science

More discussion on Functional Capacity Evaluations


Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work “fitness”. 

I’ve received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable.  I haven’t found anything recently, and I’m still concerned that FCE are used inappropriately for people with chronic pain.  There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves – and have a flare-up for some days afterwards but get a “good” report suggesting they have put in “full effort” and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies – and avoid a flare-up but receive a “bad” report, suggesting they haven’t put in “full effort” and despite this, they can manage a full time job of a certain MET demand.

I can’t understand why FCE providers don’t work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. 

For the record, I’m not against establishing functional abilities.  And I think having a systematic approach to doing this.  I am against FCE’s being touted as a way to reliably determine work capacity, or to being able to determine “effort” through “consistency”. There simply isn’t published evidence to support these claims.  If someone can provide me with evidence, I’ll gladly change my mind because if there is one thing scientific training teaches, it’s that it’s OK to change your mind – if there’s evidence to do so.

This doesn’t mean that FCE’s would then be fine and dandy – because, as I’ve seen far too many times – HOW they’re used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same.

Here’s my original post, and some very good references are at the end of it.

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The Graded Motor Imagery Handbook – a review


I love getting presents, and I love books, so what could be better than getting a book to review as a present!

Graded motor imagery (GMI) has become incredibly popular in pain management, especially for people with unilateral pain.  It’s a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence.  For those who don’t know – level B1 evidence means there are several RCT’s, and at least one meta-analysis showing support for this approach.

Back to the book.  Like all the NOI books it’s an unusual size, has groovy graphics and an easy-to-use layout. It’s a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes.  The illustrations and photographs are clear and provide excellent guidance for clinicians.  Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler’s favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment.   Each chapter can stand alone, and it’s not necessary to read from beginning to end – but of course, it does help!

This book isn’t for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain – and the translation into the “real world” – are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.

Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment.  GMI has best application in people with unilateral pain such as CRPS and phantom limb pain – although it has been extended to other pains.  These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.

Back to the book again!   I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI.  His writing is clear and provides an excellent scientific basis for the approach.  He doesn’t extend his writing into psychological aspects of pain beyond the concepts of what he calls “neurotags”, or “interconnected neurones … that produce an output”.  Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action).  I have learned these associations as just that – associations between various aspects of learning and anticipation, and have called them the neuromatrix – but NOI have used the term neurotag, and I guess it’s as good a name as any.

The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written.  While it’s possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer’s neuroscience, and Butler’s metaphors, it becomes far more flexible.  I like this.  It is a chapter that I think many clinicians will turn to regularly – but as is emphasised throughout this handbook, patients/participants should read this stuff too.

Worth getting? Yes, I think so. 

My caution lies in over-interpreting the application of GMI beyond the evidence-base.  If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her.  Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain.  Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world.  After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport – where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment.

Where to get it? Go here – and let ‘em know I sent you.

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What is this thing called pain?


ResearchBlogging.org
As I’m busy writing up research papers for publications to “count” towards my research productivity, I’m reminded of one reason I keep on blogging – and it’s this: blogs are open to anyone.  People can comment on what I write.  When someone comments, whether they agree, disagree, or simply pose a question, it’s an opportunity for dialogue and reflection. That’s not nearly as easy to do in a peer-reviewed journal!

As a result of comments from my post yesterday, I’m musing on ways to explain the distinction between acute and chronic pain that will make sense to someone who experiences fluctuations in pain intensity. I think I’m clear in my own mind between the two, but perhaps things are not as distinct as I’ve made them – or maybe I haven’t explained things well.

There are several ways that acute pain can be distinguished from chronic pain, none of them particularly satisfactory except, maybe, one.  We can think of the association between pain and tissue damage or threat of tissue damage.  In acute pain, tissue damage or the potential to damage tissue is often present – but not always.  Think of a typical “tension” headache.  It’s usually short term, but not associated with muscle damage.

We can consider duration – how long does this pain persist?  Acute pain is typically short-term, it does end at some point – sometimes well after the need for a “warning” alarm is necessary – but what about chronic hip osteoarthritis?

Some of the other factors I see used to distinguish acute pain from chronic include – quality of the sensation, how quickly the pain comes on, whether psychosocial factors are relevant, whether disability or illness behaviour is present, even the location or specificity of the pain can be used as an identifying factor.

We can also think of usefulness – acute pain is usually useful.  It tells we need to do something, take action to reduce the threat to our body’s integrity.  I think this is probably the most useful definition of the lot, even in the case of a “tension” headache – when it  might simply be an indication we need to have some time out, drink more water or get some new glasses.

Chronic pain has a bad rap.  There are many clinicians who consider that chronic pain is almost entirely influenced by psychosocial factors – therefore the person with pain needs to simply “get over it” and they’ll recover.  Then there are those who think chronic pain is simply pain that hasn’t had the “source” of the pain identified yet – find that source, burn it or cut it or otherwise remove it, and the pain will be gone.  And for some kinds of ongoing pain, like an osteoarthritic hip, that’s the case.

