Research

Persistent pain and movement practices


Here I go, stepping into “the bio” to write about movement. Oh dear, what am I doing?

Movement practices of various kinds are part and parcel of pain management. In fact, to read some of the material in social media-land, exercise is the be-all and end-all of pain management, maybe with a dash of psychology. Can we please stop doing this?

I’ve said it often, for many forms of persistent pain, especially the most common forms – nonspecific chronic low back pain, fibromyalgia, and osteoarthritic pain – movement is a good thing, but the effect sizes are small for both pain intensity and disability (eg Jayden, et al., 2021). I’ve reproduced the author’s conclusions below:

We found moderate‐certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low‐certainty evidence) and functional limitations outcomes (moderate‐certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

So for chronic low back pain, short-term pain intensity reduction is clinically significant, but neither functional limitations nor pain intensity reductions over the long-term reached clinical significance. Ouch! This means that we must not oversell the usefulness of exercise as a panacea for chronic pain.

Some missing bits in this meta-analysis: how many people carried on doing their exercise programmes? Why did they keep on going if they didn’t experience reduced pain or better function? How many people dropped out from follow-up?

But my biggest question is “Why does increased physical fitness and reduced pain not translate into better function in daily life?” And of course, my next question is “What might improve the daily life outcomes for people with pain?”

I might also ask why there is so much emphasis on exercise as an approach for chronic pain? Why oh why? One reason could be the assumptions made about the reasons people have trouble with daily life activities. A reasonable assumption might be that people are unfit. Another might be that people don’t have confidence to move. But if these assumptions were true, we’d see better results than this. Perhaps we need to be much more sophisticated and begin to explore what really does impact a person’s daily life activities? My plea therefore is that we cease doing RCTs comparing exercises of various forms to placebo, no treatment or usual care. Please. We know movement is a good thing, and with the enormous number of studies carried out, surely we can stop now?!*

Here are some clinical reasoning pointers when employing movement practices. I’m being agnostic with respect to what form of movement practice [insert your favourite here].

  • Find out what the person enjoys doing for movement/exercise. Aim to do this, or build towards doing this. Start low and build up intensity, load and frequency.
  • Find out why the person has stopped doing their movement/exercise practice. If pain has stopped them, be curious about what they think is going on, what they think the pain means, what happens if they experience pain doing their favourite movement practice, and find out how long and how much they’ve done before pain stops them. Then address unhelpful beliefs, re-set the starting point and progress in a gentle graded way.
  • If the person hasn’t ever been a movement/exercise person, be curious about why. Explore this in detail – beliefs about movement, movement practices they’ve tried, time available, cost, all the things that might get in the way of doing a movement practice. You might find it was a high school physical ed. practice that totally put them off – but look beyond “exercise” or “sports” and remember that movement includes walking, dancing, gardening, playing with the dog, fishing, kayaking….

When you’re starting to generate a movement practice programme, for goodness sake ask the person when they’re going to find time to do it, and don’t make it too long! Explore when might be the most convenient time, and what might make it easy to do. Use low cost, low-tech practices. Find out what might get in the way of doing the movement practice, and do some problem-solving – anticipate what goes through a person’s mind and together, come up with counter-arguments or better, think of some really important values that might underpin the reason to do what is undoubtedly difficult for this person in their life.

Think about life-long habits and routines. How might this person explore options that could fit into their life as they get older? What might they do if the weather is bad, or they have an addition to the family? How many different movement practices can you and the person think of? And remember, if it’s OK for a person at a gym to do “leg day” one day, and “arm day” another, it’s perfectly fine for someone to do gardening one day, and go for a walk up the hill the next. Don’t be boring! Invite exploration and variety.

Work on translating the movement practices you and the person do in clinic into the daily life movements the person is having trouble doing. This might mean asking the person about their daily life and what’s most difficult for them to do right now. If it’s bending to load/unload the dishwasher, ask them what’s going on, what comes up for them when they do this? Is the problem about physical capability – or is it because it’s at the end of a long day at work, they’re tired and haven’t been sleeping and they’re worrying about how the pain in their back is going to affect their sleep tonight? If it’s the latter – guess what, physical exercise isn’t going to change this! So talk about what they can do to help with their sleep, or if that’s not your forte, talk to another team member (occupational therapist, psychologist) about what might help.

Note that as clinicians, we have no right to dictate what a person’s life looks like. This means we can’t judge a person for their choice of movement practice. We also can’t dictate how often or how intense their “workout” should be. It’s going to vary, depending on all the things this person in front of you values most. And we must respect this – don’t be judgemental, their values may be very different from yours, and this is perfectly OK. Just help them explore the good – and not so good – of their choices.

Finally, don’t be afraid to have fun with movement! Play a little. If disc golf is the person’s thing – go try it out! If jive dance is their thing, maybe it’s time you gave that a go. If they like hiking to a quiet spot to do a little bird photography, go with them and carry your own camera gear. If their life is so busy that movement practice gets squeezed out, work with them to find ways to get movement snacks into their day. Don’t be boring. And worry a little less about “prescribing” movement, and much more about experiencing your body as a living sensory being – get in the moment and enjoy what your body is able to do. That is really what we’re encouraging in movement practices for chronic pain.

*A couple of other guesses for why exercise gets seen as The Best Thing – it’s “cheap” in comparison with other options, people can do it reasonably easily after therapy, there are LOTS of physiotherapists and others who offer this, it appeals to our “simple” (but wrong) beliefs about pain, psychological approaches are more expensive (though don’t offer better outcomes), daily life occupational therapy approaches are really hard to conduct as RCTs….

Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 18 December 2022.

The joy of having many data points


Researchers and clinicians are drawn to studies with many participants. Especially randomised controlled trials, where two groups are randomly divided and one gets “the real thing” while the other does not. The joy comes from knowing that results from these kinds of studies suggest that, all things being equal, the differences between the groups is “real” and not just by chance.

When we come to analyse the graphs from these kinds of studies, what we hope to see are two nice bell-shaped curves, with distinct peaks (the arithmetic mean) and long tails either side – and a clear separation between the mean of one group (the experimental one) and the control group.

It should look a bit like this:

Now one of the problems in doing research is that we can’t always guarantee a large sample – for example, it’s difficult to find enough people with a relatively rare problem like complex regional pain syndrome to randomly split the groups to iron out major differences between them. And, this kind of research design presumes the principle of ergodicity – here for more information from Wikipedia, or here for a more detailed examination relating to generalising from groups to individuals.

This research design also struggles to deal with distributions that don’t conform to the lovely bell curve – things like bimodal distributions, or skewed distributions. And if we draw only on the mean – we don’t get to see these delightful peaks and troughs – or the people at either end of the curves.

The more variables we add to analysis, the more complex the statistics needed – so in the case of pain research, we often have to simplify the research question, do complex maths to “normalise” the results, and ultimately we get research that doesn’t look the slightest bit like the people we see in clinical practice. No wonder we get results that don’t look nearly as nice as the research studies!

Now I don’t mind statistics at all, but I do mind research papers that don’t declare the assumptions made when using analyses. Many papers assume the reader knows these assumptions – unlike qualitative research where the authors philosophical assumptions are openly stated, and where epistemology and ontology are considered part of the research design.

So why might lots of data points be cool?

Most of us working in a clinic will be seeing an individual. One person, with all their unique history, attributes, vulnerabilities, preferences and values. When we extrapolate the findings from RCTs especially, and apply them to this unique person, we risk failing to acknowledge that we’re violating the principle of ergodicity, and that our person may be one of those falling at the tails of that bell curve: or worse, in the middle of a bimodal distribution. Given that most pain problems, particularly persistent pain, are multifactorial, applying a single “solution” no matter how many studies showing a positive effect there are, may not cut it.

