theory

Pain – or disability?


One of the fundamental distinctions we need to make when working with people who experience pain is to understand the difference between experiencing pain – and the behaviour or actions or responses we make to this experience. This is crucial because we can never know “what it is like” to experience pain – and all we have to rely on as external observers is what we see the person doing. Differentiating between the various dimensions associated with our experience of pain makes it far easier to address each part in the distinct ways needed.

Let me explain. We know the current definition of pain – an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms (IASP, 1979). One of the key points of this definition was to remove the need for nociception as a requirement for pain to be present. So when we unpack what we understand about pain, the first step is to recognise that it’s an experience. Something we can never share with another person – just like we can’t share joy, the taste of a great craft beer, or what a lover’s touch is like.

We therefore have an inexact relationship between two concepts: nociception, or the biological mechanisms at play until the point at which we are conscious of pain; and pain, or the experience of what it is like to have an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms.

But wait, there’s more. Given that this experience is a subjective, internal and personal experience – how do we know when someone is experiencing pain?

When I ask students, their answer is “oh you can see grimacing, wincing, or they tell you” – and it’s true! But let’s notice something: they’re all behaviours. Things people do, either involuntarily or voluntarily, to signal that they’re sore. Behaviours or actions are not a direct indication of “what it is like” to experience pain. Like nociception and pain, there is an inexact relationship between what someone does when they’re experiencing pain – and their resultant behaviour. So we now have three somewhat overlapping concepts: nociception (biology), pain (experience), and behaviours (actions). They overlap because there is no direct 1:1 relationship between these concepts – although in some cases it may seem like there is.

What else influences our pain experience? If you’ve been paying attention to my blog these last few weeks, you’ll know that thoughts or beliefs and emotions also influence both our experience of pain and our behaviour. For example, if we know that the pain we’re experiencing is for good (such as post-surgical pain after hip replacement), we tend to be more forgiving, or at least more willing to experience it than if someone attacked us with a scalpel down some back alley! We have plenty of evidence that simply knowing the supposed cause, and something about the biology of pain, can help people to feel a little differently about it (emotions), and to move differently (behaviour) (Moseley & Butler, 2015; Tegner, Frederiksen, Esbensen & Juhl, in press), while emotions in both experimental and clinical studies have been shown to strongly affect pain intensity – and subsequent behavioural responses (Orenius, Raij, Nuortimo, Naatanen, Lipsanen, & Karlsson, 2017). Once again, the relationships are not exact – which is almost always the case when we’re studying complex systems!

Because thoughts, beliefs and emotions have both impacts on nociceptive processes and on pain experience and behaviours, I’ve depicted them as overlapping (if there was a way to show this in 3-D believe me, I would!).

But wait, there’s more!

We know context makes an enormous difference to a person’s experience of pain AND the behaviours they take in response to their pain. While contextual factors don’t directly influence nociception, these factors do influence thoughts and beliefs, emotions, and behaviour. For example, we know that in adolescents with pain, parental responses influence the amount of treatment seeking (Stone, Bruehl, Smith, Garber & Walker, 2018); and that spouses or partners of people living with pain can affect both pain intensity and behaviour because of the way they interact (Burns, Post, Smith, Porter, Buvanendran, Fras & Keefe, 2018). We also know that in different communities, responses to pain can differ: people who pursue body suspension (being pierced and suspended by hooks) are supported by those around them to “hang in there” (no pun intended!). Factors such as legislation make a difference to pursuing treatment, while treatment itself can perpetuate disability and may even increase attention to pain.

Why bother explaining all this?

The implications of understanding these associations are quite profound. Firstly, nociception is a small but important contributor to our pain experience. Most pain starts with a nociceptive stimulus, even if it ultimately ends up less influential than cortical ‘interpretive’ processes. Secondly, the experience we have of pain is something we can’t share – and thirdly the only way we can begin to infer that another person has pain is via their behaviours, or what they do. This means pain measures like the visual analogue scale, FACES scale, numeric rating scale are not direct measures but are used by people to give a message about their pain. All behaviour is influenced by both our thoughts/beliefs and emotions and contextual factors including who is nearby, past responses they’ve made to our messages, what’s normal or expected in various contexts, and the purpose we believe our behaviour will serve. And of course, many of the influences and behaviours we do are not things we’re consciously aware of because we’ve been doing them since we were born.

So when I think about what we might do to help someone with their pain, I firstly acknowledge that I can’t directly influence someone’s own experience. I’m working to influence what they do about their pain, their relationship to their pain, their beliefs and understanding, their emotions and how they communicate this to other people around them. And to me, the first step is being ready to hear what people believe about their pain. Only after I’ve successfully conveyed this to the person can I ever begin to come alongside them to help them change what they do.

