The relationship between pain and disability is a particularly vexing one in primary care. It would be great if it was possible to get rid of pain and be assured that any lingering effects on function would be similarly abolished, but it just doesn’t seem to be quite that simple.
Many different approaches to managing this situation have been suggested. One is to argue that people should be referred for a quick pain reduction injection – for those who have pain that is thought to respond to this approach. Another is to just “reassure” and review often. And still another is to provide a cognitive behavioural approach usually reserved for those referred to a secondary or tertiary treatment centre.
For several reasons I find the first and second options above not particularly satisfying.
For the avoidance of doubt, I want to make sure readers are aware that I am not agin pain reduction techniques. In fact, they’re a very good thing because, and this is the important point, they allow people to get back doing what is important to them. There are a few “provided that’s” to this because, as I’m going to show, people who have had a bout of pain don’t always “get back doing what is important to them”.
The second option of providing reassurance is also less than satisfactory because despite this approach being endorsed in numerous guidelines for managing acute musculoskeletal pain, very few specific recommendations as to how to provide reassurance have been given. Reassurance can be both unsatisfying to the person on the receiving end, and in some cases, increase the likelihood that the person remains fearful of moving and continues to look for more reassurance (Linton, McCracken & Vlaeyen, 2008).
Why doesn’t “taking the pain away” just return the person to the way they were?
Good question, glad you asked it! While abolishing the pain does, in many cases, return the peripheral nervous system and tissues to normal, this situation doesn’t apply to the central nervous system – and most particularly, those parts of the brain concerned with appraisals and judgements, anxiety and emotion, and memory. Let me explain.
When we are born, we arrive in the world with a functioning set of reflexes that respond quickly to input that startles the nervous system out of “comfort”. Loud noises, textures against the skin, new tastes – all of these provoke a startle response and we cry in protest. Thankfully most of these responses settle down as the nervous system habituates to those features of the environment that reoccur, but our responses are shaped by how adults around us respond to the same events, and how they respond to our behaviour. This is the effect of social and cultural influences. At the same time, we begin to develop preferences – some genetically shaped, others from what we observe and imagine about other people, and some from our own processing of the external and internal world.
It’s these factors that influence our responses to sensations that our brains ultimately determine are harmful or potentially harmful – and our brains let “us” know about this in the form of our experience of pain.
We develop tolerances to experiences as we’re exposed to them over time. Think of the sensation of biting into a
HOT CHILLI PEPPER.
Some of you will be thinking “Ouch! No way I’d do that!”, while others of you will be thinking “Yeah baby! Bring it on!”
The way we appraise, or think about/judge a situation influences our emotional response to it. This in turn influences what we are prepared to do about it.
Returning to the chilli pepper, even the next day after having had the HOT CHILLI PEPPER, you can remember the experience. (As an aside, this ability to remember what has happened – and then predict what might happen in the future – is what I drew on when I suggested that you think about it. ) You also made some decisions in your mind when I asked you to think of it, based on your appraisal of the sensation, and your emotional response to it.
When we experience pain, even if that pain goes after a while, we judge it and we have feelings about it, and we make decisions about what we will – or won’t – do if that situation arises again.
And this is why reducing pain but failing to also address thoughts and beliefs about what has happened and the possibility of it happening again does not always give the outcome we are hoping for.
The papers by Lamb and colleagues demonstrate that group CBT for low-back pain can be delivered in a cost-effective way in primary care, with good long-term effectiveness. Isn’t it time this approach was seriously implemented?
Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-eff ectiveness analysis Lancet, 375 (9718), 916-923 : DOI:10.1016/S0140- 6736(09)62164-4
Lamb, S., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E., & Underwood, M. (2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) PAIN DOI: 10.1016/j.pain.2011.11.016
Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.
Filed under: Chronic pain, Cognitive Behavioural Therapy, Coping strategies, Pain, Pain conditions Tagged: biopsychosocial, CBT, Chronic pain, Cognitive Behavioural Therapy, healthcare, Pain, pain management, treatment
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Sign in nowAwesome post (anjd responses) once again Bronnie.
I totally understand that some people will not be able to follow this path, and that some following this path will not find the same benefits as others. A patient with profound CRPS found some improvement practising Metta (loving kindness meditation) when his daughter survived though with paraplegia a horrible hit and run pedestrian-car accident. His intention was to decrease the stress related to her circumstances, and it helped his signs and symptoms.