Over the years I’ve worked in chronic pain management, I think I can confidently say that chronic pain can be sharp, stabbing, dull, burning, deep, aching – all the same kinds of sensations that acute pain can be.  Its onset can be pretty rapid, but also insidious or gradualBoth acute and chronic pain are strongly influenced by psychosocial factors – things like attention, general alertness level, “threat value” or beliefs about what the pain means, attention from others, past learning – all of these things influence our experience of both acute and chronic pain, although it’s probably true to say that as pain persists, many of these psychosocial factors play an increasingly important role in the disability associated with pain.

There are other definitions of chronic pain.  One is duration – pain that persists beyond “normal healing time” (whatever this is).  Alternatively, pain that has been present for three to six months.  My problem with this definition is that it’s common for people to have pain around a fracture site for up to 12 months even when bony union is progressing normally.  Is this chronic pain?  What about instances where the pain is intermittent – migraine? Noncardiac chest pain? Abdominal pain?

So, what about chronic pain that fluctuates?  This seems to be the case more often than not.  It’s very very rare for me to hear someone say their chronic pain is at exactly the same intensity day in, day out.  When I do hear it, I like to spend some time exploring this experience in more detail.  Without fail, with gentle enquiry, fluctuations of pain intensity are there but may be subtle.

Why is recognising this so important?  Well, let me first put to bed any idea that I think people with chronic pain are immune to acute pain – that’s so not true.  What is arguable is whether fluctuations in pain, particularly when they’re the “same old, same old” pain, need to be managed using acute pain treatments.

And this is important because

  • so many acute pain treatments are passive,
  • take time away from living,
  • put the person getting the treatment at risk of yet another diagnosis or explanation,
  • reduce the opportunity to gain confidence with using self management strategies,
  • in the case of medication can put the person at risk of addiction or inappropriate use of this,
  • and, often unrecognised, can train the person to begin to fear (& then avoid) experiencing pain – leading to increased distress and continued treatment seeking

Am I advocating never using adjuntive intervention? See yesterday’s post in answer to that! But at the same time, I’d suggest that it’s pretty important to be aware of the risks.

So far, in answer to the question posed in my title, one of the best descriptions of the various types of pain and of the distinction between “normal” pain and “pathological” pain there is, Clifford Woolf’s paper is my choice.  Actually, the whole issue of this journal (which is – fabulously! – completely open access online!) could be required reading for anyone wanting to be informed about advances in our knowledge of pain.  I particularly love the examples he provides for each type of pain problem and how they arise.  That’s great stuff.

But even this set of wonderful papers doesn’t really explore some of the aspects of pain that don’t really get mentioned – disability and the effects of social, family, community attitudes and responses.  Yes, I know they’re messy to research.  They’re complex. They differ across countries, cities, villages and families.  But oh how powerful they are in our experience of pain.

Woolf, C. (2010). What is this thing called pain? Journal of Clinical Investigation, 120 (11), 3742-3744 DOI: 10.1172/JCI45178

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Black and white thinking must be abolished


Black and white thinking, for those readers unfamiliar with cognitive distortions, refers to the tendency to reduce complex ideas and situations into simple, dichotomous, and mutually exclusive categories.

Think of good or bad, yes or no, all correct or all wrong, acute pain or chronic pain, neuromatrix or peripheral mechanisms, cure the pain or manage the pain.

It’s a way of simplifying arguments or decisions that can work well when the situation requires very fast decision-making, or where the options are very limited.

It doesn’t work at all in the messy and complicated worlds of clinical reasoning, theory development, or in discussions to broaden understanding.

I’m pondering this because of the way various aspects of pain management and the science of pain are misrepresented as opposed to each other, when maybe it’s not quite so simple.

I hope (crossing fingers and toes) that I’m not doing prone to doing it too often on the pages of this blog, or elsewhere for that matter!

There are multiple strands of research into pain at present. 

There are the reductionists who focus exhaustively on smaller and smaller elements of biology to explain the processes involved in nociception and transmission from noxious input to the perception of pain and back to the responses as a result. 

There are the phenomenologists who focus on the ‘lived experience’ of the individuals who have pain.

There are those who are furiously investigating laterality and cortical processing.

There are others feverishly working on ways to abolish all pain, and those who are equally enthusiastically researching why so many people are unbothered by their pain even though it’s severe.

Can you see all those opportunities for opposing views? for argument and debate?  It’s common for any of us to think mainly in terms of our own orientation, and there are many factors in human cognitive bias and group decision-making that get in the way of us working towards consensus – or even hearing each other.  And that can lead to trouble within teams, especially multi- or inter-disciplinary teams.

I wonder if it’s time to apply some of the cognitive techniques we can use with patients to ourselves as clinicians.  Let’s take a quick look at some of the basics.

