28018: Pain in body part, other specified (fourth level) – at this level, there was total agreement

This demonstrates very good inter-rater reliability, although it should be appreciated that there were only three individuals involved. A larger number of raters would have provided a much better determination of the accuracy of this approach to content validation – but would also increase the time required to do it!

Now, for the real work of this study: what areas were covered by the three assessment tools, and which areas were not well-covered?

  • The representation of body functions is similar in all three measures incorporating pain and sleep.
  • All three questionnaires contain a similar number of concepts representing the ICF component “activities and participation.’’
  • None of the selected instruments covered aspects of remunerative work (d850). ‘‘Domestic life, other specified’’ (d698), which had to be linked for carrying out household tasks (‘‘doing any of the jobs that I usually do around the house,’’ ‘‘heavy jobs around the house’’), is applicable only for the RMQ.

The two research questions were: whether three common instruments cover the areas in the ICF, and whether the framework was a useful way to determine content.

  1. It was found that yes, all three instruments cover aspects of the ICF – to varying extents. Only one looked at the psychological impact of pain, and none looked at factors such as fatigue that are well-known to be associated with poorer function. Interestingly, none of the measures looked at ‘context’ – for example, ‘attitudes of immediate family members or friends or society are important prognostic determinants for life satisfaction, work performance, and disability in patients with back pain. This also holds true for remunerative work, which is not covered by any of the measures.’
  2. The second question was whether the ICF could be helpful as a framework – one use of this type of comparison work is to create an item bank. Item banks consist of large sets of questions representing various levels of a latent variable that can be used to develop brief, efficient scales for measuring that latent variable. Using Rasch analysis, items the measure the variable of interest can be identified and selected to form a measurement tool that precisely assesses that specific level of function.
  3. The first finding alone is interesting – why have these very important areas of function been ignored? Does this reflect the western idea that ‘the person with the disability’ exists in isolation?

    The final comment I want to make is about the usefulness of this research from a clinical perspective. Key areas that are well-known to be important both to people with pain, and to funders of health care and compensation are not included in three commonly-used assessment tools. Perhaps if these agencies could see their way to fund this type of comparison, it might be possible to develop supplementary measures to ensure this information is available for use in clinical situations.

    Sigl, T., Cieza, A., Brockow, T., Chatterji, S., Kostanjsek, N., Stucki, G. (2006). Content Comparison of Low Back Pain-Specific Measures Based on the International Classification of Functioning, Disability and Health (ICF). Clinical Journal of Pain, 22(2), 147-153.

    World Health Organization. International Classification of Functioning,
    Disability and Health: ICF. Geneva: WHO, 2001.
    Schultz IZ, Crook JM, Berkowitz J, et al. Biopsychosocial multivariate
    predictive model of occupational low back disability. Spine. 2002;27:

    Takeyachi Y, Konno S, Otani K, et al. Correlation of low back pain with
    functional status, general health perception, social participation, subjective
    happiness, patient satisfaction. Spine. 2003;28:1461–1466.

Context and sociocultural factors

I posted yesterday about how little social and cultural factors seem to be included in assessing and managing pain, and I had hoped to find some papers to discuss today. Events conspired and I have failed in that endeavour, so this post is, unusually for me, almost entirely my opinion.

So, sticking my neck out, why do I think the sociocultural context needs to be included when someone presents with their pain problem?

Well, the first thing that springs to mind is how has that person has found their way to a treatment facility – how did they get referred and by whom? To present for treatment means that at some point, this person has decided the pain they are experiencing is undesirable, and something needs to be done about it (whether that ‘something’ is diagnosis, elimination or confirmation of its impact). This decision to seek help seems to be based largely on whether it’s ‘normal’ or ‘expected’ in the culture in which the person lives.

