Opportunity for a conversation

I had a wonderful discussion with another occupational therapist about the profession’s response to the earthquake.  “How”, she asked, “Can occupational therapists from the other end of the country help those in Christchurch?”

To further this discussion, I’ve added a new page to my blog for people to contribute their thoughts about how occupational therapists can aid in the recovery process for people in Christchurch.

Feel free to contribute, comment, say your piece – and even if you’re not an occupational therapist, but you have some thoughts about how occupational therapy as a profession might be able to help, please add your comments too.

Go here for the page…

The importance of doing nothing

While recovering from my postconcussion syndrome, I learned a lot about saying no and letting go. I’m not usually prone to doing this, so it was a surprise to me to find out that not only could I do it, but I have carried on doing it and enjoying it! I don’t have any literature to support today’s post, but my own personal experience (an N of 1 study!).

I wonder how often in rehabilitation or pain management, we even think about scheduling time for the people we work with to just do nothing. I think sometimes we might under-estimate the amount of energy that goes into following a programme of therapy. Here’s just a little from my experience.

Every day I was going to work for half a day, returning home to sleep for an hour and a half. Then I would do my speech language therapy for about 20 minutes, then need to stop and rest for another half hour. By then I would have a thundering headache so would go for a walk or do some bellydance practice to shake it off, then need another 30 – 45 minutes to rest to recover.

“I thought if I held out long enough, someone would find a cure”

I’ve written about acceptance before (here) , (here) oh and (here) – it’s one of those topics that seems to come up again and again (or is that ‘cos I’m looking for it?!).

I have been reading about self efficacy beliefs especially relating to beliefs about returning to work, and the thought crossed my mind that people can hold contradictory beliefs about their condition and their confidence to do things despite pain, but that it probably has some sort of emotional cost. Not sure that I’ve found any specific literature to support that, but hold the thought in your mind!

Anyway, today I was reading an article by Busch, Goransson & Melin (2007) about self-efficacy beliefs predicting sustained long-term sick absenteeism in individuals with chronic musculoskeletal pain. In it they describe the results of a survey of 233 people with chronic pain, aged under 60, who had jobs to return to and had not taken early retirement – the long-term sick leave people. The group were divided into those who had been considered ‘work capable’ (they had been removed from the sick leave register in Sweden in the previous 6 months), or currently sick listed. All participants were given an initial questionnaire which included questions on:
(1) demographics
(2) perceived physical and psychological health
(3) working conditions
(4) involvement in rehabilitation
(5) individual factors including beliefs and mastery
(6) perceived consequences of long-term sick leave

The specific questions and questionnaires used are described in the actual article, so I’ll cut to the chase and get on with the results…
After this initial survey, four follow-up surveys were conducted 6 – 12 months after the initial one. The outcome measures of interest at these follow-ups were sick leave days.

Using regression analyses, five significant predictors were found:

• psychological health,
• mastery,
• mental demands at work,
• recovery beliefs, and
• sick absenteeism earlier in life.

The strongest predictor was beliefs about recovery, and the next strongest was a sense of mastery.

Once again, it seems that the physical characteristics of work and the physical capacities of individuals are less useful for predicting return to work than whether the person thinks they will recover. The actual question used was ‘A year from now, do you think your health will be better or worse?’

I’m not entirely sure that this is a question of self-efficacy, however that aside, it seems that the person’s own opinion of whether they are ‘well’ or not has an incredibly powerful effect on whether an individual will or won’t meet the challenge of the workplace.

As the authors in this paper say ‘beliefs about one’s recovery can be interpreted in different ways. They can reflect medical ‘facts’ about one’s disorder, communicated by medical staff or others.’

The person I quoted in the headline today said to me, ‘I thought I shouldn’t go back to work because then they wouldn’t think I needed to have my hand fixed, and if I held out long enough, someone would find a cure’.

He had been told that he shouldn’t risk his hand in a work situation because ‘it might make your recovery slower’.

If only someone had said to him that staying off work would likely mean he would lose his job and make eventual return to work much more difficult!

How does this fit with acceptance? The man I’m working with is slowly moving to a place where he accepts that his hand doesn’t perform exactly the way it used to – and that this doesn’t mean an absolute disaster for him.  Neither does it mean he needs to give up hope that things will be different in the future.  Or that someone might find a ‘cure’.

In the meantime he has a life to live, and he is gaining confidence (self-efficacy) that if he starts to take steps to regain control in his life, he’ll begin to ‘live’ a fuller, more ‘normal’ life.

Self efficacy is about being confident that one can achieve success in a given situation. Acceptance is about giving up a resentful struggle against things being the way they are, and getting on with life – I think they may be linked. It’s very hard to feel confident if you are struggling against the reality of life being different from the way you want it to be.

As for our role as health providers? Well it seems to me, if we instill in people the belief that they shouldn’t return to work in case they delay their recovery, or that we don’t believe they can cope with hearing that their problem may be chronic, we’re undoubtedly contributing to the negative effects of low self-efficacy. If instead we work hard to instill in our patients that we believe they have the ability to do ‘normal’ things in life, like return to work, and that recovery is more than pain reduction, we may contribute to their confidence. I hope we do this!

