There are some days I despair that the biopsychosocial model will EVER take hold in the died-in-the-wool medical interventionist strongholds.

This quote from a discussion with a colleague might help you join in my pity party…The conversation is about a case of a young woman with 18 month history of neck pain post-MVA, she has been to pain management and ‘while this has helped her understand and manage her pain better, the pain persists to the point that she is becoming increasingly frustrated, with deterioration in her work, personal and social environment.’

In my discussion with my colleague, he stated that ‘…the reasons that the patient is frustrated is that she still has pain.  Take that away (if it is possible) and the other problems go too.’ He went on to say ‘I am not trying to eliminate psychsocial factors.  They are important but it is the pain that is the underlying problem.  If it can be removed then it should be.  If not then the psychosocial issues are the only thing that can be addressed.’

His basic assumption is that the only contribution psychosocial factors have in this person’s situation are in response to her having ongoing pain. I’d be the first person to agree that having pain is incredibly stressful, and that most people will respond with frustration and eventual demoralisation.  And reducing or removing pain will almost certainly result in an improvement in mood and a reduction in distress and frustration.

Where do I start in responding to my colleague?

The whole experience of pain is psychological: until we attend to the stimulus, then interpret it as threatening, it is meaningless.  The nervous system doesn’t sit around waiting for a stimulus to reach it before reacting to it – instead, the nervous system is actively seeking out, sorting through, prioritising and selecting which stimuli it will integrate and respond to.  Remember the nervous system includes the brain, with all the social, cultural and learned experiences the person has had – and the predictions that brain within the person can make, and the meaning of what-is-happening-now to the person.

Some of our responses are ‘automatic’, much pain behaviour is based on reflex action designed to protect us, but over which we develop voluntary control.  By ‘automatic’ I mean – we don’t think about it any more, it’s habitual, probably done since we were babies.

So, our nervous system is ready and waiting and our experience of having pain is entirely about our interpretation of it – psychosocial factors are integral to having pain.  So to suggest that ‘psychosocial issues are the only thing that can be addressed’ - and only after pain cannot be relieved makes me feel he doesn’t understand that the pain experience in total is psychological.

Back to the relationship between pain and disability. Why do we work so hard to help people with pain?  It’s because having pain can be distressing, and can influence function (but not always).  Unless I’m mistaken in my reading of the literature around pain and disability, the relationship between having pain and being disabled by it (and being distressed, frustrated, seeking treatment for it, needing help for it) is not as simple and straightforward as 1 + 1 = 2.

Let’s take a look at some of the studies that show this.

1. A study in primary care, with patients with an average of 10 days low back pain looked at the relationship between pain intensity, disability as measured on the Roland Morris Questionnaire, and Quality of Life.  On day one, simple correlation was r = 0.347 between VAS and RMQ; on day 15, simple correlation was r = 0.570 between VAS and RMQ.  VAS score explains 12% of the RMQ on Day One, while on Day 15, the VAS score explains 33% of the RMQ score.  The authors conclude:  ‘Clinically relevant improvements in pain may lead to almost unnoticeable changes in disability and quality of life. Therefore, these variables should be assessed separately when evaluating the effect of any form of treatment for low back pain.’  (Kovacs, Abraira,  Zamora, et al., 2004).
2. A longitudinal cohort study with 6-month follow-up of 218 patients with chronic neck pain, given usual treatment by physiotherapists. A range of measures were taken of pain, disability, satisfaction with treatment, and impairment. No strong correlations were found among disability, patient satisfaction, pain, and physical impairments although the correlations tended to increase in the follow-up assessments. Moderate correlation was found between disability and pain (r range, .55–.63); a fair relationship was found between pain and patient satisfaction (r range, .43–.48), but only weak relationships were found between physical impairments and pain (r range, −.08 to −.25). The authors conclude:The findings support the suggestion that clinicians should address as many relevant aspects of a presenting clinical entity as possible in the management of chronic neck pain. (Chiu, Lam & Hedley, 2005).
3. Just in case, here is one final paper that, although published in 2002, summarises the state of play in terms of psychosocial factors and low back pain. Written by Pincus, Vlaeyen, Kendall et al (2002), it ‘aims to outline evidence-based theories that have lead to the identification of yellow flags (psychosocial risk factors for developing long-term disability) for nonspecific LBP’. Just a snippet or two from this might help to put some of this information into perspective, particularly around the belief that psychosocial factors don’t really need to be dealt with ‘if the pain can be removed’.