Making the right guesses about when to introduce a practice with a person in pain is quite an art. Yogi’s having practised mindfulness, moving meditation, deep awareness, …, often suggest that making friends with pain is really helpful. Not for most people who have not practiced such things before. For them it is ridiculous and insulting. Yet at some time in their recovery process, this might be exactly the technique to help them move forward some more. As you point out Bronnie, by educating the person about pain science, we could provide some evidence that practising gratitude might be helpful from a physiology point of view. This helps foster motivation, and validates that the pain is a real thing (reality is that for most people, without pain education, practising gratitude would reinforce that the problem is in their head – not real).
Did The Beatles have it right? “All you need is love”? Certainly our physiology is better off when when we live in love rather than in fear, and Buddhist practice would suggest that the most important love is for self.
Maybe love and gratitude are not identical, but it would be interesting to look at how similarly the endocrine and immune systems and central and autonomic nervous systems respond when we practice the two.
Neil
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[...] education, and many other topics. The author was originally trained as an occupational therapist. In this post, she discusses what to do when a patient is “inconsistent” with their pain behavior or [...]
Don’t know if anyone is still responding–this blog is pretty old, but I am experiencing such a problem as addressed here. I had knee surgery, was progressing well with PT, but had an injury which caused great pain and quite a set-back. Since then, I’ve experience extreme anxiety, nausea, etc. just thinking about walking from place to place. I’ve become way too reliant on my crutch, and should certainly be able to walk around my house without it. However, I panic, and freeze up. Deep-breathing can help get me going, but I really need to overcome this–it’s affecting every aspect of my life.
Glad to know this is a “real” disorder!
I’m really sorry to hear that your pain has given you such a hard time. Anxiety is definitely a significant factor in experiencing pain, and yes it can definitely trigger anxiety attacks like you’ve described. To get help, you can start with long, slow breaths OUT – you’ll always breathe in! – and then open your eyes and place your hands on something and feel your body touching the ground, the support you’re on, and all the other sensations that help your brain remember that you’re safe. Learning good diaphragmatic breathing is probably the first skill to develop before starting on a graduated set of steps to take back what you want from life.
To set goals for being more independent, start with the first one you’ve mentioned – walking around the house without your crutch. See if you can just walk from one room to another and back without it first. Do this for one week or until you feel more comfortable doing so – remember to use your breathing and let yourself be fully aware that you are bigger than your anxiety. One step at a time. Once you’ve achieved this step, set another goal – maybe walking around your living area without your crutch. Do this in the same way you’ve done the first goal. Then set yourself another goal – maybe to put your crutch by the front door, and not to use it at all inside. But only do this once you begin to feel more confident walking around in one room and walking from room to room.
If you find this “live” exposure too hard, try first relaxing then using your breathing, begin to imagine yourself walking calmly, tall and confidently. Your mind’s eye is good at this sort of thing so imagine the sensations of walking tall, feeling graceful and confident. If you’re good at visualising, this is when you can imagine seeing yourself walking this way. If you find it easier to “feel the feelings”, imagine the sensations. Make it as vivid as you can in your imagination. Then begin by walking around in one room for maybe an hour without the crutch – and then you’re ready to start the graded exposure above.
If this is all way too hard, you can see a good occupational therapist with an interest in chronic pain management, or a good clinical psychologist with experience in pain management, or a physiotherapist with experience in graded exposure for chronic pain. It’s always worth asking any health professional about their interest and experience in working in this area, because not all clinicians have the necessary skills to do this kind of work.
I’d love to know how you get on, drop me a line through the “About” page, and I’ll get it as email.
cheers
Bronnie
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Hello,
I am an OT in Ottawa, Canada. I just happended to stumble across your blog today. I’m blown away! What a fantastic resource. I will definitely be back!
Thank you!
Sarah
Hi Sarah
Thanks so much for your kind comments. I’ve sent you the password for the OT only area, there’s not a lot in it but I do occasionally get the urge to rant!
kind regards
Bronnie
great post! This reminds me of the studies done on Meditation and the brain. The more wellbeing we offer ourselves, the more our happiness and contentment remain. Seligman has some great research out there and hopefully the new research coming out of Denmark with help perpetuate further support of what he is trying to do.