Firstly, why do we use black and white thinking?  Well, it simplifies things.  If we’re feeling a little bit sad, we’re more likely to tell a loved one that we’re feeling “terrible”.  We don’t mean to exaggerate, we’re aiming to get empathy from the person we’re talking to, so we unintentionally use dichotomous language – we think in terms of feeling “amazing” vs feeling “terrible”.   Humans like to identify patterns, and to group similar things together so we can generalise.  We like to reduce an argument into “either – or”.  And when we do this, once again because of our tendency to look for information that confirms our own position, we often fail to recognise other alternatives, or information that doesn’t fit with our own views.

What we can do is step back and carry out some metacognition – thinking about our own thinking.

Some questions we can use to challenge our own position are:

  • How did I come to that conclusion?
  • What’s the evidence for the other position?
  • Is it possible to use “and” instead of “either/or”?
  • What are the other options?
  • Are there parts of my argument that can’t explain something the other position can explain?
  • This idea is only an idea – not my personal possession
  • Consider saying things like “at the moment my position is…”, “I’m attracted to this idea currently…”

I’ve personally found it useful to relax a little and recognise that in the end, the data will speak for itself.  So, for example, I was initially not keen on mirrorbox and laterality training for CRPS.  The studies, especially in the early stages, weren’t carried out in people with the degree of chronicity and complex psychosocial background that I saw.   Over time, and as the evidence has been gathering, I’ve changed my position.  I don’t mind acknowledging this change – in the end, it’s not my ego that’s important, nor “my” ideas – it’s what helps this person at this time with this particular problem.

Having said this, developing critical thinking skills, and in particular, being able to unpack and delve into how a study has been conducted and whether the conclusions drawn are supported by the data is vital.  Cherry picking, or selecting studies that support one view or another while ignoring or failing to account for studies with conflicting findings, just doesn’t do – again I try to relax a little, because in the end the balance of evidence does fall one way or another.  Or, in the case of chronic pain management, maybe there is so much to learn that what we know now is not even beginning to find answers.

If you’re keen to learn more about how to develop critical thinking, Foundation for Critical Thinking has a wealth of information.

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What to do about catastrophising even when you’re not a psychologist


ResearchBlogging.org
OK, it’s time I stopped the suspense.  This post is about what to do about catastrophising even when you’re a physiotherapist, massage therapist, acupuncturist, nurse, occupational therapist, social worker – oh just about anyone working with people who have pain!

Catastrophising is “an exaggerated negative “mental set” brought to bear during actual or anticipated pain experience” (Sullivan, Thorn, Haythornthwaite, Keefe, Martin, Bradley and Lefebvre, 2001).  It’s demonstrated when people describe their pain in highly vivid and negative terms “My muscles feel like they are tearing away from the bone”, “I can’t cope with this any more”, “I keep on thinking about the pain all the time” and so on.  Catastrophising is associated with greater distress, lower mood, greater disability and poorer prognosis (Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, & Lefebvre JC, 2001).

A recent study of army troops found that catastrophising is present even in young, healthy people (Ciccon, Chandler and Kline, 2010).  In this study, 25.9% of those reporting acute pain, and 51.3% of those reporting chronic pain endorsed catastrophising beliefs.  And this group of people were not seeking treatment (as an aside, this is one of few studies to look at non-treatment-seeking people)!  The study also found that in those with high levels of catastrophising, mental health problems were more prevalent, and that catastrophising explained a good proportion of work disability.  In other words, even in this very healthy group of people, catastrophising was associated with greater vulnerability to having difficult managing pain and keeping mentally healthy.  If this finding is identified in other non-treatment-seeking people, I think we can confidently draw the conclusion that catastrophising may be one of the more prevalent unhelpful cognitive biases around.

Hopefully I’ve made the point that catastrophising is something that needs to be identified because of the profound effect it has on how people can live well despite having pain.  The argument is that by addressing catastrophising, people will be more able to cope with their pain, feel less helpless and distressed, and live lives less hampered by their pain.

What do we do about catastrophising?

I think (watch out – soapbox time!) that anyone who works with people who have pain and tend to catastrophise must help those people develop coping strategies to help them cope effectively.   It’s not enough to think that psychologists alone need to do this job.  This is because, as the Ciccone and colleagues study shows, catastrophising is very prevalent even in those people who are relatively well.  The people in that study weren’t likely to seek treatment from a psychologist for their pain – they’re far more likely to see a physiotherapist, an osteopath or chiropractor, an acupuncturist, a massage therapist.

Furthermore, in groups of people who do see a psychologist about their pain, at least in New Zealand, they’ll also most commonly be seeing other clinicians such as physiotherapists or occupational therapists – and a consistent approach is vital.  It only takes one clinician to reinforce an unhelpful belief for the work of the team to be undermined.

I also argue that the best time and place to work on reality testing unhelpful thoughts and beliefs is when people are doing things they’re worried about – in other words, when they’re working on movements, discussing work, developing an exercise programme, working on how they might do household activities, sports and so on.