Let me give you an example: and yes, it’s perhaps a little outrageous, and yes, it does relate to acute pain!
In one group in New Zealand society, body piercing and suspension is one way to generate a ‘natural high’. The individual and his or her supporters (usually members of the same social group) congregate and encourage each other through the process of suspending the body from large hooks inserted through the skin of the back. As the process continues, some of the participants begin to swing their bodies from the hooks, and I’ve watched one participant swing and run across a stage to gain more momentum. Although the physical trauma is clear and pain is experienced as the hooks are initially inserted, over the 10 – 20 minutes of the process, these individuals start to feel euphoric and describe the feeling as ‘bringing me closer to a spiritual plane’, ‘overcoming my physical self’, ‘getting in touch with the inner self’.

The practice of body piercing is ancient, and an accepted part of many cultures including Sri Lanka where it forms a part of a ritual to the Hindu god Murugan, and the Phillipines where ritual re-enactments of the crucifixion, complete with nails piercing the hands are performed on Good Friday. Tattooing is also an accepted part of many cultures including New Zealand Maori and the Pacific Islands.

For many of us, the thought of submitting to painful procedures as a recreational activity is just not something we would ever do. However, we may participate in weekend sports – netball, rugby, skiing, running, weight-training…and sustain pain with the ‘support’ of our friends!

So it’s not surprising that if our willingness to experience acute pain can be influenced by social and cultural factors, treatment seeking for persistent pain can also be influenced.

Two common pain problems come to mind: the headache and the backache. Headaches are usually managed with simple analgesia and a quiet night or a walk. Backaches – well for many of us (around half of those that have an episode of back pain in a year (Walker, Muller & Grant, 2004) we will seek health care from a GP or chiropracter or similar. If we don’t initially attend, our families and friends or employers will suggest we do if our function is affected. Who we see will be influenced by our culture – in New Zealand, it’ll be a GP or physiotherapist or chiropracter; in rural China, it will more likely be a practitioner of traditional chinese medicine, or an acupuncturist.

The impact of even our acute pain on our lives will depend on our social context – our work, whether we live alone, the responsibilities for household tasks or caring for family members. And most especially, our pain behaviours will be influenced by others around us – our nearest and dearest strongly shape the kinds of things we do when we are sore (e.g. Smith, Keefe, Caldwell, Romano & Baucom, 2004).

And these are the things that we may well miss assessing if we don’t meet the person’s family (how many people attend a pain assessment alone, without any family present?), or talk to their colleagues. What’s more, we don’t typically include these people in management either – despite our knowledge that people changing behaviour really need to have the support of those who see them every day, especially in the period immediately after a pain management programme. In New Zealand anyway, ACC claimants receiving compensation for an accident rarely have encouragement or funding to enable their family members to also be included in intervention – even when roles have changed significantly, or the relationship is under strain. The ‘claimant’ is the person with the problem – even when we know that people live within a family, community, social, sporting, church system.

Tomorrow I hope to post on some of the factors to assess when considering the sociocultural and contextual factors in a person’s pain experience. If you’ve enjoyed this post, and want to read more – don’t forget you can subscribe using the RSS feed button at the top of the page, or you can simply bookmark the blog. And I love comments and respond – even if you don’t like what I have to say!

Smith, S. J. A., Keefe, F. J., Caldwell, D. S., Romano, J., & Baucom, D. (2004). Gender differences in patient-spouse interactions: A sequential analysis of behavioral interactions in patients having osteoarthritic knee pain. Pain, 112(1-2), 183-187.

Walker, B. F., Muller, R., & Grant, W. D. (2004). Low back pain in Australian adults. health provider utilization and care seeking. Journal of Manipulative & Physiological Therapeutics, 27(5), 327-335.

It’s not rocket science – it’s respecting the individual

Using cognitive behavioral therapies in pain management isn’t really rocket science, it’s simply being aware of the principles of learning from both a cognitive (thinking) point of view and a behavioural point of view. It is, however, complex – by that I mean, there are many threads to systematically follow and actively manage.