 

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2018). Spouse criticism and hostility during marital interaction: effects on pain intensity and behaviors among individuals with chronic low back pain. Pain, 159(1), 25-32.

Moseley, G. L., & Butler, D. S. (2015). Fifteen years of explaining pain: The past, present, and future. J Pain, 16(9), 807-813. doi:10.1016/j.jpain.2015.05.005

Orenius, T. I., Raij, T. T., Nuortimo, A., Näätänen, P., Lipsanen, J., & Karlsson, H. (2017). The interaction of emotion and pain in the insula and secondary somatosensory cortex. Neuroscience, 349, 185-194.

Porreca, F., & Navratilova, E. (2017). Reward, motivation, and emotion of pain and its relief. Pain, 158, S43-S49.

Stone, A. L., Bruehl, S., Smith, C. A., Garber, J., & Walker, L. S. (2018). Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain. Pain, 159(2), 298-305.

Tegner, H., Frederiksen, P., Esbensen, B. A., & Juhl, C. (2018). Neurophysiological pain-education for patients with chronic low back pain-a systematic review and meta-analysis. The Clinical Journal of Pain.

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Back to basics about psychosocial factors and pain (ii)


But what about the bio? No, not the biographical, the biological! It’s something I often get asked – like “if you think pain is psychological/psychosocial factors play a part then you’re obviously not including the biological” – oh woe is me, for no, pain definitely involves the biological. But it’s not quite as simple as we’ve come to believe.

Let’s begin at the very beginning. Can we have pain – and not know about it?

The answer is – no, and that’s exactly why anaesthetics are used. The distinction between pain and nociception is that it’s entirely possible for nociception to be occurring all the time, even while unconscious, whereas pain can only be experienced by a conscious person. What this means is nociception is about activity in the nociceptive system right up until the point at which we become conscious of it. And the point at which we become conscious of the ouch shifts depending on a bunch of things, one of which is how much attention we have available, our current goals, whether we’ve had this experience before, what we think the experience is about, and what we’ve learned about this experience from our community.

So, I’m going to discuss pain biology from the brain down instead of nociceptive fibres because our brains are not just blank pages waiting for information to hit it – but actively filter, select and augment information to (a) keep us alive and safe, and (b) help us reach our goals. Louis Gifford put this nicely – our brain is sampling from our context, cognitive set, mood, chemical and structural inputs (neurodegeneration, metabolic changes and plasticity) as well as our current sensory input (which is the bit we usually start from). What the brain then does is generate outputs – the experience of pain, movements, immune response, endocrine responses, and what goes on in our somatosensory system (Gifford, 1998).

What parts of the brain are active when we feel pain?

Well, there are at least three parallel cortical processes – one is essentially about where we hurt and involves the S1 or somatosensory cortex, the parietal operculum, the cingulate cortex and the posterior insula. The second is about attention or salience and involves the anterior cingulate cortex, the amygdala and the anterior insula. The third is about generating and integrating a behavioural response – and involves the frontal cortex (orbitofrontal, anterolateral and prefrontal), the middle cingulate cortex, and the posterior cingulate cortex. (Fenton, Shih, & Zoltan, 2015).

Now before I go any further, I want to point out that our understanding of these networks is based on various brain imaging studies – and brain imaging studies do not show the “what it is like” to experience pain. Our understanding is incomplete still because imaging technology is still evolving (see Borsook, Sava & Becerra (2010) for more information). But it is from the studies that we begin to  get an understanding of the complexity of the processes and networks involved in producing our experience – no wonder some feel overwhelmed by the sheer volume of information we could explore when trying to understand pain! Especially if our focus has traditionally been on peripheral to spinal nociceptive processing – by the time we get to the brain we’re overloaded and it just seems a bit hard to comprehend.

When we investigate what Melzack calls the “neuromatrix” we need to remember that our understanding is incomplete. What we do know is there is no “pain matrix” but instead there is a salience matrix where simultaneous processing across multiple locations in the brain occur. These locations include areas generally associated with emotions, areas associated with cognitions, and with location and response generation. And importantly, there is never a time when these areas are completely inactive – there is constant activity throughout the networks, meaning that when a stimulus arrives from the periphery, it arrives into an active “salience” network – always determining the question “compared with what is happening right now (goals and alertness) how dangerous/important is this really?”