For years I’ve been pointing out the value, both in research and in clinical practice, of single case experimental designs. There are loads of reasons for using this approach, and it’s a method with a long history. Essentially, the person serves as their own control, they take lots of measurements before introducing a treatment, the treatment is applied and changes in the measurements are closely monitored. If there’s a change in the expected direction, we can test whether it was the treatment by withdrawing said treatment, and closely monitoring any changes in the measurements. Of course, there are challenges to using this approach – we have to be able to withdraw the treatment, and that doesn’t work if it’s something like “information”. But there are ways around this – and the method of intensive longitudinal repeated measures is becoming a rich source of information about change processes.

Change processes are changes that mediate the final outcome. In other words, when we do a treatment, either the treatment directly causes the end outcome – eg give someone a raised toilet seat, and they can get off the toilet because the toilet is at a good height for them – or via some other process – eg by giving the raised toilet seat, the person gains confidence to get on and off the toilet so it’s not the toilet seat per se, but enhanced confidence that mediates the outcome.

Change processes matter because once we’ve identified them, we can develop ways to work with them more effectively. We can also measure the progress a person makes on more than one change process, and refine what we do in our treatments in response. The more data points we collect from that one person, the more we can track their trajectory – and the better we can understand what’s going on in their world to influence their responses.

Technology for repeated measures in real time has become much smarter and more invisible than it used to be. We can still employ some of the simpler techniques – a pen and paper diary still has used! But we then have to rely on the person remembering to fill them in. Passive data collection using wearable technology is something many of us use to track fitness, diet, sleep, travel, heart rate variability and so on. Set the parameters, and as long as you’re wearing the gadget, your data is captured.

Before anyone leaps in to tell me the gadgets are prone to measurement error, believe me I know! For example, monitoring sleep using a phone (or even a smartwatch) doesn’t monitor sleep depth, it monitors movement (and records snoring LOL). However – and this is important – it is more likely to get used than anything requiring me to do something extra in my day. And we can integrate both passive data collection and active data collection using similar technologies. For example, it’s not difficult to send an SMS (instant text message) at random times during the day to ask someone a brief and simple question.

Where these repeated measures approaches get a bit gnarly is in analysing the data – but even this doesn’t mean it can’t be done. The analyses require a good understanding of what it is being measured (and why), and how best to use complex statistical analyses to understand how one factor (variable) might influence another.

The advantages of using intensive measures in clinic lie with understanding how, for example, one day of additional activity (measured using the step counter combined with GPS tracking) might directly influence mood the next day (or pain, or energy levels or whatever). We still need to apply critical thinking to uncover the causal mechanisms (is it plausible for factor X to directly cause a change in factor Y?) and to check whether the results are stable over time (or just a chance fluctuation). Another advantage is that we can quickly step in to experiment with an intervention – and watch what happens. For example, if we think being very active on one day has an effect on mood the following day, we can test this out: try experimenting with a day of lots of activity, and monitor what happens the next day, or the converse, do very little and monitor what happens with mood the following day. Rinse and repeat until we’re certain that for this person, activity level has an effect on mood.

And the study that made me think about all this? It’s this one by Whibley, Williams, Clauw, Sliwinski and Kratz (2022) – click

If we want to really develop excellent clinically-relevant research-based ways to understand what might be going on for the one person in front of us, and not for the large mixed group of people included in a randomised controlled trial, we could be inspired to look at intensive repeated “micro-longitudinal” research strategies as models for clinic-based research.

Whibley, D., Williams, D. A., Clauw, D. J., Sliwinski, M. J., & Kratz, A. L. (2022). Within-day rhythms of pain and cognitive function in people with and without fibromyalgia: synchronous or syncopated? Pain, 163(3), 474-482. https://doi.org/10.1097/j.pain.0000000000002370

How much “pain ed” do people need? And what to do when someone is not convinced…


This post has been a long time coming. There’s no doubt that giving explanations about pain mechanisms is common, and that we’ve (health professionals) been doing it a looooong time. Yes, way back to the 1970’s! In the early 1980’s when I started working in this field it was already commonplace to offer people an explanation for chronic pain (and to explain why some pains are such pains, while others bother us less – even when they involve the same degree of nociceptive input). Of course, way back then we used Gate Control Theory (GCT) to explain the distinction between hurt and harm, to explore why attention and emotion matter, and to introduce the idea of counter-stimulation and TENS: suffice to say clinicians used these metaphors especially for people with persistent pain (Katz & Rosenbloom, 2015).

Then along came Moseley, Nicholas and Hodges (2004) with a nicely-designed RCT comparing “pain neurophysiology” education with “back anatomy and physiology” provided by “trained physical therapist educators.” The results of this study showed “Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability.” Somehow the lack of relationship between changes in pain cognitions and physical performance and perceived disability got lost in translation, but what happened next was an explosion of interest in the effects of providing explanations about pain mechanisms.

Today, the old adage “if you have a hammer, all you see are nails” seems to apply when it comes to “pain mechanism explanations.” Everyone gets an explanation, many of the explanations are exactly the same (sometimes down to the same book being used), and I wonder how people with pain feel about this. Like the way we feel at the end of Christmas Day feasting – noooooo! not another mouthful!

Recently I was asked “how much pain ed do people need?” and my first thought was “it depends.” That’s my answer to most things in pain! Suffice to say, I think we need sound clinical reasoning before we launch into any intervention, and this means we need to understand the rationale for giving someone a pain mechanisms explanation. This post attempts to shed some light on when it might be useful.

One reason given for “educating” people (please, no! “educating” someone sounds so like an info-dump, and focuses us on what WE do, rather than on the EFFECT this information is intended to have) – one reason is to reduce pain intensity. Education, however, doesn’t have an incredibly powerful action on my pain when I burn myself doing silversmithing. The effect of information on pain may be via appraisal: if I think my pain is not a direct measure of tissue damage, then I might not be as distressed by it (and indeed, this is one of the effects identified in the Moseley, et al., 2004 study – changes in the Survey of Pain Attitudes and the Pain Catastrophising Scale showing reduced catastrophising brought about by recognising that hurt isn’t equal to harm).

As a result of not being as distressed, a person doesn’t have to communicate their fear through a number on a 0 – 100mm VAS. Because remember, we don’t have a pure measure of pain intensity and the VAS is a communication device. Pain behaviour, or what we do about our pain, is at least partly about communicating to others (Hadjistavropoulos et al., 2011; Lackner & Gurtmann, 2004) – and we all know we’d never get prescribed analgesia in an Emergency Dept with 30mm pain on a 0 – 100mm VAS!

Similarly, if we’re not as afraid of what pain means, we’re less likely to be worried about moving – so I wasn’t at all surprised to see the changes in straight leg raising and other physical performance measures. I also wasn’t surprised to see no change to perceived disability because doing functional activities in the real world is a whole lot more scary than in a controlled, supervised clinical setting. Remember this, folks, when you’re prescribing movement practices: they do not directly transfer into confidence and performance in daily life!

So if giving an explanation is about reducing distress, maybe it’s also about reducing uncertainty. Zaman and colleagues (2021) found that uncertainty hasn’t been studied as much as I’d hope and worse, it’s often studied in experimental settings where there is certainty that the pain will end, and this in turn is quite unlike me and my fibromyalgia pain which is both unpredictable and not controllable. There’s no doubt that helping someone understand that their pain isn’t a dread disease (cancer, some weird inflammatory disease, a nasty neurological – oh wait, it IS a nasty neurological thing…!) will likely reduce their distress, and might even reduce uncertainty – because at least we know what it’s not! But uncertainty remains with persistent pain because no-one knows when/if it will end, often we don’t know why it gets set off, and we clearly don’t have a handle on why it goes on and flares.

It makes sense, then, to consider pain mechanism explanations when a person 1) is not sure what it all means, 2) worries that it’s something nasty, and 3) thinks it’s both a direct reflection of what has happened to their tissues and 4) that they personally can’t do much about it.