There does need to be a fairly large emphasis on assessing or understanding (or formulating, if you prefer psychological language) the factors that are working together to influence the person’s presentation. A formulation is simply a set of premises or hypotheses that, if they are tested and found to hold true, help to explain why this person is presenting the way they are, and to predict how they might respond in certain situations.

In chronic pain management, this means incorporating biophysical or biomedical elements, along with psychological and social elements. The complex blending of all these factors is what gives each individual a unique presentation and a unique set of concerns. And this is why it’s important never to think there is a ‘standard’ or routine way to help people with chronic pain develop ways to cope and move forward. ‘Cookie cutter’ or ‘recipe’ methods simply won’t work as effectively as an individualised approach.

My main concern currently is that the biomedical/biophysical and psychological aspects of assessment are fairly well covered in many settings – the aspect that is least well assessed and addressed is the social. ‘Social’ covers an area of influence that begins with interactions between the individual and his or her family, through to the influence of mass media and systems of governance and policy within a society. I think in New Zealand anyway, the psychological assessments are becoming over-emphasised, and the lack of emphasis on roles, function, interactions

Today let’s look at the words of people experiencing chronic pain – a great reading is Mandy Corbett, Nadine E. Foster, Bie Nio Ong’s paper ‘Living with low back pain—Stories of hope and despair’.

It incorporates the narratives of six people experiencing chronic pain, and themes that emerge include the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were ‘uncertainty’, ‘impact on self’, ‘social context of living with pain’, and ‘worry and fear of the future’. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge.

‘They [others with back pain] go through what
I’ve been through. They’ve got to come through
it all: the stress, the anger, er…the feeling of uselessness, and it can take a toll on a
marriage and a family so bad, to the point that,
that person may not have a family in 18 months,
four years’

‘You know, I can’t have one
day a week off. I’ve got to do full-time and I’m
finding it very hard and I’m frightened that I’m
going to do it because I have to, but then I end up
getting worse and I just can’t cope. What do I
do? Because that worries me. I can’t go off sick. I
can’t afford to go on half pay. So .. so that’s a
real dilemma.’

‘He positions himself as a social persona
who contributes both to his family and to the
community, and re-affirming himself in this way
forms the foundation for a generalised hope where
he can have faith in the future’

Can we spend a while listening to the social context of the people we work with? Considering both the impact and the influence of the wider social factors that abound when an individual experiences their personal pain.

More tomorrow on the social context of pain.

Corbett, M., et al. Living with low back pain—Stories of hope and despair. Social Science & Medicine (2007), doi:10.1016/j.socscimed.2007.06.008

Colour therapy…
With only a small proportion of the people experiencing acute low back pain becoming chronically disabled by their pain, a holy grail of sorts has been to quickly and effectively identify those who need additional help and those who don’t.

The ‘Psychosocial Yellow Flags’ initially developed in New Zealand by Kendall, Linton & Main (1999) provides a useful mnemonic for the factors that have been established as predicting longterm disability – but requires clinicians to be aware of the flags, and record them. Because the ‘Yellow Flags’ are not ‘objective’ and can’t be summed or scored, there is no way to determine a cut-off point to identify those people only just at risk – and the tendency is to under-estimate those who need more assistance, while many clinicians report that they don’t feel comfortable or confident to assess ‘Yellow Flags’ in a primary health setting.

For those who can’t remember, the risk factors known to be associated with ongoing disability in people with acute low back pain are:

A: Attitudes and beliefs – e.g. catastrophising, a passive approach to rehabilitation, ‘Doctor fix me’, hurt = harm

B: Behaviours – e.g. resting for extended periods, poor sleep, using aids and appliances such as crutches or braces, inappropriate use of medication, self medication

C: Compensation – e.g. difficulty obtaining cover, inadequate or ineffective case management, multiple claims in the past, poor knowledge of what is available for assistance

D: Diagnosis/Doctor or treatment provider effects – unexplained technical language that is misunderstood, multiple diagnoses, multiple investigations, multiple ineffective treatments, assuring a ‘techno-fix’ is available, recommending changing jobs or stopping jobs