For a lovely image showing the various areas of the brain involved in processing this experience – click here for the full article – take a look at this image from Denk, McMahon & Tracey (2014)

Now if you’re wondering why I haven’t covered the brainstem and spinal cord etc – do not worry, these will be coming soon! But I won’t be discussing nociception because this is usually discussed in undergraduate training and is often the focus and only aspect of pain covered!

Next time – delving into mechanisms!

What are the implications of the complexity of central processing?

  1. The brain is not simply waiting for information – it actively seeks information relevant to survival
  2. Psychological processes such as attention, emotion and decision-making are biological
  3. The point at which we become aware of pain shifts depending on inputs (bottom up) as well as salience, emotions and consciousness (top down) and contextual factors including what we learn from our socio-cultural environment

And what this means is that psychosocial factors are integral to a biopsychosocial framework for understanding pain. In other words – it is not possible to divide the experience of pain into biological, psychological or social only, except for teaching/learning purposes.

 

 

Borsook, D., Sava, S., & Becerra, L. (2010). The pain imaging revolution: advancing pain into the 21st century. Neuroscientist, 16(2), 171-185. doi:10.1177/1073858409349902

Denk, F., McMahon, S. B., & Tracey, I. (2014). Pain vulnerability: A neurobiological perspective. Nat Neurosci, 17(2), 192-200. doi:10.1038/nn.3628

Fenton, B. W., Shih, E., & Zolton, J. (2015). The neurobiology of pain perception in normal and persistent pain. Pain Management, 5(4), 297-317.

Gifford, L. (1998). Pain, the Tissues and the Nervous System: A conceptual model. Physiotherapy, 84(1), 27-36. doi:10.1016/S0031-9406(05)65900-7

Being flexible – and how language can make you inflexible


One of the reasons humans seem to dominate our natural world is our flexibility. We don’t have the best eyesight, hearing, strength, speed, stamina or indeed any single attribute that means we’re King (or Queen) of the Jungle, but what we do have is the ability to adapt our environment to maximise the benefits to ourselves. Being flexible means we can find many different ways to achieve a certain goal. It means we don’t get stuck using the same solution when that solution doesn’t work. We try lots of different ways to achieve what we want.

Or are we?

There are plenty of times when I’ve had to firmly remind myself “the definition of insanity is to try doing the same thing again and again, hoping for a different result” I have no idea where that quote came from, but it seems applicable!

Rules

Thankfully, humans don’t have to experience adverse events directly to learn from them. We can learn from what other people tell us. Sometimes what others tell us is helpful – “watch out, walking on a sprain is gonna hurt!” Other times, when what someone tells us is true – but not applicable in our context – we can learn something that isn’t helpful. “Watch out, walking on anything painful is bad”. We can over-generalise or develop an arbitrary rule that is inflexible.

Now this happens all the time. We learn to avoid things that could potentially harm us on the basis of words – parents, teachers, friends, officials all tell us not to do things that could harm us so we avoid dangers without actually having to face them. When we learn this, the function or relationship between events and the way we relate to them gets influenced by what we’re told rather than the actual event itself. So, for example, we learn that when someone tells us off for doing something dumb, we re-experience what it feels like to be ashamed. We don’t want to experience shame, so we avoid situations that look like (function in the same way as) whatever it was we might have done to be told off.

Experiential avoidance and symbolic generalisations

Because we use language to depict these situations and because language can bring back all those associations between the event, object, emotions and experiences, we quickly learn to generalise these relationships – in RFT (relational frame theory) terms, we develop symbolic generalisations. What this means is that even though the actual object, event, emotion etc is not present, just describing something like those things can elicit the same response. And when we don’t like that experience we use every means possible to avoid experiencing it – so we avoid, try to forget, try not to think about it, keep busy, avoid talking about it, pretend it’s not there.

Through avoiding, we develop a whole lot of new associations – “doing this to avoid that” begins to relate “this” to whatever we’re avoiding. So, for example, keeping busy to avoid feeling sad can become a trigger for sad feelings. Sitting stiffly and avoiding bending can become a trigger for worrying about the potential for pain if we do bend.  So, doing things that help us avoid a  negative association can build into a whole set of behaviours that initially help us avoid but ultimately elicit the very things we were hoping not to experience. We become inflexible as the rules we use develop into constraints across a larger range of stimuli/experiences than we originally intended.

Deliberately trying to avoid an experience is tricky, there can be a whole lot of unintended consequences – and no more so than when the negative experience we’re trying to avoid is pain.