We might also think of giving someone some information about their pain if we want to help them understand why we might be trying something like mindfulness, relaxation, stress management, or even normal movement. We can employ the little we know about cortical processes and descending inhibition, and polyvagal theory and sympathethic arousal, as well as physiological responses to movement/exercise to explain the rationale for these interventions if we so choose.

BUT we don’t have to all the time. Why? Because we can do these things anyway and help the person explore their responses in vivo! This may be more powerful than giving any kind of ham-fisted explanation, whether it be a cookie cutter one, or a tailor-made metaphor.

A few posts ago, I wrote about McCracken and Scott’s (2022) paper exploring the potential problems of making sense. This showed that sense-making can impede a person’s readiness to engage in therapy if their desire to make sense means they reject explanations that don’t fit with their understanding or when they overthink what the explanations mean. In these instances, it makes much more sense for us (see what I did then?) to help them begin to do what matters in their life than continue looking for explanations.

My guidelines for working through “pain mechanisms”?

  • If the person is a geek and likes to delve into learning about their body and responses – go for it! (ie, people like me :-))
  • If the person asks for information, or has questions about specific aspects of their pain or treatment
  • As part of generating a case formulation, where the person and you collaborate to develop a model of what’s going on for them. As a clinician you’ll be using guided discovery to work out the processes that occur in predictable patterns, and these patterns in turn can become the focus of where and how you might interrupt them.
  • After asking the person for their understanding, and there’s something in their version that’s unhelpful for their progress. For example, if the person tells you that they think a scan will uncover “the real reason” for their pain, or if they’ve taken on board an unhelpful belief that their joints are grinding bone on bone… you know the sort of thing. After asking permission to explore these thoughts/beliefs, you might find it OK to offer an alternative – but if it’s not getting in the way of them engaging in therapy, then just go along with it and use guided discovery instead.

What to do instead of explaining mechanisms?

  • Focus on helping the person move towards what matters in their life, even if it doesn’t always make sense to the person. Use their experiences to guide their understanding, it’s far more powerful than any kind of external “truth”.
  • Use guided discovery, drawing from their own experiences and asking them to reflect on the effect of what they do and know on their experience. For example, ask the person what it’s like when they’ve been worrying about what’s going on in their OA knee, what do they notice about their overall stress level, what does that do to their pain, what effect might that worry have on sleep or fatigue and how this might influence their pain and doing what matters.
  • Offer skills to help deal with uncertainty and worries such as mindfulness (but OMG not to reduce pain, puhleaze!), attention management, and cognitive defusion.
  • Always draw a connection between what you explain and what this means clinically. For example, if you want to discuss nociplastic mechanisms, what this might mean is a tendency for “normal” injuries or tissue disruption pain to hang around a lot longer. It might also mean pain spreads out a bit more. It can help explain why many medications are ineffective. And it’s useful when another clinician has suggested that because “there’s nothing on your scan, therefore there’s nothing wrong.” But tread lightly because there is SO much we do not know!

I like to draw on the principles of motivational interviewing in my work with people. Respecting their autonomy and right to decide means I need to ask permission before I give information to them. I need to have a clear clinical reason for doing so – and this isn’t “because it reduces pain” – it needs to have specific indications for this person. Understanding how and why “pain education” can be helpful is critical, and always remembering that knowing “about” something doesn’t mean it changes behaviour. I’m still not keen on spiders even though I know we have no poisonous ones here in Aotearoa, and I’m much bigger than them!

Katz, J., & Rosenbloom, B. N. (2015). The golden anniversary of Melzack and Wall’s gate control theory of pain: Celebrating 50 years of pain research and management. Pain Research & Management: The Journal of the Canadian Pain Society, 20(6), 285-286.

Hadjistavropoulos, T., Craig, K. D., Duck, S., Cano, A., Goubert, L., Jackson, P. L., Mogil, J. S., Rainville, P., Sullivan, M. J., de C. Williams, A. C., Vervoort, T., & Fitzgerald, T. D. (2011). A Biopsychosocial Formulation of Pain Communication. Psychological Bulletin, 137(6), 910-939. https://doi.org/10.1037/a0023876

Lackner, J. M., & Gurtman, M. B. (2004). Pain catastrophizing and interpersonal problems: a circumplex analysis of the communal coping model. Pain, 110(3), 597-604. https://doi.org/10.1016/j.pain.2004.04.011

McCracken, L. M., & Scott, W. (2022). Potential Misfortunes in ‘Making Sense’: A Cross-sectional Study in People with Chronic Pain. J Pain. https://doi.org/10.1016/j.jpain.2022.09.008

Moseley, G. L., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain, 20(5), 324-330.

Zaman, J., Van Oudenhove, L., & Vlaeyen, J. W. S. (2021). Uncertainty in a context of pain: disliked but also more painful? Pain, 162(4), 995-998. https://doi.org/10.1097/j.pain.0000000000002106

Making sense: Does it help people with pain?


I love it when my biases are challenged (seriously, I do!). And in the study I’m talking about today, my biases are sorely challenged – but perhaps not as much as I initially thought.

Lance McCracken is one of my favourite researchers investigating processes of acceptance and living a good life in the presence of chronic pain. In this paper, he collaborates with a colleague currently involved in the INPUT pain management programme established at Guy’s and St Thomas’ NHS originally by Michael Nicholas who draws on a CBT model of pain management, and now more firmly in the third wave camp of ACT (Acceptance and Commitment Therapy). The paper is ‘Making sense’ and describes a cross-sectional study of sense-making by people with chronic pain attending the INPUT programme.

Making sense is something humans do without even thinking about it. Humans are prone to (and probably for good adaptive reasons) generate patterns out of random information. We gaze at shadows at night and think we see faces or intruders, and we look at clouds and see dragons and kittens. When we’re sore we also try to make sense of what’s going on – does this ouch feel like something I’ve had before? does it feel mysterious or can I carry on? have other people I know had this same ouch and what did they do?

In the search for making sense out of pain that otherwise seems random, clinicians have, since time immemorial, generated all sorts of stories about what might be going on. The wandering uterus. The evil spirit. The slipped disc. The leg length discrepancy. Clinicians, when faced with their own uncertainty about what exactly pain represents, can encourage patients to seek diagnosis: some sort of “explanation” for the problem. When that’s insufficient, more recently we’ve seen the flourishing of explanations for pain from a neurobiological perspective, particularly “pain as an expression of threat to bodily integrity”, a decision that is “made by the brain”.

My own research, investigating the experiences of people who indicated they live well with pain, reflected this same process. They sought a name for their experience, they wanted to understand the impact of pain on daily doing – those fluctuations and variances that emerge during the days and weeks early in the journey of learning that this pain isn’t going anywhere soon (Lennox Thompson, et al., 2019). Note that the group of people I recruited had come to the point where they identified that they were living well with pain – this group of people represent a small percentage of those who live with chronic pain, and not those who are seeking treatment.

OK, so what did McCracken and Scott (2022) find?

Bear in mind that this study was designed to measure the construct of sense-making in people seeking treatment for chronic pain. Also bear in mind the authors come from a perspective of functional contextualism, or a philosophy of science that argues for “…studying the current and historical context in which behavior evolves … to develop analytic concepts and rules that are useful for predicting and changing psychological events in a variety of settings.” What this means to me is that the form of whatever behaviour we’re observing/measuring matters less that the purpose or function of that behaviour in a specific context.

OK, on with the study.

451 adults attending an interprofessional pain management programme were participants in this study, and the measures were taken before they started treatment. They completed a battery of measures including ones measuring acceptance, cognitive fusion, committed action, tolerance of uncertainty, and pain measures such as the Brief Pain Inventory, numeric rating scale.