It’s time we start to measure how to make people happy and what happiness is as opposed to how many people need or should be on medication.
-Brian
Love!
Great post – I’ve just been discussing fear of movement with a patient who is quite phobic about doing anything that might aggravate her chronic low back pain.
Hai.. I’m a former OT from Indonesia (no longer practicing) but I’m interested in studying OT further – i’m interested ini analysis activity and OT role in obstetric and gynecology cases
i’ll visit your blog more offten after this and recommend this blog to my OT friends
Welcome to the blog! It’s great to see people from around the world getting interested and involved in helping people with pain.
Thank you for the information. It will be helpful and I will put it to use. It is always better to get information that is accurate. Thank you
Please excuse me, i need to rant a bit as i am in the middle of some really bad s)(*.
I am not in pain, my mother is. She has metastatic lung cancer and for no apparent reason at her back started hurting.
One day, two weeks after it started, she almost faints, we go to er. OTW there she takes 2 ibuprofen. We get into a room where i cannot get any attention from anyone, its an er so this happens, so i fetch her purse out and she takes two more ibu.
When it is finally time to see the dr, he says that she likely almost fainted from pain. He speaks of constipation but does not ask about it nor really let us speak. My mother was constipated, not from pain pills unless ibuprofen does it, because she cannot comfortably sit on a toilet to evacuate her bowels. The dr does not ask about the bottle of ibu sitting conspicuously on the tray, left it there for them to see. He asked her pain level when she almost passed out, she says 8, this is one tough lady tht is a ten to most. He asks her pain now, she says 4, this is with 800 mg of ibu but he does not ask about that.
The doctor says to my mother, do u need pain pills. My mother is over seventy and has been told all of her life taking pain pills is a bad thing, she hasnt taken one since the 1960s, she has suffered thru broken bones with just an asprine, crazy if u ask me. This time, i pipe up, yes she does need pain pill, man she really does, cant u see she just almost passed out from pain? I tell the doctor that she thinks taking pain pills is a bad thing. The doctor does not correct this misconception in her, he agrees she does not need pain pills but gives a prescription for 12 tramadol.
My mother agrees with me to take the tramadol, still not enough relief to sit on the toilet comfortably but she can now cough without yelling out.
I get her to the ocologist two days later and i explain to them she cannot sit on a toilet and she cant seem to shit standing up, u need to help her understand pain pills are fine when u need them. He did. He gave her some vicodin and i was finally able to help my mother with that other little problem while we wait to see her regular dr. Now the ct scan and the bone scan apparently didnt show what was wrong with her back, this is falling into the realm of the regular dr…not a particularly good one.
The regular doctor when we see her immediately starts harping about the vicodin like we need to run, not walk, my mother straight to detox. She states at my mother age, she should be going to a Pain clinic, i thought these were for chronic pain! I was alarmed more than a bit, i asked her if we should not worry more about the source of the pain. She does do a fair evaluation but never once asks about the pain….my mother is sitting in her evaluation room dizzy from pain and she is insisting it is the vicodin despite my mother not having taken any that day until just b4 the dr came. this dr has some major issues about narcotics for sure. She states that she heard all about our er visit from dr miller, who also failed to ask enough questions…. i am guessing we are pegged as drug seekers. My mom has been going to this hack for 16 years, she was aware that dr was not much good but was not sick enough to care, of course the dr never did catch her cancer that was another er visit. This dr only prescribes lidocain patches…
I called reg dr back…patches are 300 dollars, she says then wait for the pain clinic, a week from now. I pay the 300, they bring her pain from omg i am sick to my stomach to omg this hurt a lot and they can only be worn 12 hr a day. 300 for that? I call her back again, i explain that she is in a ton of pain and the patches are only for part of the day…her response is pretty much so sad get used to it.
I have been a slave to my mothers pain for over a week, she cant even stand without help. If i go to an er or even back to the oncologist then i am dr shopping for pain pills. It has been most painful to me to give up totally my life because doctors seem to be too reluctant to admit that some people really do need pain pills. I am really looking forward to the pain clinic where i expect my mother to be put on some proper pain medications while we wait for a proper diagnosis of whatever this is. I have an appointment with a new doctor two days after the pain clinic, her current dr isnt to be tolerated, cant be dr shopping after the pain clinic…i just want someone interested in how she feels. Maybe the first words in the exam room wont be u dont need pain pills but how are u…..what a wonderful difference that would make.