Yes, psychologists have specialist training in working with thoughts, beliefs and emotions.  Occupational therapists, physiotherapists and other allied health clinicians are always influencing thoughts, beliefs and emotions.  To think we don’t is to ignore the incredibly powerful influence we wield almost because we tend to do it indirectly.

I argue that if we have an influence on people, we need to develop that skill so we can influence positively and helpfully.  In the case of catastrophising, I don’t think we need to become psychologists – that would devalue the other aspects of our various professions.  I do think we need to look at what we say, how we say it, and how we work with people within our professional scopes to maximise the benefit of our input.

What can we do to influence catastrophising?

Here’s another Healthskills Advice for Non-Psychologists working with people who tend to catastrophise!

  1. Find out what the person thinks is going on, and how they’ve arrived at this belief – listen well and with empathy.
  2. Empathise – say something like “It sounds like this is really scary/worrying/hard to handle.”
  3. Ask if it’s OK to give them your perspective – most of the time people will say yes, but asking gives you their permission to provide new information, and they’ll be more willing to listen.
  4. Use calm, neutral language to give an evidence-based explanation – keep it simple, and beware technical language that can be misinterpreted!  For example, an “unstable back” might be your technojargon for poor recruitment of muscles, but your patient may well have an image of their back breaking or collapsing if they move. Don’t you DARE give them a theoretical explanation that has no evidence in the peer-reviewed literature. EVER.
  5. Check out what they’ve heard.  You can ask them “Can you tell me how what I’ve just gone through might mean to you?” or “Can you let me know how that might apply to you?”.
  6. Listen to their response.  Reflect back to them your understanding of their interpretation.  This may seem repetitive, but it’s so important for people to know that you’re listening to them.
  7. Check if they have questions or doubts.  Listen to these without interrupting or saying they’re wrong.  These are their beliefs!
  8. Ask them if they’re willing to test your interpretation out, or how they might test their own interpretation.  You can ask them “how likely is it that this is true?”, “what makes you think this will happen?”, “what’s the most likely thing that will happen?”, “what does it mean if this happens?”.
  9. Set up an opportunity to test their interpretation (or your new one, if they’re prepared to).  This is in the nature of a mini-experiment – so if they think they will get stuck on the ground if they try to get down, see if they’ll do so while you’re there.  Be prepared for qualifiers – “oh but it didn’t happen because you were there”, so make sure you point out what they did to manage.
  10. Finally, make sure you convey confidence that, even though they are worried about “the worse thing happening” – you know they will get by.  They’re not asked to enjoy the process of getting by – but they can manage, and the catastrophe is averted. If pain increase is their personal catastrophe, it’s likely the belief that they “can’t cope”, or not liking the negative consequences of having an increase in pain (feeling irritable, wanting to rest, having to work with pain the rest of the day) that is the problem.  And managing that is for my next post!

It’s worth remembering Mark Twain’s comment: “I’ve had a lot of problems in my life and most of them never happened.”

Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336

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Pain behaviours persist…


ResearchBlogging.org
I’m taking a tiny detour from the world of catastrophising – but only a tiny one because catastrophising is associated with greater levels of pain behaviour, and of course, discussion about pain behaviour is how I came to begin my exploration of catastrophising anyway!

There have been several schools of thought, or models of treatment, for people with pain.  While the current focus and the one over the past five to ten years or so has been strongly cognitive in focus (let’s help people understand their thoughts about pain and how these influence emotions and subsequently affect behaviour), well before then in the origins of pain management, a behavioural approach dominated.  Wilbert Fordyce is credited with developing the first pain management programme based on modifying what people do in response to pain rather than working to reduce pain itself.  (Here’s a link to one of his papers)

I’m a bit of a fan of behavioural approaches because to me the true test of a treatment is whether the person begins to do “normal” things again – go out and have fun, return to work, be with family and so on.  They also seem to be effective – for example, graded exposure is very effective for pain-related anxiety and avoidance.

In this study by Martel, Thibault and Sullivan (2010), people with back pain were recorded on two separate occasions (on averge 22 days apart) while carrying out two lifting tasks designed to elicit pain behaviours.  These recordings were reviewed by trained observers who recorded the number of pain behaviours in each segment of film using a standardised coding scheme (developed by Keefe and Block, 1982).  Participants in the lifting tasks also completed a range of questionnaires – the Tampa Scale for Kinesiophobia, the McGill Pain Questionnaire, and the Pain Catastrophising Scale.

Before I describe the findings, in this study two different forms of pain behaviour were identified – communicative behaviours are things like grimacing, speaking, sighing, moaning and so on; while protective behaviours are things like guarding, holding, touching, or rubbing.

What the researchers found was that pain behaviours are pretty stable irrespective of sex, pain severity or psychological characteristics, but that different forms of pain behaviour demonstrated different degrees of stability.