‘At least three stages can be identified in which psychosocial factors have the potential to influence low back problems.The first is during the preonset period (before symptomatic back pain develops), the second is at the time of seeking help (health care, support, and/or compensation), and the third is during the development of chronicity. This final stage is more thoroughly researched and understood than the former two.’ (my highlights)

‘It is necessary to differentiate between factors that lead to the onset of back pain, and those that lead to reporting and seeking health-care and other forms of support.’ These authors note studies in which it has been found that people who are already distressed are more likely to seek help/treatment than those who are not distressed, and these people are more likely to go on to experience chronic disability from their pain. ‘The point at which an individual seeks help is mediated by a complex mixture of medical, work-related beliefs and behavior, and a variety of psychosocial factors.’ These factors haven’t been studied well, neither have the factors that lead a person to NOT persist with seeking help.

A study based in primary care in Israel included not only the patients’ perceptions of worry, coping, limitations, expectation of pain relief, and pain interference, but also those of their clinicians. This information independently and in combination with each other were found to predict outcome up to 12 months later. … the focus on long-term and stable characteristics of patients as risk factors (such as premorbidity, high levels of depression, and catastrophizing) might overlook important and immediate predictors, such as patients [and clinicians - my insertion] perceptions and expectations.

Before we can suggest that a certain treatment to abolish pain ‘works’, particularly to reduce disability, we need to have a good, hard look at the type of patient who seeks treatment – and the type of clinicians who provide it. Several studies were provided to me to support the use of interventions for facet joint pain (see below). Although the methodology is sound, we can’t generalise from the findings in these studies to all people experiencing neck or back pain. Quite apart from the duration of pain, we need to know much more about whether these patients ‘look like’ the people we see in daily practice.

I admit I see more complex patients with more disability than someone working in an acute or sub-acute clinic, but unless my colleague and others like him ensure their patients ‘look like’ the ones in the studies they’re referring to (which means they would have to take some sort of measures to assess the risk factors), I’m not sure their patients are that different. After all, there is a complex interplay between the patient, the referrer, the clinicians, and even the funder and employer and community, that all influence who looks for treatment and who doesn’t.

I know I’m beating my head against a wall to try change a dogmatic viewpoint  – and yet I have read the literature and just don’t think the picture is quite that simple. And maybe the years I’ve worked in the biopsychosocial model, researching the psychosocial factors involved in pain and disability mean I have a more complex and perhaps sophisticated understanding of the relationship between these factors.  Is it worth my while trying to provide evidence to clinicians who have a much simpler but perhaps less accurate view of the world? I wonder what others think?

Chiu TT, Lam T-H, Hedley AJ. (2005). Correlation among physical impairments, pain, disability, and patient satisfaction in patients with chronic neck pain. Archives of Physical Medicine & Rehabilitation, 86(3), 534-540.

Kovacs, Abraira, Zamora, Gil del Real,  Llobera, Fernandez,; the Kovacs-Atencion Primaria Group. (2004).
Correlation between pain, disability, and quality of life in patients with common low back pain. Spine. 29(2):206-210.

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850
Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital nerve headache: a prevalence study. J Neurol Neurosurg Psychiatry 1994;57:1187-1190.

Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20:20-26.

Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21:1737-1745.

I am on the search for a way to retrain my brain to cross my legs every-time I am sitting in my chair. I only cross my right leg over my left. This constant position is definitely not helping me with my posture. Almost half (45 percent) of American women cross their legs most or nearly all the time. I am looking at the 4 ways to commit to changing a habit. I find this article interesting and I have made the decision to make a change for the best. Wish me luck!! I caught myself today at least 15 times crossing my legs.

As for my Egoscue e-cises. I am finding some great shaking going on while I do the Static Wall w/ Splits. The more I relax my upper body and pull by feet back at me the more I watch my legs shake. After 1 minute I get up and it just feels like I ran a 1/2 Marathon all over my legs feel wobbly. My legs continue to shake as I go right into Supine Foot Circles and Point Flex.