E: Emotions – anger, depression, sense of helplessness or feeling out of control, numbed emotions

F: Family and friends – unintentionally reinforcing pain behaviour, unsupportive of returning to work, punishing responses, or being socially isolated

W: Work – an employer who is unsupportive, history of frequent job changes or limited employment history, heavy manual work, monotonous work, high responsibility with limited control, shiftwork, working alone or while isolated, disliking the job

As I mentioned, these factors are well-known, and relatively easily recognised. Many people say to me that they have an intuitive ‘feel’ for those who will have trouble recovering from ALBP – but feel that if they ask about these factors, they risk ”opening Pandora’s box’, or being unable to extricate themselves from a complex or emotionally charged situation. Many people don’t feel adequately skilled in managing the issues involved, and would prefer to either let well enough alone, or quickly refer to someone else (Crawford, Ryan & Shipton, 2007).

Well, I don’t agree with any of those options. Although sometimes people will have ‘saved up’ a lot of their concerns and want to offload with a lot of emotion, for many people it’s a simple case of exploring what their concerns are and problem-solving around the practical issues. A referral to a psychologist or counsellor isn’t always necessary, and can for some people escalate their distress and disability.

What skills can you use to identify and manage ‘Yellow Flags’?

Open-ended questions like ‘How do you feel about your recovery so far?’, ‘Are there any things that concern you about your recovery?’, ‘What do you think is going on in your back?’, ‘What do you think this [diagnosis] means for you?’

Reflective listening demonstrates two things: (1) that you are listening and (2) that you want to understand. It should be used whenever someone begins to display emotional responses. Reflective listening can be simple ‘So from what you’ve said, I think you mean….’, or more complex ‘It seems that you think your boss wants you to go back to full duties and you’re not sure you can. I wonder if you’re feeling really anxious?’ When in doubt, reflect!

Action and responsibility – Then it can be really useful to pose this question: ‘So where does this leave you?’ or ‘What do you think you need to have happen next?’

For many people the step of demonstrating your acceptance of their point of view and understanding their distress is a good start. And many ‘Yellow Flags’ can be simply influenced by the person themselves – just being given permission to think of a solution that they’re ready to do, or being asked whether they want to hear of other options allows the person to feel more in control.

And for slightly more complex situations – such as financial strain from time off work, or difficulty within a relationship because of changed roles – these can be helped by budgetting advice, bringing the partner in to the clinic to be a part of the rehabilitation, or asking the person to think of community-based self-help organisations. Intense psychological therapy isn’t always necessary, and if misguided or not consistent with other messages about engaging in activity despite pain, can impede recovery.

And if you’re REALLY pressed for time, but still want to ‘pick winners and losers’ – a study by Westman, Linton, Ohrvik, Wahle´& Leppert (2007) finds support for the use of the ‘Orebro Musculoskeletal Pain Screening Questionnaire’, which is a 25 item questionnaire covering five groups (function, pain, psychological factors, fear avoidance, and miscellaneous which includes things like sick leave, age, gender, nationality, monotonous or heavy work and job satisfaction. It’s been used extensively in New Zealand in a compensation setting since 1999, as a screening tool to identify those who may be at increased risk of ongoing disability. This study reviews its use in sub-acute pain, with a three-year follow-up to identify the predictive validity of the instrument for sick leave.

The results are very strong – psychosocial factors as measured by OMPSQ were related to work disability and perceived health even 3 years after treatment in primary care. The screening questionnaire had discriminative power even for patients with non-acute or recurrent pain problems. The OMPSQ had better predictive power than any of the questionnaires included in the study, which included the Job Strain, the Coping Strategies Questionnaire (CSQ),
the Pain Catastrophizing Scale (PCS) and the Tampa Scale for Kinesiophobia (TSK). This study shows that among the factors, pain and function are the factors most strongly related to sick leave 3 years later.