If you’ve enjoyed this post, and want to read more you can subscribe to my blog using the RSS feed link above left. Or you can simply bookmark my blog and come back for more! And yes, I do love comments – keep ’em coming!

Busch, H., Göransson, S., Melin, B. (2007). Self-Efficacy Beliefs Predict Sustained Long-Term Sick Absenteeism in Individuals With Chronic Musculoskeletal Pain. Pain Practice, 7(3), 234-240. DOI: 10.1111/j.1533-2500.2007.00134.x

Smoking and pain

Something I’ve noticed many times is the number of people experiencing chronic pain who also smoke. It used to be thought that people who smoke perhaps had poorer health behaviours which lead them to be less fit, less careful about eating well, and perhaps to having poorer responses to stressors generally. And I’ve heard it said that people who smoke have ‘addictive personalities’. Well it’s not quite a simple as either explanation – but it’s time to put some of the evidence forward about smoking, nicotine, and pain.

This is not an exhaustive review by any means, just a couple of papers that I thought might help when considering whether to suggest quitting smoking to people who have ongoing pain.
I ought to add that the studies I refer to don’t demonstrate causation – they are correlational studies, which mean that there is an association between smoking and chronic pain, but we don’t know whether the relationship is direct, or perhaps mediated through other things – and I’ve suggested some above.
Despite this, here are some papers that are quite persuasive.

The first is a large national study published in 2006, specifically looking at tobacco smoking and pain in the general population – quite different from our hospital patients, or those directly seeking treatment. Quoting directly from the abstract: Former and current heavy smokers had higher odds for greater numbers of pain locations and for moderate and intense pain than never smokers after adjustment for analgesic medicament use and behavior-related risk factors. Female former heavy smokers had an adjusted odds ratio (OR) of 1.6 (95% confidence interval, CI, 1.2-2.2) and male former heavy smokers had an adjusted OR of 1.4 (CI 1.1-1.8) for higher numbers of pain locations compared to never smoking women and men respectively (female current smokers: OR 1.4, CI 1.0-1.9; male current smokers: OR 1.3, CI 1.1-1.7).

The findings suggest that former and current heavy smokers are more likely to report more pain locations and more intense pain than never smokers.

Well, that’s quite high odds! And sadly, it doesn’t seem to make a lot of difference whether you’ve stopped smoking or continue to smoke – the odds are still high.

A second study worth considering is this one published in 2005, where people consulting a GP for the first time with acute low back pain were followed. Again quoting from the abstract: At 4 weeks and 3 months 76% of the patients had recovered. Mean pain intensity and mean disability scores dropped 58% and 68%, respectively, of initial levels during the 3 months. The proportion with sickness absence was 8% at 4 weeks and 6% at 3 months. Several sociodemographic, clinical, and psychological factors were of prognostic value. Compared with their respective reference categories, age above 45 years (odds ratio 4.4, 95% confidence interval 1.4-14.0), smoking (3.0, 1.1-8.5), two or more neurological signs (4.6, 1.4-14.9), a score of >90 on the psychosocial screening (3.1, 1.0-9.4), and high levels of distress (4.1, 1.3-12.8) were the best prognostic factors of nonrecovery at 3 months.

And a final study worth mentioning is a very recently published one by Ryall and colleagues, studying people attending primary care and physiotherapy for arm pain: Altogether, 313 (83%) of 375 subjects completed follow-up, including 53% with ‘continuing’ and 24% with ‘unremitting’ pain. ‘Continuing’ pain was predicted most strongly by male sex (OR 1.9, 95% CI 1.2-3.2) (this association was restricted largely to the elbow), higher frequency of pain in the past month at baseline (OR 2.5, 95% CI 1.1-5.6), chronic pain at sites outside the arm (ORs 1.6-2.4 for different sites) and current smoking (OR 3.3, 95% CI 1.6-6.6). There were also indications that mental health and fear-avoidance beliefs influenced prognosis. Predictors for the other two adverse outcomes were similar.

Curious – some very strong pointers that smoking increases the risk of persistent pain and poorer recovery from acute pain, yet I’m not sure that I’ve ever heard that in public health messages about smoking, and I’ve not yet heard of quitting smoking efforts targeting people with chronic pain. Time for action? I think so.
BTW I don’t know why I get smiley’s through my posts – any geeks out there able to tell me? Can’t see it in the HTML code, but then again, I’m not a technophile…

Grotle, M., Brox, J. I., Veierod, M. B., Glomsrod, B., Lonn, J. H., & Vollestad, N. K. (2005). Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time. Spine, 30(8), 976-982

John, U., Hanke, M., Meyer, C., Volzke, H., Baumeister, S. E., & Alte, D. (2006). Tobacco smoking in relation to pain in a national general population survey. Preventive Medicine, 43(6), 477-481.

Ryall, C., Coggon, D., Peveler, R., Poole, J., & Palmer, K. T. (2007). A prospective cohort study of arm pain in primary care and physiotherapy–prognostic determinants. Rheumatology, 46(3), 508-515.