Please listen when someone says they are in pain. i am sorry u get all kinds of jerks who want to get high but ask the right questions dont assume. I feel the dr in the emergency room has a bit of an excuse but not a particularly good one.
Very good info. Lucky me I found your blog by chance (stumbleupon). I have bookmarked it for later!
This post is a beautiful share. Thank you for your sensitive insight, Bronnie. Mirrored images or echoes of my own experiences swim within it. It brings to mind the meaning of “anecdotal evidence” and how it is discounted by so many that misconstrue the true meaning of scientific inquiry. Anecdotal evidence=clinical experience–>inform the path of scientific inquiry. Keep up the great work and world expanding posts:)
BJ Erkan, LMP
Wonderful post!
As a very long-time meditator, I would just stress that, while the instructions for mindfulness practice are simple, and can stated fully in a couple of minutes, the number of ways to screw it up are infinite, and a lot of back-and-forth is almost always needed to make sure someone really gets it.
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I totally agree Dale, it’s easy to describe but very difficult to do. That’s why I think it’s so important to practice it yourself.
Thanks so much. Yes, the back and forth of observation to research to practice to more observation and again is what makes for a living research programme. Now that I’m moving into an active research phase of my working career, I hope I can maintain that grounding in the real world.
Sounds like you’ve been having such a difficult time! I’m not a doctor, and I don’t prescribe, so it’s my job to really listen. At the same time it’s even more important for doctors to listen because that’s the only way to find out about a person’s pain. I hope you are able to find a way to get support for both your mother and yourself.
It’s really awesome to read this post about pain management Calgary it gives me lots of information. Keep it up!
I read this opinion piece with interest. As a practicing Rheumatologist I must share with you my feeling that this piece is simplistic and misleading. FM is NOT established as a central nervous system disorder! In fact, there is a large body of scientific information showing that FM patients have a significant peripheral component to their disorder. They do have, of course, central amplification of their pain JUST AS EVERY OTHER CHRONIC PAIN CONDITION HAS.
Please don’t mistake this short sighted opinion /fluff for science, or even scientific opinion. FM patient’s benefit most from treatment of their PERIPHERAL disorder. That is , their musculoskeletal problem!
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Hi Scribedoc,
Thanks for your thoughts on Fibromyalgia. I’ve heard it said that FM has a significant peripheral component to their disorder before, and like you’ve indicated, there is a body of scientific information suggesting that management of this aspect of FM pain is helpful. I couldn’t find support, however, from guidelines on the management of fibromyalgia. This from Hauser, Thieme & Turk (2010) “Both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, EULAR assigned the highest level of recommendation to a set of to pharmacological treatment. Although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels.”
None of these guidelines supported treatment of peripheral aspects of the disorder – and as someone who has FM, I’d find it a challenge to have every area of pain injected or infused, given that the pain so often travels from one part of my body to another. Can I respectfully suggest that fibromyalgia may well have aspects of peripheral nociception, and these should be managed effectively, but at some point it may be far more useful to focus on central mechanisms and treatment processes that encourage acceptance and graduated activity. The profession that delivers this set of interventions doesn’t matter nearly as much as the empathy and commitment to helping a person with FM live as rich and full a life as possible. I’d argue that any medical professional can do this, but it’s more likely to happen with a nonmedical clinician.
I was pleased to come across this (a bit late!), as I’ve just written a post on the topic. Thank you for covering the research base. I’d agree a problem is the confusing terminology, and a second problem for me is when professionals assume if it doesn’t work well for a person it must be the fault of the person. I don’t think any one strategy works for all. You make a good point that there is no evidence for it’s effectiveness on it’s own, and I confess I didn’t realise that. I have only worked ith the strategy as part of a programme. I’m interested in it geng called a passive coping skill – I’d argue that pacing (as I use it!) takes the initiative; by working out a level of activity they can do on a ‘ggod’ or’bad’ day and then sticking to it, it puts a person back in control of their activities. That has certainly been the response of some (not all) clients in previous programmes I’ve worked in. And absolutely agree that pacing shouldn’t become a ‘do always’ strategy – I mention in my post a lady who chose to not pace herself when she spent aday weith her grandkids – it was more important to her to really enter into being and playing with them than sticking to a rigid routine. Great site, I’m off to have a look around!