I am excited to see how my body has changed at my follow up. Posture! Posture!

Narconon of Georgia warns parents to safeguard their medication and properly dispose of it when it is no longer needed or wanted.

Every day 2500 youngsters age 12 to 17 try a painkiller for the first time and prescription drugs are more abused by teens than any illicit street drug, except for marijuana.  This is according to the 2006 National Survey on Drug Use and Health conducted by the U.S. Substance Abuse and Mental Health Services Administration.

Operation Medicine Cabinet, a campaign sponsored by Narconon of Georgia and a local Sheriff’s department, provides individuals with a safe way to properly dispose of unused and potentially dangerous medication.  Proper control and disposal of potentially dangerous medication is vital, due to the trend of prescription drug abuse with youth.

Kids think that taking prescription drugs and over the counter medication for their next high is safer than street drugs and they are easy to get according to a survey done by The National Center on Addiction and Substance Abuse (CASA).  This recent survey found that one in five teens can get prescription drugs within an hour and the most common source is their own home or friends.

This same survey found that two thirds of kids report that drugs are either used, kept or sold at their school.

These “friends” or classmates providing the drugs are not likely to report the truth about abusing prescription drugs.  That truth is that abuse can lead to paranoia, addiction, seizures or even death.

Let’s help by getting the Xanax, Oxycontin, Adderall and over the counter medications locked up or thrown away properly when it is not being used correctly.

If the medicine cabinet has been open too long, and someone has already become addicted, then get them into drug treatment.

Narconon drug rehab 877-413-3073

Doc,

Grant me the Xanax to accept the things I cannot change

The Adderall to change the things I can

And the Paxil to know the difference

Standing Tricep Stretch ~

1. Stand with your feet pointing straight ahead and hip-width apart
2. Bring one arm straight overhead and bend your elbow so that the palm of your hand is touching the shoulder blade of the same arm, not your neck
3. Place the other hand on the raised elbow
4. Apply gentle backward pressure to the elbow to stretch the triceps muscle of the bent arm
* Relax your stomach
* Don’t let the bent elbow drift towards the other shoulder once it’s over your head
5. Hold 1 minute
6. Switch sides and repeat

Note: You might feel a slight stretch in the tricep or the left side of your body as you pull the left arm up overhead

Justin – Egoscue San Diego : E-cise of the Week Standing Tricep Stretch

At least, not in the Army.  They might just take you up on your offer.

Joe (do I really have to tell you that this isn’t even close to the guy’s real name?) had problems with his left leg after 2 deployments to Iraq and multiple exposures to high-velocity trauma.  Lots of problems, shall we say.  The leg often doesn’t work much at all.  Sometimes, this overwhelming feeling of burning pain spreads from his mid shin up to his knee and then pulses up into his thigh for hours.

But what’s debilitating leg pain got to do with being in the Army?  At least, that’s how Joe sees it.  Unlike most soldiers in the WTU, Joe is determined to stay in the military.  He wants to be sent “down range” (deployed) again.  Tomorrow, if possible.  He loves his unit and enjoys the excitement of his job. 

Joe does not understand that a soldier who can’t walk probably isn’t going to do well in a war zone.

Actually, Joe is quite smart.  He understands perfectly well that a debilitated soldier can’t perform a required in a combat situation.  But he doesn’t care.  He loves the Army.  Lives for the Army.  So he has worked with a lawyer for over a year now to keep himself in the Army.  The WTU doc before me has worked to this end – admittedly with some bemusement – for the past few months as well.

Recently, Joe met with a special review board comprised of high-ranking commanders.  They evaluated his chart, looked over the reports of his injuries, and then interviewed him personally.  I think this occurred at Walter Reed Hospital, in Washington D.C. in – the Mecca of Army Medicine.  As you might imagine, this was a big deal.

I don’t know the exact specifics of that interview, but here’s my reenactment:

“Soldier, you’ve served your country well.  We thank you for your sacrifice and heroism.  After thorough review of your file, we have determined that you are no longer qualified for active duty and will therefore be separated from the military with full medical coverage and benefits.  You will be given an honorable discharge and should have no problems entering civilian life.”

“Sir, it’s the leg, right?  That’s the problem?” Says Joe.

“Correct, Sargent.”