The research aim was to investigate a way to measure not only the positives from sense-making, but also the potential adverse effects of doing so. Concurrent with developing the measure, analyses of the inflexible ways we make sense were carried out in relation to outcomes: pain interference, depression and participation.

In the results (read through the analysis, BTW, it’s beautifully detailed), women were found to overthink compared with men, older people tended to want to avoid a sense of incoherence, and more educated people also tended to overthink.

Now, a little theory: coherence can be either literal or functional. Literal coherence is like “common sense” – so if I interpret my pain as meaning something is damaged, and moving it is bad, this is literal coherence. Functional coherence might occur when I realise that I hurt whether I’m doing things, or not, and I decide “this is how it is, I might as well get on with life”. In effect, as McCracken and Scott say, “these terms reflect the difference between language, thoughts and behavior fitting together consistently, (thoughts agree with other thoughts and behavior) versus behavior and goals in life fitting together consistently (behavior patterns succeed in reaching goals even when this seems to contradict “good sense”).

In daily life, people consistently prefer to solve problems and avoid insoluble problems. Makes sense, doesn’t it? Why try to deal with things that won’t change, even if we try hard to change them? BUT then we have insoluble problems that don’t make sense: the earthquakes in Christchurch New Zealand in 2011-2013 were random and we hadn’t had earthquake activity in our city for centuries – consequently we had many crackpots coming up with “predictions” for the next swarm of earthquakes based on phases of the moon or fracking or climate change. Anything to help people feel like they had a sense of control over something that did not make sense.

Chronic pain is often an equally insoluble problem. Many times pain like this does not make sense at all. No injury precipitated my fibromyalgia. There’s no imaging or biomarker for pain intensity. Existing biomedical diagnoses based on structural or biochemical or neurological processes don’t tell us much about who might get chronic pain, how intense it might be, or the impact of that pain on a person’s life. But clinicians and people with pain earnestly seek something, something to explain what’s going on.

For both clinicians and people living with pain, constantly searching for The Thing to explain pain can be exhausting, demoralising and linked to unhelpful patterns of behaviour. Clinicians might repeat the same treatment even though it didn’t work the first time. They might refer the person for more investigations, just in case something was missed. They might refer the person to another clinician, or, worse, they may attribute the pain to “mental illness” or “psychosocial factors”. Many, many clinicians think that giving a person a book about how pain might be constructed “in the brain” will be enough for people to make sense of what’s going on. People with pain might be afraid to get on with life in case they’re doing harm, or because they’re hoping the fix might be around the corner and life can “get back to normal”. They may spend enormous sums of money, time and emotion on treatments to either diagnose the problem, or treat it. They might spend hours brooding on what it could be. Their lives often stop – people with pain have called this “the endless limbo”.

Now there is a measure of sense-making I guess we’ll find out more about this part of learning to live with pain. The three subscales identified were “avoidance of incoherence”, “overthinking”, and “functional coherence”, though the last subscale had poor psychometric properties so wasn’t included in the final analyses.

My wish, however, is that rather than applying this measure to people attempting to make sense of something outside of their experience, we might develop a measure of how rigidly clinicians stick to “coherence” in the face of puzzling pain problems. Perhaps what might be even more influential, we might develop a measure of what happens when a vulnerable person trying to make sense of their pain meets a clinician with a high level of inflexibility about “what is going on”, because despite all the research we have into people living with pain, we haven’t yet recognised the power of the clinician in perpetuating unhelpful inflexibility.

Lance M McCracken , Whitney Scott , Potential Misfortunes in ‘Making Sense’: A Cross-sectional Study in People with Chronic Pain, Journal of Pain (2022), doi: https://doi.org/10.1016/j.jpain.2022.09.008

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

“The social” – a brief look at family


Our most important relationships, the ones we learn most from, probably occur in families (Bowlby, 1978). As kids, even before we begin to speak, we observe our family members – and there’s reasonable evidence showing that how well these early relationships develop influences our experience of pain and how we express it.

I had the occasion to read a little about adolescent and children’s pain, and the influence of parents on young people as they grow up. There’s a great deal of research interest in children’s pain because children with persistent pain grow up to be adults – usually also with persistent pain. And good evidence that parents with persistent pain can, through mechanisms including depression and catastrophising, influence pain and disability in their children (Brown et al., 2022; Brown et al., 2021).

The research is fascinating. Some studies investigating predictors of chronic pain in children, some investigating disability – and a small number of studies looking at what we can do to help parents cope with the pain their children are experiencing. Not many studies (54 in a 2021 scoping review – see Lee et al., 2021). And sooooo many studies focusing exclusively, or close to, the influence of Mothers on children. Where’s Dad? Can I repeat that: where’s Dad?

More recent studies indicate the number of Fathers and Mothers – yay, we’re getting an idea of how many are recruited into these studies – and yet overwhelmingly, it’s Mothers who form the majority of participants. I wonder what effect having a Dad with chronic pain might have on a kid? And it’s only recently that oh darn animal models actually include females… it’s those pesky hormones dammit!

Turning to the next most important relationship, apart from parents, there’s a good deal of research looking at partners. Again, there exists a bias towards heterosexual couples, so we’re a little biased here. There is a wealth of material to review in this area of pain, with some brilliant research designs such as repeated interviews over 18 months, followed by 22 days of repeated daily measures (eg Martire et al., 2019); investigating people with pain problems as common as knee osteoarthritis and chronic low back pain; and examining relationships between things like sleep, caregiving burden, catastrophising, relationship satisfaction, agreement about pain intensity between partners, beliefs and perceptions about pain on interactions, anger, stress. HEAPS of fascinating research to delve into.

And yet, how many clinicians, and programmes, routinely include partners? How accessible are treatment sessions for couples to attend? Who, in a pain management team consisting of largely physiotherapy plus a dollop of psychology, looks after this aspect of living with persistent pain? Waaay back in the day, like the mid-2010s, the facility I worked in had a social worker with experience in family systems and relationships – but there are few social workers working in pain management in New Zealand/Aotearoa, and unless something has changed that I don’t know about, our national insurer doesn’t recognise the value of social workers (and, for that matter, the need to include partners in therapy for chronic pain).

When I review the many studies of this part of “the social” and compare the findings from these investigations against current clinical practice, I see an enormous knowledge and skill gap. If the questions we ask people with pain about their relationship are “how is your relationship with your partner?” we’re probably going to hear “oh they’re really supportive” or “I don’t let them know how I am”. Without adequate knowledge about the kinds of factors that negatively influence the partner’s response to the person with pain we’re likely to be oblivious to the risk of partner abuse (56% of people in this study reported past partner abuse, while 29% of the respondents had been abused in the previous year – Craner et al., 2020); we might not be aware that spouses with poor sleep because their partner was sore, were more likely to be angry (Marini, et al., 2020); that 52% of partners without pain reported high-to-severe burden of having to do more both at work and home because their partner was sore (Suso-Ribera et al., 2020) – or that if a spouse without pain did not have confidence in the pain management of their partner with pain, they were more negative (Nah et al., 2020) or that when a spouse without pain thought their partner’s pain “was a mystery” they were more critical and made more invalidating responses (Burns et al., 2019).

You see, while “the social” is complex, difficult to research, and very broad – ranging from employment status, occupation, educational status, ethnicity, culture, gender, sex – it also includes the very intimate and formative relationships we have with our family. In New Zealand/Aotearoa, with our emphasis on Te Whare Tapa Whā as a model of health and for chronic pain, where relationships with whanau are vital, isn’t it time we addressed this lack?

Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Brown, D. T., Claus, B. B., Konning, A., & Wager, J. (2022, Mar). Unified multifactorial model of parental factors in community-based pediatric chronic pain. Journal of Pediatric Psychology, 47(2), 121-131. https://doi.org/doi: 10.1093/jpepsy/jsab085

Brown, D., Rosenthal, N., Konning, A., & Wager, J. (2021, Feb). Intergenerational transmission of chronic pain-related disability: The explanatory effects of depressive symptoms. Pain, 162(2), 653-662. https://doi.org/10.1097/j.pain.0000000000002066

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019, Oct). Spouse and patient beliefs and perceptions about chronic pain: Effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186. https://doi.org/https://doi.org/10.1016/j.jpain.2019.04.001

Craner, J. R., Lake, E. S., Bancroft, K. E., & Hanson, K. M. (2020, Nov). Partner abuse among treatment-seeking individuals with chronic pain: Prevalence, characteristics, and association with pain-related outcomes. Pain Medicine, 21(11), 2789-2798. https://doi.org/10.1093/pm/pnaa126

Donnelly, T. J., Palermo, T. M., & Newton-John, T. R. O. (2020, Jul). Parent cognitive, behavioural, and affective factors and their relation to child pain and functioning in pediatric chronic pain: a systematic review and meta-analysis. Pain, 161(7), 1401-1419. https://doi.org/10.1097/j.pain.0000000000001833

Lee, S., Dick, B. D., Jordan, A., & McMurtry, C. (2021, Nov). Psychological interventions for parents of youth with chronic pain: A scoping review. The Clinical Journal of Pain, 37(11), 825-844. https://doi.org/10.1097/AJP.0000000000000977

Marini, C. M., Martire, L. M., Jones, D. R., Zhaoyang, R., & Buxton, O. M. (2020, Jun). Daily links between sleep and anger among spouses of chronic pain patients. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 75(5), 927-936. https://doi.org/10.1093/geronb/gby111

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841-2847. https://doi.org/10.1097/j.pain.0000000000001673

Meredith, P., Ownsworth, T., & Strong, J. (2008, Mar). A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clinical Psychology Review, 28(3), 407-429.

Nah, S., Martire, L. M., & Zhaoyang, R. (2020, Oct). Perceived patient pain and spousal caregivers’ negative affect: The moderating role of spouse confidence in patients’ pain management. Journal of Aging and Health, 32(9), 1282-1290. https://doi.org/10.1177/0898264320919631

Suso-Ribera, C., Yakobov, E., Carriere, J. S., & Garcia-Palacios, A. (2020, Oct). The impact of chronic pain on patients and spouses: Consequences on occupational status, distribution of household chores and care-giving burden. European Journal of Pain, 24(9), 1730-1740. https://doi.org/10.1002/ejp.1616

Biopsychological pain management is not enough


I recently read a preprint of an editorial for Pain, the IASP journal. It was written by Prof Michael Nicholas, and the title reads “The biopsychosocial model of pain 40 years on: time for a reappraisal?” The paper outlines when and how pain became conceptualised within a biopsychosocial framework by the pioneers of interprofessional pain management: John Loeser (1982) and Gordon Waddell (1984). Nicholas points out the arguments against a biopsychosocial model with some people considering that despite it being a “holistic” framework, it often gets applied in a biomedical and psychological way. In other words, that biomedical concerns are prioritised, with the psychosocial factors relegated to second place and only after the biomedical treatments have not helped. Still others separate the relationships between “bio” “psycho” and “social” such that the interdependent nature of these factors is not recognisable.

Nicholas declares, too:

“… that cognitive behavioural therapy interventions that did not also include workplace modifications or service coordination components were not effective in helping workers with mental health conditions in RTW. That means, just like in the case of reducing time lost at school for children in pain, the treatment providers for adults in pain for whom RTW is a goal should liaise closely with the workplace. Unfortunately, as the studies from the systematic reviews examined earlier for a range of common pain therapies indicated, engaging with the workplace as part of the treatment seems to be rarely attempted.

I find this confusing. In 1999 I completed my MSc thesis looking at this very thing: pain management combined with a focus on using pain management approaches in the workplace. The programme was called “WorkAbilities” and included visits to the workplace, liaison with employers and even job seeking for those who didn’t have a job to return to. The confusion for me lies in the fact that I’ve been doing pain rehabilitation within the workplace since the mid-1980’s – and that while today’s approach for people funded by ACC is separated from pain management (more is the pity), there are many clinicians actively working in pain rehabilitation in the context of returning to work here in New Zealand.

I’m further puzzled by the complete lack of inclusion by Nicholas of occupational therapy’s contribution to “the social” aspects of learning to live well with pain. This, despite the many studies showing occupational therapists are intimately connected with social context: the things people do in their daily lives, with the people and environmental contexts in which they do them. You see, occupational therapists do this routinely. We work with the person in their own environment and this includes home, work, leisure.

For those that remain unaware of what occupational therapists offer people with pain, I put it like this: Occupational therapists provide contextualised therapy, our work is in knowledge translation or generalising the things people learn in gyms, and in clinics, and helping people do these things in their life, their way.

An example might help.

Joe (not his real name) had a sore back, he’d had it for about three months and was seeing a physiotherapist and a psychologist funded by ACC (NZ’s national insurer). Not much was changing. He remained fearful of moving especially in his workplace where he was a heavy diesel mechanic and was under pressure from a newly promoted workshop manager to get things done quickly. Joe was sore and cranky, didn’t sleep well, and his partner was getting fed up. Joe’s problems were:

  • guarding his lower back when moving
  • fear he would further hurt his back if he lifted heavy things, or worked in a bent-over position, or the usual awkward positions diesel mechanics adopt
  • avoiding said movements and positions, or doing them with gritted teeth and a lot of guarding
  • poor sleep despite the sleep hygiene his psychologist had prescribed
  • irritability
  • thoroughly enjoying the gym-based exercise programme
  • hating mindfulness and any of the CBT-based strategies the psychologist was offering him, because as he put it “I never did homework when I went to school, do you think I’m going to do it now? and this mindfulness thing doesn’t work!”

The occupational therapist visited Joe at home. She went through his daily routine and noticed that he didn’t spend any time on “fun” things or with his mates. His intimacy with his partner was scant because the medications he was on were making it hard for him to even get an erection, and his partner was scared he’d be hurt when they made love. Besides, she was fed up with all the time he had to spend going in to the gym after work when he wasn’t doing simple things around home, like mowing lawns, or helping with grocery shopping.

She went into his workplace and found it was a small four-person operation, with one workshop manager, two mechanics and one apprentice. The workshop was a health and safety hazard, messy and cramped, and open to the weather. The relationships between the team were strained with unpleasant digs at his failure to keep up the pace. The workshop manager said that he’d do his best to help Joe out – but in the end he needed to get the work out on time. The other mechanic, an old hand, meanwhile was telling Joe to suck it up and be a man, but also to watch out because Joe shouldn’t do as he’d done and shagged his back.

What did our erstwhile occupational therapist do? Absolutely nothing new that the physiotherapist and psychologist hadn’t taught Joe – but she worked out when, where and how Joe could USE the strategies they’d discussed in his life contexts. She went through the way he moved in the workshop and guided him to relax a little and find some new movement patterns to be able to do his work. She graded the challenges for him, and stayed with him as he experimented. She discussed alternating the tasks he did, interspersing tasks that involved bending forward with those where he could stand upright or even work above his head (in the pit). She discussed how he could use being fully present at various times during the day (mindfulness) to check in with his body and go for a brisk walk if he felt himself tensing up. She worked through communication strategies that they rehearsed and he implemented to let his manager know what he could – and could not – do.

They discussed his home life, and ways he could begin doing some of the household tasks he’d been avoiding, and she showed him how to go about this. They worked out the best time of day to do this – and to vary the exercise he did so that it wasn’t all about the gym. He started to walk over rough ground to get more confident for when he went fishing again, and he got himself a little stool to sit on from time to time. Joe and his occupational therapist talked about his relationship with his partner, and they met together with her so they could share what his back pain meant, the restrictions he had, what he could do, and how else they could be intimate. Joe was encouraged to rehearse and then tell his doctor about the effect of his meds on his sex life.