I seem to remember this being described years ago in terms of pleasurable/rewarding activities ‘closing the pain gate’ so that the pain signals ‘couldn’t get through’. Excellent news that the research is continuing as our understanding develops. Especially interesting, now that positive psychologist are researching the different aspects of happiness (eg Seligman), might be studying whether it makes a difference if the engaging activities are, say, simply pleasurable, or those giving a sense of accomplishment, or engaging of our interest, or having meaning for us or offering connection with others (to use Seligman’s model). Or the influence of strengths on pain perception…
Hello
I’m in Dorset, inthe UK and I’m an occupational therapist who used to work in mental health and then in a condition management programme (people with ongoing conditions wishing to return to work). I work now as a health and well-being coach (privately) including with people who have received all available treatments and want to get on with their lives, with or without continuing symptoms. As a coach (trained in cognitive behavioural coaching) I don’t offer ‘treatment’ for any condition but I do my best to stay on top of research in a range of areas that are relevant to my clients. I work from a background of CBT, occupational therapy,behaviour change theory and motivational interviewing, solution focused approaches and positive psychology. Thanks for a great site.
Thanks so much Sally! I love the connections I make with people around the world and especially occupational therapists who have found the passion for pain management. We can offer the people we work with so much, and those people deserve more than they usually get from a medical/cure-oriented health system. Sounds like we have some common themes in terms of the approach we take with people, and I really hope I can offer you things that might be useful to you
Good points – I think positive psychology has started to uncover things that many people have thought about, but not been able to demonstrate. I hope that we can build on this to help people with pain live better, more fulfilled lives. The pain gate has been superceded by the neuromatrix – which really invokes the whole central nervous system rather than just the spinal cord – as well as endocrine and other systems that are triggered by the neuromatrix in response to the brain’s detection of some sort of threat. Great stuff for clinicians using nonpharmacological approaches to managing pain, because it gives great scope to developing strategies that can be effective, with fewer side effects than drugs.
Glad to be of help! I too was surprised about the lack of evidence base for this strategy. And strangely enough, when I talk with people who are viewed as living “well” (my PhD topic), they don’t use it either! I have to say I do use it personally (to a certain extent), so it would be great to develop an evidence base that can determine when and how it is effective. I think the reason it falls into the passive end of the coping spectrum is that people may use it as a way to avoid “overdoing” when in fact they may “underdo” at the best of times! After all, 80% of nothing is nothing! And 80% is what many clinicians use as their baseline. I guess the way I define it now is calling it “activity management” and talking about establishing a consistent amount of activity that can be sustained even on a bad day, and forming a baseline from which progressive increases in activity can be developed.
You already have!
As someone with ‘love of learning’ and curiosity’ as two of her signature strengths (Peterson), I couldn’t be happier with your helpful response. Lots for me to go study and learn!
Thanks for breaking this study down for us, Bronnie.
A little anecdote re. fear. In January, I dislocated my hip (I’ve since found out that I need a revision). Anyway, I’m my own “lab”, so it was interesting to note my thoughts when I first went back into the swimming pool.
“What if I dislocate my hip, here?” (a frisson of fear) … “Well, you’re an excellent swimmer, so you’d be able to stay calm, plus it’s highly unlikely that it would happen here..” (recognizing and reasoning) … “But, what would the lifeguards do?” … “You’d tell them what you’d need….and how to proceed.” (having some control – since a dislocated hip hurts like h***, and it’s highly unlikely they would have seen one of those situations. I know in my life-guarding days, we never trained for that!)
Getting people to think about how best to live/move/work/play, then providing some strategies to augment their re-introduction/integration into the world of movement. Priceless!
Reblogged this on ripenedpear3 and commented:
This is exactly the type of article I have been trying to find!
Hi Bronwyn
My name is David Robertson and Linda Robertson (unrelated, other than I was her student:-) referred me to your blog. I’m an OT educator living and working in Scotland. I read your biog and I also qualified in 1984, completed an MSc in Ergonomics and I’m currently working on a PhD. I’ve been in contact with Linda as I’m interested in thinking and reasoning, and the experience of new graduates and she has kindly assisted me with a couple of queries. I’ve spent the evening looking at your blog and I’m very impressed. I’d like to refer my students to it next academic year, if that would be okay.