Rule-governed behaviour

The thing is, once we develop a rule we begin to follow the rules rather than trying it out ourselves. We place less emphasis on our own experience. Let’s use an example from pain. A person feels uncomfortable bending over while carrying a laundry basket. A kind therapist suggests that bending over isn’t safe, so the person should use “safe handling” techniques. While the therapist is present, the person uses the so-called safe techniques but all the while thinks “if I bend over incorrectly, it must be unsafe because these are “safe handling” techniques”. The person develops a rule. Now when the person begins to move something she uses the “safe handling” techniques but finds it really difficult at times because she has to lift children into the back of the car so they can get into the car seat. She feels worried that she’s not using the “safe handling” techniques rather than feeling what actually happens when she lifts the child.  She instead avoids lifting the child into the car and asks for help. Another person comes along, scoops the child up, plonks him into the car seat and the job’s done.

Rules are helpful, they save us time and harm. They’ve accelerated our rate of learning. BUT they come at the expense of flexibility. There are times when it’s useful not to use “safe handling” techniques – ever tried crawling under your house with a bag of tools? Or get a screaming toddler into the back seat of a two-door car?

Rules also begin to influence the associations we make between events – before the kind therapist advised the person that she should use “safe handling” techniques, the person never thought about how she got the children into the back seat of the car. Now she does. And every time she lifts something off the ground she also thinks about her back. And when she carries her groceries. And bends over to make the bed. And maybe even as she reaches overhead to get something from a cupboard. Or lifts the ironing board and opens it out.

How stuck is that? And how often have we as clinicians inadvertently generated rules that teach our clients to avoid a movement or experience?

Next week: pliance and tracking and what these mean…

Villatte, M., Viullatte, J., & Hayes, S. (2016). Mastering the clinical conversation: Language as intervention. The Guilford Press: New York. ISBN: 9781462523061

Central sensitisation – can a questionnaire help find out who is, and who isn’t?


My orthopaedic colleagues have been asking for a way to identify which surgical candidate is unlikely to have a good outcome after major joint surgery. They know that between 10 – 50% of people undergoing surgery will have chronic pain.  5 – 10% of those people experiencing pain that’s rated >5/10 on a numeric rating scale where 0 = no pain, and 10 = most severe pain you can imagine ( Kehlet, Jensen, & Woolf, 2006). The people with severe pain are the kind of people who hear “well the surgery I did went well…” and can be left wondering why they ever decided to go ahead with their surgery.

Two main factors seem to be important in postsurgical chronic pain: the presence of central sensitisation (usually indicated by reporting chronic pain in at least two other areas of the body) and catastrophising. I’ve discussed catastrophising a great deal here and here .

What I haven’t talked about is central sensitisation. Now, the idea that people can experience chronic pain associated with changes in the way the nervous system responds to stimuli isn’t new, but the neurobiology of it is still slowly being unravelled.  I’m not going to get into definitions or whether having changes in the nervous system equates with “chronic pain” (because pain is an experience and the neurobiology is just the scaffolding that seems present, the two are not equivalent). I want to talk about the measurement of this “sensitisation” and whether a pen and paper tool might be one way of screening people who are at greatest risk of developing problems if they proceed with surgery.

First of all, what symptoms come under this broad heading of “response to an abnormally sensitised nervous system”? Well, Yunus (2007) proposed that because there are similarities between several so-called “medically unexplained symptoms” such as fibromyalgia, chronic fatigue, irritable bowel disorder and so on, perhaps there is a common aetiology for them. Based on evidence that central sensitisation involves enhanced processing of many sensory experiences, Yunus proposed the term “central sensitivity syndrome” – basically a disorder of the nociceptive system. Obviously it’s pretty complicated, but various researchers have proposed that “dysregulation in both ascending and descending central nervous system pathways as a result of physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system, as a result of physical trauma or viral infection… including a dysfunction of the stress system, including the hypothalamic–pituitary–adrenal axis (Mayer, Neblett, Cohen, Howard, Choi et al, 2012, p. 277)”. (what are “pain impulses”?!)

By proposing this mechanism, various researchers have been able to pull together a number of symptoms that people experience, and their premise is that the more symptoms individuals endorse, the more likely it is that they have an underlying central sensitisation disorder.

The authors completed a literature review to identify symptoms and comorbidities associated with fibromyalgia and the other disorders they believe indicate a sensitised central nervous system. they then develop a self-report instrument and asked people with these problems to complete it, and compared their results with a group of people who wouldn’t usually be thought to have any sensitisation problems (students and staff at a University – we could argue this, but let’s not!).