“What if the leg wasn’t a problem?  What then, sir?”

“Why, you’d stay in the military, Son!  Send you down range week after next.  Get you back in the fiiigght, boy!”

“Then cut it off!  Just cut the damn thing off!  I can run on a prosthetic.  There’s less to clean up if I get crosswise of an IED (roadside bomb) again, right?  Just send me down there with a couple of extra legs in my pack and I’m all good.”

This – honest to God – is a relatively faithful reenactment of this soldier’s conversation with his Army superiors.  Admiring his courage and commitment, I was more surprised to find that, following this meeting, our doctors in the WTU received this order from on high:

****de, de, d, d, deeeee —Official communication from High Command:  SGT Joe to be referred to surgery for evaluation of chronic leg dysfunction and pain.  Consider surgical correction.  Amputation a viable option.——-de, d, d, deeee,

***** Stop.

Complex Pain – Transcript from Catalyst aired on ABC TV 09/07/2009

This report is about Complex Regional Pain Syndrome and includes some interesting information about the brain’s role in chronic pain. Important distinctions are made between acute and chronic pain and we get a picture of how chronic pain affects people’s life day to day and longer term. The concept of neuro-plasticity is an interesting one, and I’m sure plays a part in fibromyalgia pain too. It will be interesting to see how understanding about this impacts upon treatment for chronic pain syndromes. The transcript can be found on the ABC website at  http://www.abc.net.au/catalyst/stories/2621515.htm

Prescription Drugs Major Source of Healthcare Waste.

The marketing efforts of pharmaceutical companies, with a new pill or drug as the new answer to every life problem, has become one of the most expensive and devastating health care issue ever to face the country.

“While many drugs are needed to help people with health issues,” comments Mary Rieser, Executive Director for the Atlanta Recovery Center, “many drugs are simply re-packaged, re-named, and released to ‘address’ some other health issue. This marketing practice, while making billions for the drug companies, has severely impacted the health and well being of millions who are not educated on the dangers of abusing prescription drugs.”

An estimated 5.2 million people admit to using prescription medication for purposes other than prescribed during the previous month, according to the National Survey on Drug Use and Health.  The largest part of that number used painkillers for reasons other than to kill pain.

For example, narcotic painkillers are derived from opium.  They can be made directly from the plant such as in the case of morphine or codeine, or they can be synthetically created in a lab, as with oxycodone or hydrocodone. They are all considered highly addictive no matter the fancy name or marketing gimmick behind them.

For the full story http://news.yourfindit.com/NewsStory.aspx?id=114206&ret

I have been experiencing a lot of chronic pain issues lately, especially when it rains. This has translating to me calling in sick to work more often than I’d like. There are days in which I suffer through the pain, my brain completely fogged over from a lack of good sleep. Lately, though, I’ve been unable to even attempt to work during my episodes of pain.

I’m nervous about going back to work tomorrow after being off sick on Friday. The day after I’ve been off because of my pain, my boss inevitably always treats me like crap, giving me the cold shoulder or loading me up with tasks. I can’t exactly give documentable reasons that it is an unfriendly work environment based on my disability, but I can tell my boss either doesn’t get it or just doesn’t care. We’ve also, in the past, experienced some disagreements related to reasonable accommodations for me, and I truly think he needs some HR training about managing a person with a disability.

At the same time and on a completely unrelated note, I have had some pretty empowering experiences lately, accomplishing both small and seemingly huge feats I never thought possible when I was first diagnosed with my illness.

The duality of being proud of how far I’ve come while still experiencing some of the yucky realities that go along with having a chronic pain issue is both amazing and maddening. Such is life.

I must have driven my parents mad as a child: I’m the eternal 4 year old asking ‘Why’! It’s got me into a lot of trouble over the years when I can’t seem to sit with the status quo, just need to ask the question, understand the reasons things are the way they are – or at least ask why they are the way they are!

In my work, I use Socratic questioning as I work with participants in both group and individual pain management. Socratic questioning is a method of enquiry ‘to challenge accuracy and completeness of thinking in a way that acts to move people towards their ultimate goal.’ It can be used poorly to almost ‘bully’ someone to come around to a specific point of view (ever watched one of those law shows where the lawyer neatly traps the witness into admitting that part of their testimony without the explanation?) – but used well, it can take you and the person on a journey to discover how they have arrived at their point of view.