  • Pain behaviours identified as primarily about communicating were more stable from time one to time two than those identified as being mainly about protecting the body part.
  • Women’s protective pain behaviour varied more than men’s protective pain behaviour, while both men and women demonstrated stable communicative pain behaviour.
  • Pain severity and the number of pain behaviours varied consistently – but, interestingly, individuals with higher levels of pain behaviour at time one also demonstrated higher levels of pain behaviour at time two irrespective of pain intensity.
  • Significant positive relationships were found between psychological variables such as catastrophising and fear of movement and pain behaviours.  Even more interesting was that even when changes in catastrophising and fear of movement reduced over time, pain behaviours remained consistent.

What do these findings mean?I think they suggest that giving information, educating or even working hard on cognitive aspects of coping may not change the behaviours that signal to other people “Hey! I’m sore!”.

This could be because of long-standing motor patterns that take a while to change, or actually need to be deliberately replaced with new or different patterns.

It could also be because behaviours are reinforced by other people – and as a result of intermittent reinforcement being so effective at strengthening behaviour, pain behaviours may persist.

Whatever the underlying reason for this finding, I’m sure we need to direct our focus more on specifically addressing pain behaviours in the future.

Martel, M., Thibault, P., & Sullivan, M. (2010). The persistence of pain behaviors in patients with chronic back pain is independent of pain and psychological factors Pain, 151 (2), 330-336 DOI: 10.1016/j.pain.2010.07.004

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Catastrophising and pain (i)


ResearchBlogging.org
One reason I love blogging is the discussion between me and readers. I wrote about the language of pain recently, and out of that discussion I’ve spent a few days digging around the literature to look at what is known about the relationship between language, pain and catastrophising. I’d argued in my post that metaphoric language can reflect distress both in the communicator and the listener, and that this is supported by fMRI studies in which various parts of the brain are activated when emotion-laden communication about pain is being carried out, while one of my readers thought I might be taking this interpretation too far.

Pain behaviour
My reason for being interested in how we communicate about pain is that talking about pain (including describing it) is a pain behaviour. Pain behaviours are a range of behaviours that occur when we are sore and seeking help, and can include voluntary and involuntary actions. There can be an assumption that people are fully aware of the behaviours they do in relation to pain, so when a person demonstrates a lot of pain behaviour some clinicians believe the person “must” know that this is what they’re doing. This is sometimes the case, but there are numerous factors that can influence the behavioural responses we have to an experience of pain.

Pain behaviours occur on a continuum, however, from involuntary such as the withdrawal reflex, through more voluntary actions such as swearing (yes, it does seem to help!) and ultimately to very complex behaviour such as seeking treatment for pain.  And from an evolutionary point of view, pain behaviours are there primarily to communicate to others that we need or want help.

Pain behaviour and catastrophising
There is a relationship between catastrophising, or “an exaggerated negative “mental set” brought to bear during actual or anticipated pain experience” (Sullivan, Thorn, Haythornthwaite, Keefe, Martin, Bradley and Lefebvre, 2001), and pain behaviours – including verbal reports of pain intensity, seeking treatment including hospital stays, use of medications, and has been posited as one reason health professionals may pursue more intensive and invasive approaches to pain assessment and treatment.  Catastrophising is thought to influence the ways in which people interpret their pain – there are several theories identifying how this might occur.  But first, let’s have a look at how catastrophising is identified.

Measuring catastrophising
As I’ve mentioned in an earlier post, there are several pen and paper measures of catastrophising.  Questionnaires are simply standardised, or repeatable sets of questions that have been tested and thought to measure some underlying concept – they’re not “x-rays of the mind” and while they’re helpful and allow researchers and clinicians to do statistics on the findings and establish how similar or different one person’s answers are from “the rest”, they are based on language.  The words and phrases that people use reflect the way they interpret a situation, and while the actual wording differs depending on the vocabulary the person commonly uses, the way the person appraises or judges a situation underpins what they say.

There are several problems levelled at questionnaire measurement of catastrophising.  Because catastrophising as a concept is “invisible” – we can’t measure it directly and have to use statements that are believed to be associated with it – some critics have identified that the Coping Strategies Questionnaire, for example, might confuse measurement of catastrophising with measurement of depression.  Others have suggested that catastrophising is so closely related to fear of pain or anxiety or even perceived disability that it might not be worth measuring it as a distinct entity.  The conclusion currently, however, is that catastrophising is a distinct concept, and the most favoured assessment tool is the Pain Catastrophising Scale.

This scale has been found to have three subscales – rumination (or “repetitively (and passively) focusing on the symptoms of distress, and on its possible causes and consequences” – thanks to Wikipedia), magnification, and helplessness.