The minutiae of daily life, translating what is learned in a clinic to that person’s own world is, and always has been, the province of occupational therapy. It’s just a little sad that such a prominent researcher and author hasn’t included any of this in this editorial.

Just a small sample of research in which occupational therapists are involved in RTW.

Bardo, J., Asiello, J., & Sleight, A. (2022). Supporting Health for the Long Haul: a literature synthesis and proposed occupational therapy self-management virtual group intervention for return-to-work. World Federation of Occupational Therapists Bulletin, 1-10.

Berglund, E., Anderzén, I., Andersén, Å., Carlsson, L., Gustavsson, C., Wallman, T., & Lytsy, P. (2018). Multidisciplinary intervention and acceptance and commitment therapy for return-to-work and increased employability among patients with mental illness and/or chronic pain: a randomized controlled trial. International journal of environmental research and public health, 15(11), 2424.

Cullen K, Irvin E, Collie A, Clay F, Gensby U, Jennings P, Hogg-Johnson S, Kristman V, Laberge M, McKenzie D. Effectiveness of workplace interventions in return-to-work for musculoskeletal, pain-related and mental health conditions: an update of the evidence and messages for practitioners. J Occup Rehabil 2018;28:1–15.

Grant, M., Rees, S., Underwood, M. et al. Obstacles to returning to work with chronic pain: in-depth interviews with people who are off work due to chronic pain and employers. BMC Musculoskelet Disord 20, 486 (2019). https://doi.org/10.1186/s12891-019-2877-5

Fischer, M. R., Persson, E. B., Stålnacke, B. M., Schult, M. L., & Löfgren, M. (2019). Return to work after interdisciplinary pain rehabilitation: one-and two-year follow-up study based on the swedish quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 51(4), 281-289.

Fischer, M. R., Schults, M. L., Stålnacke, B. M., Ekholm, J., Persson, E. B., & Löfgren, M. (2020). Variability in patient characteristics and service provision of interdisciplinary pain rehabilitation: A study using? the Swedish national quality registry for pain rehabilitation. Journal of Rehabilitation Medicine, 52(11), 1-10.

Ibrahim, M.E., Weber, K., Courvoisier, D.S. et al. Recovering the capability to work among patients with chronic low Back pain after a four-week, multidisciplinary biopsychosocial rehabilitation program: 18-month follow-up study. BMC Musculoskelet Disord 20, 439 (2019). https://doi.org/10.1186/s12891-019-2831-6

Marom, B. S., Ratzon, N. Z., Carel, R. S., & Sharabi, M. (2019). Return-to-work barriers among manual workers after hand injuries: 1-year follow-up cohort study. Archives of physical medicine and rehabilitation, 100(3), 422-432.

Michel, C., Guêné, V., Michon, E., Roquelaure, Y., & Petit, A. (2018). Return to work after rehabilitation in chronic low back pain workers. Does the interprofessional collaboration work?. Journal of Interprofessional Care, 32(4), 521-524

Nicholas, M.K. (in press). The biopsychosocial model of pain 40 years on: time for a reappraisal? Pain.

Scopes, roles, interprofessional practice and person-centred healthcare


A topic that almost immediately gets my hackles up is the one of scopes and roles in pain management and rehabilitation. It’s like “Oooh but that’s MY stuff, get out of it!” and I can see Gollum saying “my preciousssss”…

I trained and graduated in 1984. As a raw newbie occupational therapist I couldn’t articulate much of what my profession brought to healthcare, except that I knew “doing”, “activities” or “occupation” was important to human wellbeing, and that I’d been trained to analyse these. I’ve learned a lot since then and got a PhD in the process. Developing as people and as clinicians is, I hope, deeply embedded in us as professionals.

Interprofessional practice is a model of healthcare recommended in pain management and rehabilitation (Oslund, et al., 2009). Interdisciplinary/interprofessional teams involve different health professionals working alongside one another using their areas of expertise, but where all use a common over-arching model such as a biopsychosocial approach. Teams meet regularly to collaborate on treatment goals and priorities (Ruan & Kaye, 2016). There is limited hierarchy and extensive communication, cooperation, and overlap between team members (Körner, 2010).

True interprofessional practice is rare. Why? Because teams on paper are not teams. Teams need time together both formally and informally, stability amongst members, a pool of common knowledge as well as an understanding of what each team member brings in to the mix. Needless to say, high trust is crucial, along with ongoing communication (Zajak et al., 2021). We can’t just use professional labels to know what another profession can offer because we [should] keep on developing.

One of the largest contributors to poor interprofessional teamwork is lack of confidence. Not just lack of confidence in the skills of the other team members, but lack of confidence in one’s own professional contribution. High trust in one another, and yourself is critical.

When you’re feeling uncertain and find it hard to articulate what you bring to a team, any encroachment on “your” turf (call it scope) will likely engender a worry that you’re unnecessary. That others are “taking over” – and in turn, this can mean you search for faults in what other team members do because this helps affirm your rights and your specialness. You might want to rigidly control who does what in a team. It boosts your sense of worth but at the expense of other team members, and more importantly, at the expense of the person the team is trying to help.

The thing is, the person with pain does not care which person in a team works with them. What they care about is that the clinician is knowledgeable, and empathic. Trustworthy. The quality of the interpersonal relationship accounted for 54.5% reduction in pain in one study by Fuentes (Fuentes et al., 2014). People with pain want to know that their individual needs have been taken into account in their treatment plan (Kinney et al., 2020).

If you’re finding it hard to work in a team, perhaps feeling vulnerable about your worth, try this:

Ask your team to meet for an hour, tops.

Ask each member of your team to say what they bring to the team – not just their profession, but what else? Consider age, humour, cultural background, additional courses, personal interests outside of work, the “social secretary”, the “librarian”…and professional skills.

Pool all of these contributions on a big piece of paper – use post-it notes of different colours for each person.

Group similar contributions together in the middle of the paper – and spread unique contributions around the outside.

Review the paper and ask each participant to add any contributions they’ve just been reminded of.

Take a good look at the common contributions and the unique ones: these are what make up your team and they’re there to use for better person-centred care.

You can add some reflective questions to this activity.

  • What are the areas of overlap? It could be goal-setting, offering information about pain, movement practices, addressing fear of pain/reinjury, helping build confidence…
  • What areas of uniqueness are there? These could be hypnosis, knowledge translation from clinic to daily life, exercise prescription, the ability to write a prescription for medications
  • What surprised you? This could be the degree of overlap, or the contribution you didn’t expect from someone, or perhaps a gap in the team’s knowledge or skills
  • What shows up in yourself as you review these contributions? These could be “yeah, right, I don’t believe you can do THAT!” or “but I can do that too!”

Handling your response to what shows up to that last question is where the enormous value of this activity lies. Remember, the team is there for the person with pain, not for you as clinicians. If you think someone is claiming a contribution you can do with more skill, this only means that you can offer that person help from time to time. If you think that you’d like to contribute in an area and you didn’t add that as one of your contributions, now is the time to put it on the paper.

Take a copy of that piece of paper, and keep it close to you.

Your mission from then on, should you choose to accept it, is to review this set of contributions when you are next developing a treatment plan for a person seeking your help. Choose the combination of clinicians that offers the range of skills and knowledge, the interpersonal skills suited, and the availability of each clinician so that the person you hope to help will be seen by a team, and not just a set of individual clinicians. Oh and add in a good case formulation as well…

Remember: it’s all about the person in person-centred pain management and rehabilitation.

Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: An experimental controlled study. Physical Therapy. 94:477–89.