I came across this interesting paper by Cary Brown, Katrina Bannigan and Joanna Gill, written for occupational therapists about the place of Socratic questioning not simply for therapy but to question the assumptions about health care. They’re arguing from a postmodernist framework, which I won’t really go into today (but watch this space!), in which they suggest that the assumptions that there is One Single Truth, and it’s biomedical, needs to be questioned. Now I won’t argue with that at all! But what I will argue with is throwing the idea of all underlying principles and science (especially empiricism) out along with the biomedical model.

I can see some of my readers rolling their eyes at the philosophy here – but hold on it does make sense!

Brown, Bannigan & Gill argue that the biomedical model of health is incomplete. I totally agree! It doesn’t include all those social and psychological factors that influence whether someone is living well or is unwell. They state ‘A postmodernist perspective of health and well-being underlines that the illness experience is not a linear, cause-and-effect equation’. They go on to say that life experiences and social, cultural, physical and economic contexts influence individual experience – you can’t really work in pain management without appreciating how much these aspects of life influence how one person lives well with pain, while another has great difficulty.

Postmodernism in health has lead to questioning the assumptions of the biomedical model – again this isn’t new, Engel’s biopsychosocial model has been used in pain management for many years (that link is to a 2002 article on the place of interviewing and relationships in heatlh). It’s almost a truism that in nonmedical management of pain, the biopsychosocial model is the one we turn to. I wish I could say that the medical practitioners I work with also recognise that model, but it’s not quite there yet for some of them!

Brown, Bannigan & Gill suggest that questioning is a strategic tool for occupational therapists so they are equipped to deal with the complexities of current healthcare practice. I don’t know where they’ve been practicing, but I can’t think of a time when my practice in pain management hasn’t been complex! But I guess if you’re working in acute orthopaedic rehabilitation, you might find it difficult to argue with the prevailing ‘give em a toilet seat on Day 2 and they can be discharged on Day 4′ attitude!

Anyway, they suggest that Socratic questioning should be used to ‘frame a critical exploration of the relationships between elements of a given issue’.

The six categories of Socratic questioning are:

1. Clarification – what is the real issue here? what are the parameters, exceptions, inclusions?
2. Assumption probes – what are the the presuppositions and unquestioned beliefs for treatment/decisions?
3. Reason and evidence probes – is there a clearly-thought-out rationale fora treatment or approach? What is the evidence for it?
4. Viewpoints and perspectives - what if we took another viewpoint, what if we had a look from the perspective of a consumer, a purchaser, a referrer?
5. Implications and consequences probes – a viewpoint may have logical implications that can be forecast. Do these make sense? Are they desirable?
6. Questions about the question – why did we start asking these questions? Where are they leading to? What does this mean for practice?

The rationale for using Socratic questions with people experiencing pain is to help them take another look at how they are viewing their pain problem – what are their assumptions? what happens if they adopt one action over time? when might one viewpoint hold true and when might another?

By exploring actions and beliefs in this way, we can develop a more robust point of view that can be not only ‘true for me’ (ie constructivist), but also ‘true for others’ (empiricist).  The questioning part seems to me to be essential (well, I would say that, it’s all I ever do!), the finding out why and what’s behind it is one way to help define key issues.  I hope that patients also get trained in how to question.

I also hope that occupational therapists don’t throw out the empiricist approach altogether.  Empiricism simply means ‘can be known by experience’ – in other words, we can test ideas out and see what happens.  I think this is a critical part of case formulation – once we’ve understood the underlying assumptions and relationships between various parts of a person’s presentation, then we may start to directly influence one of those factors – and then watch to see what happens. 

In a very real way, we are experimenting in pain management, because we don’t know the exact mechanisms that are in play so we need to carefully influence one thing at a time to discern the effect – and use Socratic questioning on our own practice to ensure we’re aware of consequences we hadn’t originally thought about.

Brown, C., Bannigan, K., & Gill, J. (2009). Questioning: A critical skill in postmodern health-care service delivery Australian Occupational Therapy Journal, 56 (3), 206-210 DOI: 10.1111/j.1440-1630.2008.00756.x