Three possible theories
Appraisals - Lazarus and Folkman proposed a general model of the ways people respond to situations. Primary appraisal involves determining whether a situation represents a threat, positive or irrelevant. Secondary appraisal involves determining coping options and likelihood of success. The PCS magnification and rumination subscales might form part of primary appraisal, while helplessness might be related to secondary appraisal.
Attention – People who demonstrate elevated levels of catastrophising also seem to focus on pain more than those with lower levels. This suggests that one of the pathways from catastrophising to the experience of pain might be via hypervigilance, or increased tendency to quickly attend to pain – and from there to negatively appraise pain as something difficult to deal with.
Coping – One form of coping is to obtain help from other people. A model that could explain the usefulness of catastrophising might be that by communicating distress, help might be obtained from other people, so that the individual doesn’t have to cope alone. The experimental and clinical evidence supporting this function of catastrophising, as demonstrated through pain behaviour and verbalisations, seems to be reasonably compelling – and my thoughts are that one way in which catastrophising language “works” is through empathy, which itself seems to be related to those darned mirror neurones.

The question nonpsychologists might have is – so do I need to use the PCS to identify people who catastrophise? And if I know someone tends to catastrophise, what does it have to do with me?

And that is for another post, so y’all come back now!

Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, & Lefebvre JC (2001). Theoretical perspectives on the relation between catastrophizing and pain. The Clinical journal of pain, 17 (1), 52-64 PMID: 11289089

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The language of pain


ResearchBlogging.org
Have you ever wondered about the ways we communicate our pain? Pain behaviour doesn’t just include nonverbal communication – one of the main ways we communicate our pain is through speech. Words are an incredibly powerful aspect of pain behaviour that strikes me as something we haven’t really studied much. When I was searching for the article to refer to in this post, I looked in PsychInfo under the terms “linguistics” and “pain” – and out of the tens of thousands of articles under each term, and total of 16 included both words. Sixteen!

The stimulus for this post comes from someone who said the term “catastrophising” is a misnomer – a way for health professionals to dismiss or minimise the suffering and distress someone who has pain is experiencing. In this person’s words “Now its no longer just a buzzword but a label that pain docs like to attach to everyone in chronic pain who indicates they are suffering. And of course as most pain docs dont particularly care for hearing about suffering of those in pain they then attempt to get them to go for some cbt or psychotropics.”

Now, I preface this next section with the notice that I’m no linguist (although it’s something I’d love to learn about!).  But in a paper by Elena Semino, it’s absolutely fascinating to read about the ways in which people describe pain – she starts by saying “sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage.”  Note the word “causes”.  She gives the example of someone describing their pain as “sharp“, “like a rake over my eyes and head, digging in and scraping away”, noting that “expressions such as “sharp pain” function metonymically when they describe pain that directly results from physical damage, and metaphorically when no such damage is involved”.  (BTW Metonyms are figures of speech that replace a word with a word that is intimately associated with that thing or concept.  For example, in New Zealand “the Beehive” refers to Parliament, because that is the name of the building in which Parliament is housed.)

The reason we use terms like “sharp” or “stabbing”, argues Semino, is that “that these uses of metaphor may facilitate some form of internal embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response.”

Pain behaviour of all types functions in the same way – evolutionary psychologists suggest that they are remnants of early signalling behaviour designed to elicit a response from those around the individual.  It makes sense that if a group of prehistoric people are hunting, someone who has pain can signal to others through crying or groaning that “something’s wrong”, hopefully eliciting some sort of caring behaviour from the rest of the troup, with the withdrawal response later helping the individual remain still and quiet in the back of the cave so as to minimise the potential for sabretooth snacking!

What Semino and others postulate is that the language we use when describing pain draws upon the neurophysiological aspects of shared experience or empathy – the “mirror neurones”.   fMRI studies of the anterior cingulate cortex, the bilateral anterior insula, rostral anterior cingulate cortex and the sensorimotor areas of the neuromatrix (aka “pain” matrix – but this is probably a misnomer) show these are activated when individuals observe another person experiencing a painful procedure or hear words describing these procedures. 

Semino quotes Avenanti et al., (2005) who suggests that there are “two forms of empathy linked to one another in an evolutionary and developmental perspective.  A comparatively simple form of empathy, based on somatic resonance, may be primarily concerned with mapping external stimuli onto one’s body.  A more complex form of empathy, based on affective resonance, may deal with emotional sharing and with the evaluation of social bonds and interpersonal relations. p.958″.

Semino therefore proposes that metaphorical descriptions of pain that allude to causes of physical damage may trigger embodied simulations of similar experiences – and that both types of empathy are enacted when we use descriptive metaphors when talking about pain.

OK, where does this leave us when thinking about “catastrophising”? Catastrophising is the tendency to “think the worst” in a situation.  An example might be saying “my headache is killing me”.  Catastrophising influences an individuals appraisal of their situation.  Although this way of describing their situation does convey an individuals level of distress, catastrophic interpretations actually impede effective problem solving and active coping.  Catastrophising is associated with increased disability, high distress, low mood and high helplessness.