Kinney, M., Seider, J., Beaty, A. F., Coughlin, K., Dyal, M., & Clewley, D. (2020, Aug). The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 36(8), 886-898. https://doi.org/10.1080/09593985.2018.1516015

Körner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), 745-755. https://doi.org/10.1177/0269215510367538

Oslund, S., Robinson, R. C., Clark, T. C., Garofalo, J. P., Behnk, P., Walker, B., Walker, K. E., Gatchel, R. J., Mahaney, M., & Noe, C. E. (2009). Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Baylor University Medical Center Proceedings, 22(3), 211-214. https://doi.org/10.1080/08998280.2009.11928516

Ruan, X., & Kaye, A. D. (2016). A Call for Saving Interdisciplinary Pain Management. Journal of Orthopaedic and Sports Physical Therapy, 46(12), 1021-1023. https://doi.org/10.2519/jospt.2016.0611

Wampold, B. E. (2018). The Therapeutic Value of the Relationship for Placebo Effects and Other Healing Practices. International Review of Neurobiology, 139, 191-210. https://doi.org/10.1016/bs.irn.2018.07.019

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Frontiers in Communication, 6(6). https://doi.org/10.3389/fcomm.2021.606445

Help me solve this puzzle


The IASP definition of pain is:

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Six key notes and etymology:

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

This definition allows for “pain is always a personal experience” and that “pain and nociception are different phenomena” – supporting the idea that the association between what goes on in the tissues and our individual experience of pain is both complex, and currently unmeasurable.

So therefore, why do we have this line in the IASP diagnostic criteria for complex regional pain syndrome: “The patient has continuing pain which is disproportionate to any inciting event” – but wait, there’s more! Kosek et al, (2021) indicate that clinical criteria for nociplastic pain include “…a history of pain hypersensitivity in the region of pain” and “Evoked pain hypersensitivity phenomena can be elicited clinically in the region of pain.”
I’m puzzled.

Pain that is “disproportionate” suggests there is “proportionate” pain… AND at the same time the definition of pain says pain is “always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.” So if I experience pain in the presence of an inciting event, and report it as “OUCH” on the ouchie scale, who can tell me whether my pain is “proportionate” or “disproportionate”?

The nociplastic criteria are similarly confusing: pain hypersensitivity in the region of pain – really painful pain where I’m already experiencing pain? Or do they mean allodynia or hyperalgesia? Or…poke me where I’m sore already and the examiner can tell whether I’m more sore than I ought to be?

Underlying these diagnostic criteria lives a sneaky little beast I call “assumed normalism.” That despite all the work over the decades, some clinicians and researchers really do believe there is a reasonable relationship between nociceptive stimulation and the degree of ouch I might feel. I’m not sure about this…

I wonder if assumed normalism relies on experimental data where people volunteer to undertake nociception tests. These are things like quantitative sensory testing where individuals report the moment they experience heat, cold, pressure, and vibration (pain threshold), and when they want the experimenter to stop doing that thing NOW (pain tolerance).

Let’s think about that situation for a moment. An experimental set-up or lab. Volunteers who know what they’re going to be asked to do. Who know they can say “STOP” when they want to. Who know that no lasting harm is going to occur (ethics, don’t you know). And who volunteers for these kinds of experiments? Nuzzo (2021) pointed out that females are well-known not to volunteer for experiments where there is “an expectation of painful, unpleasant, or risky procedures” and cites research from as far back as 1976! (Rosnow & Rosenthal, 1976) – and earlier (Howe, 1960).

But more than this, Horowitz (2009) states “…QST is a subjective psychophysical test entirely dependent upon patient motivation, alertness, and concentration. Patients can willingly perform poorly, and even when not doing so, there are large intra- and interindividual variations.”

How have clinical diagnostic criteria included definitions that seem too have slid by scrutiny?

Why does it matter?

As soon as we begin thinking of “normal” “objective” “proportional” or “disproportional” in leaps human judgement. Bias. The opportunity to dismiss a person’s experience – on the basis of what we can observe, or what the person can demonstrate. We can only infer that someone else is experiencing pain on the basis of their behaviour – what a person says, does, in the presence of pain, in a particular context. And bias exists when it comes to interpreting behaviour.

As a person living with pain, should I aim to “look well” and be judged as “not suffering enough for pain to be a problem”, or “look poorly and be judged as “not using coping strategies, wanting attention”…

Because, unless all the qualitative studies I’ve read are really erroneous, bias and stigmatising from clinicians and insurers is a thing. From adolescents (Wakefield, 2021), people tapering opioids (Benintendi et al., 2021), gender (yeah, I mean women, Zhang et al., 2021) – oh the list is long….

So, perhaps we could consider an alternative way to describing these kinds of pains: I personally prefer “severe” but maybe there are other words?

Benintendi, A., Kosakowski, S., Lagisetty, P., Larochelle, M., Bohnert, A. S., & Bazzi, A. R. (2021). “I felt like I had a scarlet letter”: Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug and alcohol dependence, 222, 108664.

Howe, E. S. (1960). Quantitative motivational differences between volunteers and nonvolunteers for a psychological experiment. Journal of Applied Psychology, 44(2), 115–120. https://doi.org/10.1037/ h0045002

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Nuzzo, J. (2021). Volunteer Bias and Female Participation in Exercise and Sports Science Research. Quest, 73(1), 82-101. https://doi.org/10.1080/00336297.2021.1875248

Rosnow, R. L., & Rosenthal, R. (1976). The volunteer subject revisited. Australian Journal of Psychology, 28(2), 97–108. https://doi.org/10.1080/00049537608255268

Wakefield, E. O., Puhl, R. M., Litt, M. D., & Zempsky, W. T. (2021). “If It Ever Really Hurts, I Try Not to Let Them Know:” The Use of Concealment as a Coping Strategy Among Adolescents With Chronic Pain. Frontiers in Psychology, 12, 1840.

Zhang, M., Zhang, Y., Li, Z., Hu, L., & Kong, Y. (2021). Sexism-related stigma affects pain perception. Neural plasticity, 2021.

The complex world of identifying nociplastic pains


Towards the end of 2017, IASP put forward a new mechanistic classification: nociplastic pain. The definition is: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

Note: Patients can have a combination of nociceptive and nociplastic pain”.

This was great news! Prior to this, the term “central sensitisation” was used and abused to describe processes involved in ongoing pain that wasn’t inflammatory or neuropathic. Problem with that term is that it’s apparent in nociceptive mechanisms, as well as both inflammatory and neuropathic…. When the way people used the term was more akin to “well, the pain hasn’t settled down, so ‘something weird’ is going on and it must be in the central nervous system so we’ll adopt this term seeing as Clifford Woolf described it in the spinal cord” (Woolf, 1996, 2007).

In other words, any pain that seemed to radiate, hang around, and no respond to treatment was “centrally sensitised”. Perhaps so. Perhaps not. Suffice to say, people got confused because most of the typical central sensitisation from nociceptive/inflammatory processes subsides over time, but these “centrally sensitised” pains did not.

I, for one, am glad there’s a group in which weird pains that don’t appear to involve typical nociceptive, inflammatory or neuropathic mechanisms can be put.

Problem is: how do we know what fits into this group? We can be pretty certain when it comes to neuropathic pain, because the definition is very clear (though not so clear in the clinic) – “Pain caused by a lesion or disease of the somatosensory nervous system.” The notes go on to say that “neuropathic pain is a description, not a diagnosis” and I’d say the same about nociplastic pains (which is why I use the plural…). I also step out to say that I don’t think ALL nociplastic pains will be found to have the same biological mechanisms, especially given how widely variable neuropathic pains are.

Nevertheless, we need some way to decide which pains are in, and which are out of this group.