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Hi Bronnie,
My name is Nicolás Sepúlveda, I’m a chilean PT, living in Santiago, Chile. I notice your blog thanks to Neuroscience and Pain Science for Manual Therapists facebook group and the Soma Simple floks. I have 4 years as a professional and now I’m starting to specialize in chronic pain and I’m very much interested in cognitive behavioral therapy, so if you could suggest me a book (or a couple) with really basic and practical foundations to understand and apply CBT that would be great, because although your blog and others have lots of information, sometimes I get a bit lost in that ocean of files, sheets, posts, comments, websites, blogs, facebook groups and so on. By the way I think your work it’s great, really patient-centered and not disease/syndrome-centered, without egos, with an open mind and evidence-based approach, keep the good work!
Great stuff! I’ll translate your handout intto spanish to use it with my patients.
Woops, I just realised that my URL is wrong. it is rehabhub.com.au.
Thanks so much for your kind words, I’m glad I can help you!
I knew abut GET.gg site offering lot’s of good worksheet’s but can always use more… thanks for the effort and links
boaz
Well said, Bronnie – thanks for your relentless passion and enthusiasm for occupational therapy in the 21st century!! Your blog is an inspiration.
Thanks so much Dene! I’m not entirely supportive of the profession – time to get our gloves off and ask some hard questions about how much the profession really wants to be taken seriously. All I know is, what I heard at NOI 2012 was much of what I learned to do waaaaay back in the early 1980′s as an undergraduate occupational therapy student. It’s like a novelty to other professions, and THEY WANT IT! Let’s make sure we lead.
Yes, thank you Bronnie.
It was a tad scary that there was no mention of OT input in the NOIgroup workshop I attended… or for that matter are there any OTs as part of the NOIgroup team? I just can’t believe how any profession could beat us to this sort of quality biopsychosocial research! Should be a wake-up call for OT world I think!
It’s great to know there are OTs out there like you. Really gives me hope for the future of our profession – there are plenty of inspiring OTs out there, maybe they just need inspiration? A push in the right direction.
Bronnie If we can’t question our own profession’s direction… Who will?
Thanks so much for your kind words – if the profession has people like you coming up through the ranks, it will be moving in the right direction too! I don’t believe there are any occupational therapists in the NOI team, partly because it is so physiotherapy focused. And it does strike me as sad that physiotherapists want to learn all this biopsychosocial stuff as if they have to do it all themselves. I thoroughly support all clinicians becoming aware of, and skilled in, the biopsychosocial model – but at the same time, it’s good to know that there are others who specialize in working this way, and translating clinic-based treatments into what a person with pain needs to do in his or her own world. I see this era as an opportunity for people with pain to get the help they need to live well, and think its now a case of occupational therapy to step up and show leadership. As a profession, we are inclined to whine from the sidelines about how other people are taking our role so now it’s time to consider novel research paradigms and make Gordon the promise of our philosophical roots.
**steps off soapbox so someone else can take over for a minute**
HI Bronnie
I think there is actually an OT attached to the NOI group, Laura von Bertouch, doing her PhD in pain research at the moment. although she didnt seem to be at the conference.
I came away from the NOI conference with conflicting thoughts. Initially I had been soooo frustrated re lack of awareness of OT contribution to pain manamgement and what we have to offer. Mind you, I have thought that for the last 25 years. But in the end I thought that maybe if it is all part of other health professions moving towards a direction that we have always embraced, then maybe we should all be merging to become functional therapists, as certainly the brain science is informing us that the traditional hands on physio approach won’t work.
And now after a few days reflection I am thinking that OT clincians in pain managment need to be talking more to researchers and educators to get some joint research projects going. Bronnie I like your question about what are the interesting hypotheses in occupational therapy that need to be explored? I think we could start with the basics, like whether the areas traditionally explored by OT’s in clinical practise in pain management make a difference. Does pacing really make a difference? Do graded actvity programs work? Does home based education differ from office based? Maybe we need to do some trans Tasman research.
Just some ideas. By the way, great to meet you and some really great OT’s at NOI conference, even if we were in a minority.