Is it normal to catastrophise?  At times, yes.  Most of us will do a little catastrophising from time to time, if we’re honest with ourselves.  But even if it’s normal, catastrophising isn’t helpful.  Again, most of us will catastrophise for a short while, then change our thinking and begin to speak differently and approach our situation differently – usually with a view to taking steps to exert some level of control over our situation.

I think it’s important to consider our use of language as health professionals, and it’s one reason for thinking about how we write reports, for example.  While we have our own technical language and use it amongst ourselves (and the term catastrophising is one of them) we need to be aware that people who don’t know the meaning of these terms can misconstrue them.  And in the case of some patients, feel misunderstood and sometimes offended.  We need to think about this and avoid using jargon where practicable.

More importantly, we need to be incredibly careful not to use terms in a pejorative or dismissive way.  We’ve moved a long way from describing a woman with pain as being “hysterical” – but terms like “functional pain” or “supratentorial” or “malingering” can still be found in some reports.

I think the best thing we can do when we’ve been talking with someone who does “catastrophise” is make it clear that we are not dismissing their pain as less than what they say it is, but instead to be sensitive to their language and reflect that their pain is very distressing and difficult to deal with.  Because in the end, that’s what the language used when sone tends to catastrophise is intended to elicit from us. 

Descriptions of Pain, Metaphor, and Embodied Simulation Metaphor and Symbol, 25 (4), 205-226 DOI: 10.1080/10926488.2010.510926

Avenanti, A., Bueti, D., Galati, G., & Aglioti, S. (2005). Transcranial magnetic stimulation highlights the sensorimotor side of empathy for pain. Nature Neuroscience, 8, 955-960.

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More “Psychological stuff isn’t in my scope of practice” so what can I do?


ResearchBlogging.orgI promised there would be more on this topic – it’s a popular one and full of vexing questions.  I left off yesterday, after making four points that IMHO might help incorporate some of the psychosocial management to a nonpsychological practice.  They were:

Give precise advice about what to do.

Give reasons for your advice.

Ask the person about their understanding of their pain.

Make sure you give clear timeframes for any activity restrictions.

The underlying rationale for each of these is to counter two main problems that appear to underpin the development of longterm disability associated with pain: catastrophising, or ‘thinking the worst’, and avoidance.

This point is really important, so listen up!

It’s not the presence of pain alone that is the problem.  It’s negative thoughts or judgements about pain, and behaviours that people do to avoid exacerbating the pain. 

Combine both of these with low mood, and we have a witches brew that can lead to longterm disability.  And it’s disability associated with pain that really is the problem because it’s about not being able to do the things that people want or need to do. 

OK, ’nuff said. While I appreciate that pain by definition is a negative emotional experience, it’s these two additional components that need to be addressed as early as possible.  And yes, that’s pretty much what Linton and colleagues found (and recommend) in the paper I’ve referred to.

Their point is that we don’t know very much about the best ways to target the tendency to catastrophise, and while our focus is often on low mood and low mood certainly has a major impact on longterm outcome, we also need to directly address catastrophising and develop targeted treatments for this.

The quote I gave yesterday from Linton et al., was incomplete – here’s the rest: “Clearly, encouragement to upgrade activities and exercises, as well as education and attempted reassurance about pain may be sufficient to achieve meaningful changes in many, but they appear to be insufficient to overcome strongly-held catastrophic beliefs by a proportion of people.” Something else needs to be added, and I think it might be doing things differently. With the emphasis on doing. Education/information alone doesn’t necessarily change behaviour…

At this point, I’m leaping off the solid ground of evidence, and into some clinical conjecture, but hopefully based on what we currently know about helping people make changes.  So please, bear this in mind when you read on…

  1. Check with the patient to find out what they think they’ve heard.  What does the person hear when you give an explanation?  What do they think you mean?  How does your explanation fit in with their personal theory of what is going on?
  2. A picture or diagram is worth a thousand words.  I find myself drawing diagrams linking the person’s thoughts, their responses in both emotions and behaviours, and I add in alternative paths and extra information that I can give to them to take away.  Personalising this information and using what the person already knows to show them that their reasoning might ‘make sense’ but has unintended consequences, or their reasoning is based on inadequate knowledge helps to make your advice on ‘doing it differently’ much more acceptable.  This is a joint discovery you and the person are making.
  3. Setting goals always needs to start where the person is at.  If you want the person to start doing things for themselves, being active in their own treatment, they need to feel that those actions are both important and that they can do them successfully.  If the person doesn’t think they can walk to the letterbox every day, even though you think that’s barely sufficient, then start with something they think they can do – and do consistently.
  4. When the person comes back to see you – check with how they’ve carried out the goals you set.  If you don’t check in on them, they’ll see the goals as unimportant.  Even if they haven’t done the goals, you can continue with your treatment – just ask what happened? What got in the way of doing the goal? What went through their mind? What external obstacles got in the way? This is where you’re starting to use psychological ‘stuff’ because often what you’ll find is that it’s thoughts/beliefs about the pain, emotions related to those thoughts about pain, and/or the influence of other things (people, events) that will directly influence recovery.