This table comes from Kosek et al., (2021) and summarises the findings from a consensus process within an expert group. They make the point that acute pain isn’t helpfully included in this group, and instead it should be used for pains that persist for 3 months or longer. They also point out that regional pain is included while discrete pain is typically not because of the central sensitisation processes involved (note: this is the correct use of the term! Confused? CS is a neurophysiological phenomenon, associated with more than nociplastic pain).

Looking at the above criteria, possible nociplastic pain is present if the person has criteria 1, and criteria 4. Probable nociplastic is present if the person has all the above.

There are some notes, of course: regional means the musculoskeletal pain is deep, regional or in several places or even widespread (not localised to one place), and each condition eg frozen shoulder and OA knee needs to be assessed separately. If there is an identifiable nociceptive source (or neuropathic source) then the pain needs to be more widespread than “usual” for that pathology. Finally, because nociplastic pain unlike neuropathic pain, has no definitive test currently, there is no “definite nociplastic” category – but once there is, this will be added.

What does this mean for us as clinicians?

Firstly it ought to stop people being thought as faking, malingering or otherwise not being believed. That should be a given but unsurprisingly because of legal and health systems and our own frustration at not being able to “fix” people, people with pain get that impression more often than they should. It also ought to stop psychopathologising people who have this kind of pain: we can’t distinguish between people with nociplastic pain and the DSM5 “Somatic Disorder” – so let’s just not add another unhelpful mental health label to what is already a stigmatised situation.

Then it ought to stop clinicians using treatments that simply don’t help – such as opioids for fibromyalgia. It might help clinicians pause before prescribing movement therapies at a level that is too intense for the person, because this only revs the nervous system up even more making the whole process unpleasant. Beginning at the level the person can manage and gradually increasing is crucial to success. And it ought to stop clinicians from administering “explanations” or “education” and expecting that alone to reduce pain. Because while cortical processes are part and parcel of every pain there is, it’s in this group of pains that some people think “top down” by thinking yourself out of pain is a thing. FWIW pain reduction is lovely and part of treatment, but shouldn’t ever be the only outcome (Ballantyne, 2015), and many times in this group of pains, may not even be an outcome.

Finally, it should stimulate helpful discussion about what “whole person” approaches to managing these pains looks like. The authors say “patients with nociplastic pain are likely to respond better to centrally than peripherally targeted therapies” and this does not mean talk therapy alone, or exercise alone, or indeed medications such as gabapentin or nortriptyline alone. To me, it means individualised, tailored, and integrated strategies to moving, managing daily life, restoring sleep, enjoying an intimate relationship, managing mood and memory, and these might best be offered by pain coaches rather than siloed “therapies” of physical, psychological or whatever other stripe there is.

Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of Chronic Pain — The Wrong Metric? New England Journal of Medicine, 373(22), 2098-2099. https://doi.org/10.1056/NEJMp1507136

Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J.-A., Rice, A. S. C., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 162(11), 2629-2634. https://doi.org/10.1097/j.pain.0000000000002324

Woolf, C. J. (1996). Windup and central sensitization are not equivalent. Pain, 66(2), 105-108.

Woolf, C. J. (2007). Central sensitization: uncovering the relation between pain and plasticity. The Journal of the American Society of Anesthesiologists, 106(4), 864-867.

Women, partner violence and pain


As the potential for greater repression of women’s autonomy grows (Afghanistan, United States, Mexico), along with racist and misogynist statements from business leaders (DGL CEO Simon Henry) it’s timely to look at pain in women. We already know that more women than men present with persistent pain (Blyth, n.d.), while women who are seen for their pain are more often misdiagnosed, offered psychiatric medication or psychological intervention only and have their experiences dismissed as “hysterical, fabricated, or nonexistent” (Samulowitz, et al., 2018). My daughter, when attending Emergency Department was offered a paracetamol and told “there’s no cure for being a woman” when seeking help for an ovarian cyst. Period pain is considered “normal” (Drabble et al., 2021). Pain in women is not a sexy topic.

Intimate partner violence is common among women. 27% of women who have had a partner report violence perpetrated against them. 24% of young women aged between 15 – 19 years report violence. Low-income countries reporting higher levels of intimate partner violence, and while data was not available for the past two years of covid-19 disruption, it’s expected that higher levels of violence are probable (Sardinha et al., 2022).

What about the intersection between partner violence and persistent pain? (BTW violence is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship and includes stalking, psychological aggression such as coercion, as well as physical and sexual violence).

Persistent pain is one of the most commonly reported health consequences of intimate partner violence (Walker, 2022), and women are more likely to be the recipients of partner abuse than men. Yet – open conversations about violence and persistent pain in women, recognising the signs and symptoms of partner violence in people seeking help for persistent pain, and adequate approaches to treatment are rare. Women may not disclose their situation for fear of being stigmatised, labelled unfairly, or having their pain – and their situation – trivialised.

Walker and colleagues (2022) carried out a systematic review of studies exploring the types of pain women experienced in association with partner violence, the severity of that pain, and the impact of pain on the person. They found that while pelvic pain was common amongst women who had been sexually abused, women also reported chest pain, back pain, neck pain, arthritis, and stiffness in joint or muscles, more frequent headaches, and more back pain – furthermore, women who had experienced partner violence reports higher pain severity, with 75% of women indicating moderate to severe pain, and the longer a women had been in an abusive relationship, the more likely they were to report higher intensity pain.

Interestingly, disability from persistent pain wasn’t measured often – only two studies from 12 included in the final review – but women with persistent pain from partner violence reported higher pain-related disability. They also reported worse impact on their mental health – more PTSD, anxiety and depression, with depression being one of the key mediator between a history of partner violence and ongoing pain.

The authors of this study (Walker et al., 2022) point out that it’s likely that women who have sustained partner violence and experience persistent pain are “not being adequately identified and responded to in clinical settings” – and that the fear of not being believed and the stigma of being on the receiving end of partner violence likely limits how many women openly discuss their situation.

Isn’t it time to get women’s pain prioritised? To get political about systems and processes that fail women? Isn’t it time to shift the narrative around women’s menstrual pain? To acknowledge that women are not mini men?

Finally, when we consider pain rehabilitation, we need to not only recognise that women have different priorities and goals for their lives than men, we also need to understand that doing rehabilitation is more complex for women than men – women report more difficulty prioritising their own rehabilitation over other responsibilities in their life (Côté & Coutu, 2010). Women may not even be referred for rehabilitation as often as men (Stålnacke et al., 2015). It’s time to prioritise understanding the lived experience of women as they pursue help for their persistent painand then do something different.

Blyth, F. (n.d.). Chronic pain in Australia: A prevalence study. Retrieved May 12, 2019, from http://www.ncbi.nlm.nih.gov/ pubmed/11166468

Daniel Côté & Marie-France Coutu(2010)A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?,Disability and Rehabilitation,32:2,87-102,DOI: 10.3109/09638280903026572

Drabble, S. J., Long, J., Alele, B., & O’Cathain, A. (2021). Constellations of pain: a qualitative study of the complexity of women’s endometriosis-related pain. British Journal of Pain, 15(3), 345-356.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018. https://doi.org/10.1155/2018/6358624

Sardinha, L., Maheu-Giroux, M., Stöckl, H., Meyer, S. R., & García-Moreno, C. (2022). Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. The Lancet, 399(10327), 803-813.

Stålnacke, B., Haukenes, I., Lehti, A., Wiklund, A., Wiklund, M. et al. (2015)
Is there a gender bias in recommendations for further rehabilitation in primary care of patients
with chronic pain after an interdisciplinary team assessment?.
Journal of Rehabilitation Medicine, 47(4): 365-371
http://dx.doi.org/10.2340/16501977-1936

Walker, N., Beek, K., Chen, H., Shang, J., Stevenson, S., Williams, K., Herzog, H., Ahmed, J., & Cullen, P. (2022). The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review. Trauma Violence Abuse, 23(2), 490-505. https://doi.org/10.1177/1524838020957989