Brilliant! The infiltration begins…
It is a good book! Covers all the bases in an easily understood (for clinicians) manner. Not sure whether some of my patients would find it as easy to read, but it certainly gives the therapists the tools to educate the patients on why we would use GMI. I recommend reading explain pain or something similar prior to this book to give you a good grounding in general pain knowledge.
I give it 4 out of 5 neurotags.
Liked your review Bronnie. I have just read both the GMI book and a paper from the european Journal of Pain 16 2012 looking at an audit into the use of GMI in 2 pain management units in the UK. They did not find an improvement in pain but reading between the lines it is likely that the patient population had myriad psychosocial issues as do most patients who are seen in interdisciplinary pain units. In my experience its hard to focus on GMI when someones relationship is breaking down, they have no money etc.! I agree that it needs to be used thoughtfully. You dont want to try it with someone at the wrong time and be unsuccessful, because it may work at another time for them and you dont want to create negative expectations. I also agree that it is not for inexperienced therapists. Mick Thacker said something at the NOI conference that I felt was very true, namely that we need to give patients ‘the tip of the iceberg’ pain education but that needs to be supported by our own pain knowledg which is the rest of the iceberg. Books like Explain Pain or manage your Pain are the iceberg tip. If we are serious about pain our knowledge needs to go much deeper than this. Pain is complicated and books written to share with patients must necessarily simplify things.
Ruth Hardman
Nice summary of my own feelings, Ruth! I guess that’s what I mean about not “over-interpreting” the evidence base. For every person we work with, we need to consider the relevant factors to their presentation – why has this person presented in this way at this time? Develop a formulation, and work from that, rather than applying anything carte blanche.
[...] real time and companies don’t pay us to “think about” taking action, so what’s the point in mindless wandering? While converting a “woulda” into an “I didn’t” does sorta pinch the skin, it really [...]
Actually, getting a tv show to include an OT in its cast of characters. What would Private Practice be like if there were a social worker, an OT, a PT a nurse midwife etc. in its cast? And who do we know who knows someone who knows someone who … knows a writer for one of the shows we’d like to include us?
Publishing? What about an article about an OT as a parent or a strong female role model or someone who has created a new program being chosen?
or Who would like to write a children’s series set on an island where a kid is the main character but there’s an OT who saves her life and teaches her important strategies?
Where is there room to portray any of us that gets the word out to the people who will insist that they get to see us? How can we educate others and influence from the ground up?
Where are there places in the telecast of the Olympics this summer that would highlight the work of the OTs who are likely in major places of renewal and rehabilitation for some of the world’s finest athletes?
We have lots of power; it just is hard to use when everyone works so hard every day at their jobs. But some of this could be fun and not hard, social – as in the who do you know game!
Wouldn’t that be awesome? I think it’s going to happen over time, but as a profession, occupational therapy has to be more confident in how it presents itself, and be more public in where it publishes. Allied health professions suffer from a profile problem, not an identity problem – and profile is about saying, publishing, quantifying and demonstrating what we do.
I cam accross this on an ‘inspirational quotes’ website: “If you don’t pay appropriate attention to what has your attention, it will take more of your attention than it deserves.” (David Allen) I have to confess I don’t know who David Allen is – but it made me think does this some up a lot of pain management (the key bit here being ‘appropriate’ attention).
Great quote! I like it – though the only David Allen I know is Dave Allen the comedian, but he could be Dave Allan!
Yes, absolutely. I remember a lady I worked with on a condition management programme where we used just this approach, and of course although you don’t mention it here you know as well as I do (better then me!) how difficult emotions and depression can also go with chronic pain, and so these needed attention also. It was a new experience for her to have professionals focus not on the condition but on the rest of her life, and she wasn’t at all sure to start with. Several weeks in she said “I’ve learned I can do things if I approach them differently”, and by the end she was walking up a flight of stairs to meet me, having previously used the lift, and working part time.
It’s so true isn’t it – our job is mainly about giving people an opportunity to try something out, and then to support their confidence while they do so. And isn’t it a privilege?!
Absolutely! And thanks for the follow.
Hey, I noticed you contributed to the “save yourself website” Do you know any good people in Wellington, NZ, for Myofacial Pain Syndrome treatment?
