More pain sites over time = greater risk of work disability
It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

  1. In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving.  In chronic pain management, we ask people to do things despite pain.
  2. In acute management, we encourage a ‘start low and go slow’ approach to increasing activity.  We do the same in chronic pain management.
  3. In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal.  In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside.  In chronic pain management, we are relatively sure that pain will persist.    So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly.  It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often.  I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem.  If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey?  If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back.  I do write most days during the week, and I do love comments.  If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to.  I’m looking forward to hearing from you!

Kamaleri, Y., Natvig, B., Ihlebaek, C., & Bruusgaard, D. (2009). Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study European Journal of Pain, 13 (4), 426-430 DOI: 10.1016/j.ejpain.2008.05.009

Attributions regarding unmet goals after treatment

After searching for a while, and finding not that much about goals in the peer-reviewed pain management literature, it’s nice to have an article that specifically discussed goals and the effect of not meeting goals on participants. This article by Guck and colleagues from the University of Nebraska, examines how a group of participants in a pain management programme view their achievement of goals – do they blame themselves, or external factors for their ‘lapse’ or ‘relapse’.
It’s interesting that this piece of research is based around the concepts of relapse prevention, because one of the main reasons for considering the place of goal-setting is to ensure participants make changes in their lives that matter to them – and retain those changes over time. So relapse prevention theory will have much to add for therapists wanting to help their clients stick with the ‘programme’. I’m not sure that many therapists would have really considered this body of knowledge in relation to physical exercise or using coping skills, because much of the theory is directly related to smoking cessation, dietary change or alcohol abstinence.

Anyway, onto the research.
In this study 100 particpants from 263 people who entered an interdisciplinary programme over a five-year period were asked to participate. Of the original 263, 30 failed to complete the programme, and of the remaining people, 100 provided complete information.

From the description, the programme sounds very similar generic and consisted of a four-week programme of exercise, medication review, active coping strategies and other issues such as work, family and social issues were also addressed in both individual and group sessions.

In the final week of the programme, relapse prevention sessions were held, covering high risk situations, and how to reduce the likelihood of the rule violation effect.

Interestingly, the group developed their goals for after the programme at the time of this discussion – in full awareness of the role of ‘slips’ and ‘lapses’. Participants develop between 4 – 6 goals, and staff assisted them to ensure goals met the ‘SMART’ goal schema. The goals were to be achieved in the next six months.

Six months after discharge from the programme, participants were contacted with a copy of their goals list, and were asked to identify whether they had met the goal, and for each unmet goal, to record on four attributional rating scales, the reason for not doing so. The attributional scales were 1 – 7 likert-type scales, with ‘internal’ to ‘external’, ‘stable’ to ‘unstable’, ‘gobal’ to ‘specific’ and ‘uncontrollable’ to ‘controllable’ factors as the anchors.

Results – Overall, the 100 participants identified 487 goals they intended to meet – 322 of these goals were recorded as met, while 165 goals were not. 46 of the 100 participants met most of their goals, while 16 failed to meet more than 2/3 of their goals. Chi-squared analysis indicated that more goals than not were met in most of the goals categories – except for work.

The causes for not meeting work and social activity goals were attributed to external rather than internal factors more often than were causes for not meeting coping skills, medication change, or exercise goals. Work goals were more often to be thought to be uncontrollable.

So, it seems that goals that were set during this programme by and large were met – except in the two areas that depend a lot on other people (social and work). And the attributions that people made as to why these goals were met or not met differed depending on the type of goal. This suggests that it’s not helpful to use the same relapse prevention model for some of the goals – that is, people do tend to believe that when they can’t manage work or social goals, it’s about external factors, uncontrollable factors, and global factors that are stable.

This makes it very difficult for people to reconsider how to cope with these demands, and from other research in relapse prevention, makes it more likely for them to feel there is nothing they can do to change the situation, and reduce the likelihood they will attempt again.

The researchers in this study suggest that people who need to set goals in social and work areas need to be taught how to cope with factors that affect work and social goals that are external and uncontrollable – unfortunately, as many pain management programmes don’t even consider return to work as a goal, and certainly don’t seem to break that goal into manageable ‘chunks’, this may remain a concern within New Zealand at least.

Once again I’m left with the impression that developing pain management skills and goals to help people return to work despite chronic pain is different from and more complex than simply helping people develop generic pain management skills. The workplace is different from the home – and goals made for using pain coping strategies, exercise and medication at home seem to be much more easily achieved than those about using them at work. Food for thought: perhaps pain management at work is a specialised area for pain management, and not simply the same as ‘any old pain management’?

Gluck, T.P., Willcockson, J.C., Schmidt, R.L., Criscuolo, C.M. (2008). Attributions regarding unmet treatment goals after interdisciplinary chronic pain rehabilitation. Clinical Journal of Pain, 24(5), 415-420.