Interestingly for me, the study demonstrated that function with focus on daily living, sleep capacity and pain experience had the most powerful predictive value concerning sick leave at 3 years. While earlier studies have shown that emotional and cognitive variables such as distress and fear avoidance beliefs have been strong predictors for 6–12-month outcomes, the best predictor in this study is having problems functioning.

The authors suggest that this probably reflects the length of the follow-up and suggests that different variables may be predictive at various stages in the process of chronification. Even though it is recognized that psychological variables are
influential factors, little is known about how and when these variables interact in the process toward disability.
Furthermore, psychological variables might operate differently for different people and at different time points.

So, this particular instrument, which has been widely used at least within New Zealand for many years, is readily available and gives clinicians and others very useful guidance on who might benefit the most from high intensity therapeutic input early.

WESTMAN, A. (2007). Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain A validation of the Orebro Musculoskeletal Pain Screening Questionnaire. European Journal of Pain DOI: 10.1016/j.ejpain.2007.10.007

Crawford C, Ryan K, Shipton E (2007) Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain, New Zealand medical journal, 120:1254, pp U2536


April already!

It’s April and time for a change of season, sadly.  For us in the southern hemisphere it means we’re moving swiftly into autumn, with the leaves outside my house becoming yellow and fluttering to the ground, and the hint of chill in the air at night and early morning.  After a weekend away, it’s a bit hard to sit down and write!

And what a weekend it was – I had an absolutely wonderful time at PainLang in Brisbane.  A four-hour forum of discussion and dialogue between a couple of really wonderful people including Professor Harold Merskey, originator of the now internationally-adopted definition of ‘pain’, Professor Jenny Strong from Queensland University, Professor Roland Sussex also from Queensland University, and a range of other researchers and clinicians who all were able to contribute to a wide-ranging discussion about the language of pain.

For me, a highlight had to be hearing Professor Merksey talking about how the definition of pain was first adopted, and his ongoing work in the medicolegal field of defining pain and disability, and establishing that there is a widespread but probably false impression that musculoskeletal pain such as whiplash is short-lived.  Some of his research and particularly his re-analysis of several studies, demonstrated that due to inadequate outcome measures and methodological limitations, there is an impression that all but a small percentage of people completely recover within three months – but in fact, somewhat closer to the truth is that around 10% of people take longer than 12 months to completely recover.  What confounds the assessment of outcome is lack of a consistent measure, and indeed it’s common for measures of:

  • pain intensity
  • disability
  • return to work
  • case closure based on ‘end of rehabilitation’
  • cessation of compensation

all to be used at different times to establish an  ‘outcome’ that is then used to determine how long it takes to recover from a musculoskeletal injury.   This creates problems when respected organisations quote figures drawn from studies without rigorous methodology and use the results from these studies to dictate policy such as duration figures for rehabilitation, types of treatments funded, or to establish whether compensation will be continued.

Another person that I listened to and think of as a kindred spirit is Professor Roland Sussex.  He is a linguistics professor and he and Professor Jenny Strong are working together to review the very commonly-used and well-known McGill Pain Questionnaire.  This is the instrument that provides a list of words, and asked the person with pain to identify the words that apply to him/her.  It was developed in the mid-1970’s, and reflects both the language and the concepts of pain from that time and the culture of North American middle-class white professionals.  Why do I think of Prof Sussex as a kindred spirit? Well, he’s a magpie for bits and pieces of information which he gleefully collects and notes down, and pulls out in conversation which is erudite, ranges over an enormous range of topics, and is entertaining and thoughtful.  While I can’t profess to achieve the level of knowledge of Prof Sussex, I too have that tendency to collect and pick over a range of tidbits of information that seems to scatter around me – and lo! and behold, it comes out on this blog!!