It depends a little – mainly whether your diagnosis has been confirmed, what outcome you’re looking for (pain reduction or pain management), and whether you’re wanting private or public treatment. Two pain management centres exist in Wellington: Hutt Hospital Pain Service and Wellington Pain Clinic. Both are public, but I’m not sure of the referral and acceptance criteria, but both provide medical management as well as self management.
I don’t know any private clinics in Wellington, nor individual practitioners, but you can always begin with these two.
I’m happy to see that this blog has continued to be monitored by the author and responses are still forthcoming.
I began my research on extreme pain and pain rebound a few days ago in response to MRI findings of a knee injury I received a few weeks prior. I just knew in my heart that I’d torn something very badly when the injury occurred but as of the MRI findings, that wasn’t the case at all. At the time of injury, I was merely squatting and shifted a bit of weight to my right side. Suddenly, a very loud pop followed by a ripping, burning feeling shot up and down the lateral side of my leg from the center of the knee. The pain was so extreme that as I was trying to stand and straighten, I began to feel faint and my spouse had to grab me to keep me from chewing grass. I did the usual thing I do when I’ve injured myself and immediately applied ice, got it elevated and waited for the pain to subside. I experienced immediate swelling over and around the patella, I was unable to bend my knee more than approximately 10 degrees and unable to bare weight at all. My spouse took me to the ER where they did the usual X-ray, placed me in a knee immobilizer and on crutches and told me to follow up with ortho within 3 days.
Sorry it’s a bit long of a history but pertinent to my question.
Ok so I did the follow up with ortho PA, MRI, different knee brace etc. MRI findings within acceptable limits minus age related arthritis. So I asked the doc, what caused the extreme pain though I hadn’t actually torn anything and he gave me a generic answer. These by the way do not satisfy me as I have a personal need to keep track of what’s happening with my body. His response was, these things happen and they take time to heal. So then I asked him to check my MRI that I’d had done on my cervical spine the same day as a post op follow up and again the findings are normal. The spinal stenosis has reverted and the hardware from my c5-c7 fusion are intact and doing what they were designed to do. Now I know something is not right in the land of health where my body is concerned.
I’d had my surgery for the fusion (accident related) in December the previous year and still experience extreme pain and numbness of the shoulder, neck, and upper left arm. I’m on 10 mg of oxycodone every 4-6 hours and have been since the original date of injury just a bit over a year ago. Yes, I know these medications are highly addictive and I have asked several times to be sent to the pain clinic so that I could come off these meds. I had to ask to go to physical therapy, it took them 2 months to get me in and then they supplied me with a list of passive exercises, a tens unit and a heating pad and that was that. I do use all of the items given on a regular basis but the relief has been minimal and doesn’t last long.
Pain is increased with activity and inactivity so I have to find a balance daily and let my body determine what it can and can’t do with every project I take on.
So my question to the ortho PA was, why, if my MRI results are within normal and acceptable ranges am I experiencing extreme pain. We discussed pain rebound to narcotics. It he really didn’t want to take the time to explain it or didn’t know enough about it to share with me. Being the dutiful student I am, I took the time to do some basic research on my own. I understand that given the amount of time I’ve been taking these meds, I certainly could be falling into this category. However, with all things involving health, nothing is cut and dry and my behaviors don’t seem to fit the “classic” pain med rebound symptoms. However, it could be said that I generally tend not to follow the “rule of thumb” as even after my appendix burst over 20 years ago, my white cell blood count remained normal before and after the surgery.
So my question is, how do I determine for myself if it is indeed pain med rebound that I’m experiencing and that my body is ” over reacting” to what wouldn’t normally be so extreme. Also, just need to add that until this injury to my cervical spine, I had an exceptionally high pain tolerance.
I wanted to add something but was pulled away to other responsibilities at the time.
There are I’m sure many patients who are placed on pain meds immediately and left on them for long periods of time because of either time constraints within the examiners office or just plain ease of access and pain control. Under these circumstances, is it any wonder we are conditioned to seek immediate relief from pain without putting in the effort required to get there on our own.
I agree with you in that there is no way to measure pain in another, even taking into account all the variables that might effect that persons perception of the pain, as the examiner will always bring with them their own perceptions and biases. As for the FCE, well, in my honest opinion that’s just a joke. It doesn’t take into account the many different ways a person can compensate for lack of any particular ability and they can ruin a person’s life goals just as fast as they can inaccurately award a malingerer for false injuries.