What they found, after much statistical analysis, is a four factor measure:

Factor 1 – Physical Symptoms (30.9%)
Factor 2 – Emotional Distress (7.2%)
Factor 3 – Headache/Jaw Symptoms (10.1%)
Factor 4 – Urological Symptoms (5.2%)

Test-retest reliability was established, and because the questionnaire could discriminate between those who reported widespread pain (aka fibromyalgia) and those who had no pain, it’s thought to have discriminant validity as well. (BTW a copy of this measure is included in the appendix of the Mayer, Neblett, Cohen, Howard, Choi, Williams et al (2012) paper – go get it!)

The researchers then went on to look at some norms for the measure and found that amongst people with chronic pain, referred to an outpatient multidisciplinary pain centre, those with more diagnosed “central sensitisation syndromes” scored more highly on this measure, and that a score of 40 on the measure was able to discriminate between those who didn’t have sensitisation and those who did (Neblett, Cohen, Choi, Hartzell, Williams, Mayer & Gatchel, 2013).

Well and good. What does it actually mean?

This is where I think this measure can come unstuck. I like the idea of people being asked about their pain and associated symptoms. We often don’t have time in a clinical interview to ask about the enormous range of symptoms people experience, so being able to get people to fill out a pen and paper measure to take stock of the different things people know about themselves is a good thing.

What this measure doesn’t yet do is indicate whether there is any underlying common causal link between these experiences. It’s tautological to list the symptoms people might experience with central sensitisation based on the literature, then ask them to indicate which ones they experience and then conclude “oh yes! this means they have central sensitisation!” All it means is that these people report similar symptoms.

What needs to happen, and is now beginning to occur, are studies examining central nervous system processing and the scores individuals obtain on this measure. That, and establishing whether, by completing this questionnaire, it is possible to predict who is more or less likely to develop things like post-surgical chronic pain. Now that would be a really good measure, and very likely to be used by my orthopaedic colleagues.

In the meantime, whatever this measure indicates, it seems to be able to differentiate between people who are more likely to report “medically unexplained symptoms” and people who don’t. This might be useful as we begin to look at targeting treatment to suit different types of persistent pain. At this point in time, though, I think this measure is more useful in research than clinical practice.

 

Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–1625

Mayer, T.G., Neblett, R., Cohen, H., Howard, K.J., Choi, Y.H., Williams, M.J., . . . Gatchel, R.J. (2012). The development and psychometric validation of the central sensitization inventory. Pain Practice, 12(4), 276-285. doi: 10.1111/j.1533-2500.2011.00493.x

Neblett, R., Cohen, H., Choi, Y., Hartzell, M.M., Williams, M., Mayer, T.G., & Gatchel, R.J. (2013). The central sensitization inventory (csi): Establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. The Journal of Pain, 14(5), 438-445. doi: http://dx.doi.org/10.1016/j.jpain.2012.11.012

Roussel, N.A., Nijs, J., Meeus, M., Mylius, V., Fayt, C., & Oostendorp, R. (2013). Central sensitization and altered central pain processing in chronic low back pain: Fact or myth? Clin J Pain, 29, 625-638. doi: 10.1097/AJP.0b013e31826f9a71

Van Oosterwijck, J., Nijs, J., Meeus, M., & Paul, L. (2013). Evidence for central sensitization in chronic whiplash: A systematic literature review. European Journal of Pain, 17(3), 299-312. doi: 10.1002/j.1532-2149.2012.00193.x

Yunus, M.B. (2007). Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis & Rheumatism, 36(6), 339-356.

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.

Catastrophising and Pain (ii)


ResearchBlogging.org
What are some of the indications that someone tends to catastrophise about their pain? How do we know? Do we have to use a questionnaire? Is it really my job to know about this if I’m not a psychologist – and what do I do about it?

These are the kinds of questions that have been posed to me as I’ve explored the topic of catastrophising, and I propose to answer the last question in my next post (sorry to keep stringing you along like this – I think many may know my take on that already!).

I work in a wonderful interdisciplinary team setting, in a centre where everyone who attends the Centre gets to complete a set of psychometrically sound questionnaires that all of the team are encouraged to use and interpret, so any of the team can be confident about identifying and working with a patient who catastrophises. BUT I know that many clinicians work alone, or work in a team that functions in a multidisciplinary way, and where patients don’t routinely complete questionnaires.

So, what can solo, primary care clinicians do?

As I mentioned before, questionnaires are not X-rays of the mind – they simply organise how information is obtained, and allow us to compare the responses from one person with the responses from many others so we can decide how similar or different this one person is. In other words, using a questionnaire is just another strategy to help assess where a person is at.