So, what did he have to say?  Well, the poor McGill, which is an instrument I have never found useful and have rarely used, has some linguistic features that make it a product of its time, and one which needs some thoughtful consideration before deciding to use.  There are several words in the instrument that are rarely found in the conversations of the people I see in my clinical practice: lacinating (which according to a number of on-line dictionaries means characterized by a sensation of cutting, piercing, or stabbing), torturing, gruelling, searing – to name a few.  The instrument also categorises these words, but the categories are not necessarily mutually exclusive, and although each category apparently ranges from less severe to very severe, this isn’t particularly clear.

Some other concerns I’ve had with the McGill also came up – the cultural bias of an instrument developed in the US for english speakers means that people from other cultures are disadvantaged by it.  We simply don’t know whether it’s possible for someone who doesn’t speak english as a first language would think of these words when describing their pain.  There are some words that are very specific to pain (eg lancinating), while there are other words that are used far more generally for many other things (eg hot, cold, burning), and this makes it especially difficult for people from other cultures to translate.

I’m not sure whether the McGill was ever meant to be a substitute for simply talking about pain, but I’ve seen it used for a wide range of things in the pain literature – from ‘diagnosing’ pain sub-types (eg neuropathic pain), to measuring outcomes of treatment, to simply being part of a battery of tests to ‘understand’ someone’s pain.  There are always concerns when we try to understand another’s pain – we can never know the qualia of another’s pain (just as we can never know whether we each see the same ‘blue’, although we use the word about the same/similar wavelength of light).  Constraining someone to a tool like the McGill doesn’t seem especially helpful for me clinically, so I’ve preferred to talk and come to some sense of understanding, albeit filtered through my own language filters, and through the filters of the person I’m talking with.

Any assessment we use will be subject to certain other ‘cultural’ aspects of communication.  This is because in order to understand another’s pain, we rely on communication, and communication is social and cultural.  Communication involves at least two people, some shared communication conventions (folkways or mores), it relies on the ability of each participant  to have a message to communicate, a method to encode it, transmit it, for that message to be received, decoded and comprehended.  Lots of opportunity for error to creep in!

Think about some of the features that are present in any conversation about pain:

  • the person with pain needs to decide whether their pain is something they wish to communicate about
  • once they decided to communicate about it, they consider/process the aspect they wish to project – and we are quite selective about what we communicate.  For example, do we want to demonstrate stoicism? martyrdom? bravery? anxiety?
  • the actual process of determing what to communicate is filtered through often subconscious processes – how many of us from a Judeo-Christian background really think about the way our Judeo-Christian heritage conceptualises pain?  Of heroes, and saints suffering, and pain as punishment, and retribution and how it was visited on Job to ‘test’ him, and removed only with God’s will?
  • And what about our own family’s view on pain? Are we from a family where pain is discussed? or one where we were told to ‘put up or shut up’?  Was one parent very vocal about pain, and what impact does that have on us? Like the child of an alcoholic, who may ‘blame’ the parent for either abstinence or alcoholism, we too may be reacting to situations in our early life…
  • And culturally, we may be from a culture where certain pains are NEVER discussed (vulvodynia, painful periods), or we may be of an age or in a state such as pregnancy where every horror story of childbirth is discussed in intimate detail.
  • Our gender makes an impact on what we will discuss, with whom and in what detail…
  • Our power in a relationship as interrogator, subject or equal makes an impact on what is asked, by whom and when – and what is answered, by whom and when
  • and finally, once a decision is made to communicate about pain, it is moderated by the response of the other person in that conversation to either increase the frequency of ‘pain talk’ or decrease it.

I’ve talked before about the words that we use when talking about pain – the importance, to me at least, of the ‘social’ in ‘psychosocial’ assessment, for fear that the interaction between the person and his or her environment (both social and nonhuman environment) will become lost.  I’ve also talked about the language of ‘injury’ being used in some circumstances, but not in others (the head’ache’ is different from the back ‘injury’???).

So, a fruitful weekend, one that I will recall very fondly indeed – a toast to Jenny and colleagues for organising such a rich and enjoyable feast for me and the others who attended!