More on this stuff tomorrow – but let me know, does what I’ve written ring true? Can you do this? Does it make sense to you as a clinician? I’m looking forward to hearing your comments.

Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009

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A new way of looking at coping, maybe?


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One half of knowing what you want is knowing what you must give up before you get it. ~Sidney Howard

Many are stubborn in pursuit of the path they have chosen, few in pursuit of the goal. ~Friedrich Wilhelm Nietzsche

There are few topics closer to my heart than goals.  This is partly because of my background in occupational therapy, where goals are seen as part of how we live purposeful, meaningful lives – but it’s also because they’re incredibly difficult to help others to do, yet goal setting is seen as integral to therapy.

I’ve also been considering the whole topic of coping recently.  What is coping? Which coping strategies are helpful? Is it possible to view coping efforts without also looking at the context in which they’re being used? My current conclusion is that, at least in pain management, coping is a concept that we really haven’t come to grips with.  Even the term ‘coping’ isn’t well-defined: is it the process of adapting to a situation? the outcome? or the strategy employed?

Karsdorp and Vlaeyen, in this pre-print article, consider the pursuit of goals as part of the problem of disability associated with chronic pain.  What? you say – how can going after a goal be part of the problem?  Let me explain.

For some time, we’ve recognised that along with the people who avoid activity and become deactivated and highly disabled, there is a somewhat smaller number of people who superficially seem to be coping well – they’re active, maintain going to work, keep the family going and so on, but at the same time can be highly distressed by their pain.  Their pain represents a roadblock that gets in the way of getting things done, but unlike the first group who stop doing and avoid experiencing pain, this group of people seem to almost redouble their efforts.  They just keep going.

One model looking at mood and the motivational effects of mood is the “mood as input” model.  This model proposes that “the motivational effect of goal pursuit on behavior is moderated by mood”.  It suggests there are two types of goal – short-term ‘hedonistic’ goals, and long-term ‘achievement’ goals.  Hedonistic goals are all about pleasure in the ‘now’ – that taste of chocolate, the joy of running and so on.  Achievement goals require a longer-term focus and may involve some hard work in the short-term – learning to ride a bicycle, drive a car, win a race.

In this model, the degree to which a person tends towards either type of goal is thought to be influenced by mood.  In other words, negative mood suggests to the individual trying to achieve a goal that they haven’t got there yet – leading to task persistence.  In other individuals, negative mood suggests that they’re not enjoying the goal any more, so they should stop.  Of course, most of us have a mixture of goals, both hedonistic and achievement, but there does seem to be a tendency towards one type or another in some individuals, and in this study by Karsdorp and Vlaeyen, it was hypothesised that those with a strong preference towards one or the other, would present with the most disability and pain, dependent on their level of negative affect.

Nearly 300 people with current pain present in any part of the body and with various diagnoses were recruited by newspaper for this study.  A large battery of questionnaires were completed including some related to goals, affect, catastrophising, perfectionism and pain-related disability.  Using exploratory factor analysis, a two-factor structure was obtained from the data – one factor related to pain, and ‘the rest’.  With the pain factor excluded, a further two factors were obtained – one related to a pain avoidance goal, and the other to a mood management goal.

After completing further analyses, mainly multiple regressions,  a nonlinear, U-shaped association was found between
pain-avoidance and pain and disability.  What this means is that a stronger endorsement of either pain-avoidance goals or achievement goals was related to greater pain and disability while controlling for other factors.

The other main finding from this study is to confirm previous research that has found an association between high “sense of responsibility” and achievement goals and between pain catastrophizing and the “hedonic” goal to find a solution for pain.  In other words, there are some people who push themselves to complete goals because of a high sense of responsibility and the negative emotions they experience when they don’t complete things to their satisfaction – and in this group, disability and distress is increased when their pain ‘gets in the way of’ achieving these goals.  Then there are other people who tend towards primarily trying to manage their mood, who are likely to catastrophise more about pain, and are more inclined to avoid activities that exacerbate their pain.

Now here is where I think we need to do more research.  Rather than classifying coping strategies according to ‘emotion-focused’ or ‘solution-focused’, or ‘active’ vs ‘passive’, I think we need to look at the function of coping strategies as they are conducted in the pursuit of things people want to do.  It’s not helpful to see people as separate from the context of what they want to do, and where they want to do it.

This model is in its early stages, the findings were relatively weak, and there is clearly much more to be done to explore the idea of goal pursuit and coping strategies, but it is nice to see that at least one group of researchers is concerned about “why” people do things as much as “what” they do.

Karsdorp, P., & Vlaeyen, J. (2011). Goals matter: Both achievement and pain-avoidance goals are associated with pain severity and disability in patients with low back and upper extremity pain PAIN DOI: 10.1016/j.pain.2011.02.018