It’s possible and sometimes really helpful to just ask
. With some proviso’s of course – asking the right questions and not just asking but also observing behaviour and putting this information together in some form of clinical reasoning about what is going on, and what this might mean for treatment.

Even if you decide to use a questionnaire (and maybe the Pain Catastrophising Scale is a useful choice), it’s important to decide who to give it to, when to give it, and most importantly, how to interpret it because numbers just don’t mean anything on their own – not even percentage change over time tells us very much if we don’t know the meaning of the domains they are representing.

Here’s another Healthskills Advice for NonPsychologists list on questionnaires and catastrophising!

  1. Some indications for considering the use of a measure of catastrophising are people who present as highly anxious or distressed about their pain, who describe their pain in dramatic metaphors or say things like “my back will snap” or “my bones and nerves are being ground away”, who say things like “I can’t stand it any more” or “it’s terrible and it can’t go on”, or who are fearful they will “end up in a wheelchair” for example.  Particularly people who believe that moving will “do damage”, and those who seem completely helpless when they have pain “there’s nothing I can do when I have pain”.
  2. It’s probably not so helpful to administer a questionnaire for catastrophising in someone who is seeing you with acute pain (first episode, within the first two or three weeks), but more useful to give it to someone who has had their pain for six weeks or more (sub-acute), who has had episodes of pain that have lasted more than six weeks before and had a slow recovery.
  3. In primary care settings most people won’t demonstrate catastrophising – but there is some research that suggests up to 25% of people with acute pain hold catastrophic beliefs (Ciccone, Chandler & Kline, 2010), and this finding was in young, fit military people!  Clearly not everyone who has catastrophic beliefs when they have acute pain go on to develop long-term disability, but the risks are higher, so a screening assessment like the Orebro Musculoskeletal Pain Questionnaire might be useful for routine administration in acute, primary care settings.
  4. It’s not very useful to use an English language questionnaire with someone who doesn’t speak English well – see if there is a questionnaire in that person’s language instead.  Be wary of using a translator to help someone answer a questionnaire, because this can lead to unintended errors and invalidate scoring.  The same applies if the person has limited comprehension.
  5. Make sure you read and understand the questionnaire, what it measures, how it’s interpreted, what the reference or normative group is, and how to score it.  If you don’t know these things, you’d be far better off not to use the questionnaire! Kthx.
  6. If you’re going to ask about catastrophising, you can ask things like
    • What goes through your mind when your pain gets bad?
    • What do you think is happening then?
    • What images go through your mind when you’re really sore?
    • What can you do to help yourself when your pain is really bad?
    • What do you think will happen in the future if your pain gets bad?
    • What do you think is going on in your body when you’re really sore?
    • What can you do to get by when your pain is bad?

Can you tell that this post is not the last in this series? But wait, there’s more!  Come on back for more, and don’t forget to comment (they’re always welcome).
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

Pain behaviours persist…


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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

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

Taking a closer look at health encounters for people with chronic pain


ResearchBlogging.org
A theme of comments made by people I’ve seen clinically is that certain health care encounters they’ve had have not been especially helpful. Some people feel belittled, some patronised, some bamboozled, some dismissed – and yet in most surveys of health care satisfaction, the rating is pretty high (Jenkinson, Coulter, Bruster, Richards & Chandola, 2002). What is an effective way to measure how well we do what we do?

One method is to look at repeat customers – but in chronic pain management this could indicate that something is wrong! After all, if we’re working to help people who have a chronic condition to self manage their pain, coming back for more is most likely going to end up in an enormous number of patients to see!  Chronic conditions, by definition, are not going to ‘come right’.

A better method is to look at outcomes – both pen and paper outcomes (questionnaire responses) and ‘real life’ outcomes such as attendances at other health care providers (Emergency Departments, GP consultations and so on), and things like the ability to return to work.  Intermediate outcomes like range of movement improvements, more strength, better cardiovascular fitness and so on are also useful to collect (although no-one has developed a robust set of repeatable physical functioning measures that can be carried out without undue fuss).

There have also been some well conducted observational studies of health care encounters, but these take a lot of time, can be invasive for both patient and clinician, and there is always a suggestion that clinicians and patients change their behaviour when they are aware of being observed.

A final method is to – yes! Ask the person.

In this interesting paper, Stomski and colleagues summarise the state of play in ways to measure chronic pain consultation quality.  They make a couple of interesting points about the ways in which clinical consultations can be improved to obtain better outcomes, points that may make some of us ponder about our own approaches:

  • Basing pain intensity assessment on people’s subjective experience, especially as health professionals frequently underestimate pain intensity.
  • Health professionals reflecting the validity of people’s chronic pain experience.
  • Addressing psychosocial factors that perpetuate and exacerbate chronic pain, particularly catastrophizing, fear-avoidance beliefs, anxiety, depression, and social isolation.
  • Affective components of the therapeutic relationship.
  • Health professionals establishing collaborative relationships by eliciting people’s preferences, providing information about their condition and available treatment options, and involving them in decisions about their care

The reviewing team used the Medical Outcomes Trust’s eight attributes for assessing measures – these are having a conceptual and measurement model; content validity; construct validity; internal consistency; test-retest reliability; number required for mean score; responsiveness; interpretability; response burden; administrative burden; conceptual and linguistic adaptations.

Cutting to the numbers, over 3,000 papers were identified, 88 full text studies were considered for inclusion, 58 potential measures were identified, but only four were able to be included. They were Treatment Helpfulness Questionnaire (THQ), Trust in Physician Scale (TIP), Picker Musculoskeletal Disorder Questionnaire (PMSDQ), Modified Perceived Involvement in Care Scale (MPICS).

As far as I can see, none of these look specifically at non-medical clinical encounters.

Now for a set of measures intended to reflect what patients think of clinical encounters, there was one rather glaring omission – none of the questionnaires had elicited participants opinions about the relevance of the items during development of the instrument.  A bit of an odd omission to me, and the authors of this paper make the point: “the content validity of most of the included measures needs to be reassessed by incorporating the target population’s views and this should be prioritized because assessments of reliability and feasibility are largely inconsequential if the measure’s content validity has not been adequately established.”

Exactly!  They also say that further qualitative studies need to be undertaken to ‘articulate in detail’ the processes underpinning interactions during consultations.  This is exactly the kind of situation in which qualitative studies give us really important information – generating theory that can then be tested in a more typical quantitative way.

These authors also point out that when developing a measure of any kind, it’s vital to consider how it’s going to be used.  In ‘formative’ measures, ie those measures that give clinicians some indication of their own performance, it’s important to know whether the instrument is reliable over time – test-retest reliability.  This has been omitted from the development of most of these tools which have, instead, looked at internal consistency.

Where does this leave us in terms of looking at our own skills in clinical situations?

Unfortunately, it doesn’t leave us too far advanced.  The conclusion from this study is that none of the measures can be used clinically – but they don’t suggest that we all go out and develop some new questionnaires! Instead, further studies looking at specific aspects of these existing tools need to be carried out.  It is vital that we learn more about how our behaviour in a consultation affects the lives of the people we hope to help.

Maybe more video recordings of clinical encounters can be made, with in-depth analysis of the communication patterns that occur during a consultation.  Maybe further discussions with patients about their experiences of consultations – what worked, what didn’t work.  Much more discussion with patients about the content of the existing questionnaires – do they reflect what patients see as important in the encounter?  And finally, how well do patient expectations and clinical outcomes match?  If a clinician is viewed as doing all the right things by patients, do the patients they see do better? and on which outcomes?

I’m a reluctant qualitative researcher.  Not because I don’t like qualitative research, because I do, but because it is so labour-intensive, and I do wonder about how readily qualitative research can be generalised.  At the same time, I recognise the value of qualitative research in generating the data that can then be used to develop quality theory.  Once we have really good quality theoretical models, then we’re able to begin good hypothesis testing.  And it’s at the hypothesis testing phase that quantitative methodology really comes into its own.

I don’t think we’re at the point where hypothesis testing can be conducted when it comes to the health care interaction for people with chronic pain.  Let’s instead focus on exploring and describing the experiences of both clinician and patient in consultations about chronic pain management.   Let’s take a closer look at health encounters for people with chronic pain.  We might learn something useful about ourselves and how we work.

Stomski, N., Mackintosh, S., & Stanley, M. (2010). Patient Self-report Measures of Chronic Pain Consultation Measures: A Systematic Review The Clinical Journal of Pain, 26 (3), 235-243 DOI: 10.1097/AJP.0b013e3181c84e76

Flexibility – of the psychological kind


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More holiday reading to ponder… One of the fascinating developments in psychology over the past 50 years is the ongoing study into what constitutes psychological health. It’s been known by many names – ego-resilience, executive control and self-regulation – but the work on these areas hasn’t been pulled together into a coherent whole until recently. The authors of this paper suggest that this is partly because of the nature of defining this particular beast – what is health after all? Their argument, and one that I find rather appealing, is that a main feature of health is to be able to apply the right kind of response to the many different situations in which we find ourselves. In other words, flexibility.

Occupational therapists in particular will rejoice at the way in which psychological flexibility is defined in this paper, because it refers to “… a number of dynamic processes that unfold over time. This could be reflected by how a person: (1) adapts to fluctuating situational demands, (2) reconfigures mental resources, (3) shifts perspective, and (4) balances competing desires, needs, and life domains. Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts.(emphasis mine).

Thinking about some of the people I’ve worked with (and reflecting on my own tendencies!), some of the problems that plague people arise from repeatedly trying to apply one set of coping strategies to a new or challenging situation.  When someone experiences a limitation in an area of function, our problem-solving minds typically want to ‘fix’ it – and while this can give us some great work-arounds it can also lead us up the garden path when those solutions don’t apply.

Let me illustrate: many of us grew up with the maxim ‘if a job is worth doing, it’s worth doing well’, or ‘don’t leave a job half-done’.  This is a great rule of thumb in most situations – it stops us from being half-hearted and it keeps us committed.  There is good reason for it being one of those things our parents and teachers drum into us.  BUT when it’s applied to managing chronic pain it can work against people – because it invites people to persist in completing activities in a ‘boom and bust’ pattern.

While most people can readily apply ‘exceptions’ to rules like ‘if a job is worth doing, it’s worth doing well’ so that if the person has a bout of influenza, or has just had an earthquake (for a very real example to us Cantabrians!), for people with chronic pain it can be hard to work out when to recalibrate expectations.  This is a very real example of the need to be flexible about expectations and behaviours.

While it’s easy to see the need to be flexible in terms of choices around temporary changes to health status or environmental demands, it’s much more difficult for many people to see the need to review choices in light of longer term changes to health status.  As a result, so many people I’ve worked with end up applying a rigid, global ‘rule’ to the way in which they live their lives, despite longstanding reductions in their functioning.  This leads to increased distress as their internal expectations don’t match what they can actually do – and a process of managing emotions while working to be more flexible with internal rules is a major part of the work of pain management.

It’s also one reason I don’t think it’s possible to work in pain management without a working knowledge of how to help people identify their thoughts and the effect of thoughts on emotions and behaviour.  After all, it’s relatively easy to ‘teach a skill’ like activity management – but a whole different ball game to help the person feel OK about applying activity management in his or her own context.

Kashdan and Rottenberg identify that there are several underlying building blocks of psychological flexibility.  These include: executive functioning – those parts of the brain involved with prioritising and integrating cognitive capabilities such as being able to shift attention away from what is less important to what is important; self-regulation – being able to tolerate distress and experience it but make choices about responding; being able to selectively apply task persistence or to choose to stop; identifying emotions and recognising their temporality.  As Kashdan and Rottenberg state: “Creating categories and labels is normal and it is only when it is automatic such that a person is unable to detach from particular thoughts and feelings, where they are viewed as objective representations of reality instead of temporary, products of the mind.” It’s that swift and automatic labelling that allows people to notice but not react, and is a skill we start to learn from childhood.

They go on to say “When a person is unable to accept frustration and unwanted negative experiences, attentional  capacity and decisionmaking capabilities are narrowed…Instead of flexibly responding to a situation in an active  manner, a person preoccupied with avoiding experiences is psychologically unavailable to adapt to the cues afforded by an existing situation.”

Finally, they identify “executive functioning also typically includes working memory and recall, information processing speed, and the ability to inhibit behavior.” Persisting memories can interfere with making accurate assessments of here and now, being able to rapidly recall information enables people to draw on appropriate knowledge for a specific situation and evaluate its usefulness, and being able to stop behaviour that is unhelpful is a really important aspect of developing an adaptive response to a new situation.

An ongoing job for any human is to “… maintain a delicate balance between investing effort into our current  surroundings and conserving mental energy for potentially significant future situations.” We typically simplify this by developing habits and routines (sound familiar Kielhofner fans?).  Part of psychological flexibility is being able to ensure these habits and routines support flexibility rather than remain fixed and not necessarily helpful.

I think the construct of psychological flexibility, and particularly acknowledging the ways in which executive functioning is such an important feature, is something clinicians working in chronic pain need to come to grips with.  If we can help people develop flexible and adaptive responses to the limitations of chronic pain, while recognising that chronic pain directly fatigues executive functioning, we’ll be going a long way towards helping people re-engage with what is valued and rewarding in their lives.  More learning for us clinicians, methinks!

Kashdan, T., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health Clinical Psychology Review, 30 (7), 865-878 DOI: 10.1016/j.cpr.2010.03.001