I hadn’t planned on writing again about chronic pain so soon, but there was an interesting article in a recent issue of USA Today about the struggles of Lt. General David Fridovich of the United States Special Operations Command (USSOCOM), headquartered at McDill Air Force Base in Tampa.  The article, which you can read here, explains how addiction to pain killers, especially narcotics, can afflict anyone, even a general officer in special ops. It’s not about enjoying the drugs, it’s about struggling to get on with life.

As you begin your journey to healing, drugs are frequently going to be a part of the process. Take the drugs, but be aware, and be prepared for the day when it’s time to wean yourself off those drugs. If you do become addicted, it doesn’t have to be the end of the world, and it doesn’t even have to have a negative effect on your career. The key here is facing up to the reality of your addiction and seeking help. Admitting that you have a problem and asking for help will be accepted at face value because addiction can be a normal part of the healing process and should be addressed as one more step in your treatment.

Don’t get caught in the trap. There are many symptoms that will present themselves during your healing. If it’s a new pain, or trouble of some other sort, you won’t hesitate to discuss it with your doctor—don’t let this be any different.

In the first post on my commentary of Robinson, Kennedy and Harmon’s review of occupational therapy for chronic pain, I argued that they have misinterpreted the cognitive behavioural approach to pain management, and in particular, that they appear to hold an outmoded view of pain as either biological/organic or psychological, and refute the place of psychosocial models in occupational therapy practice.

Yesterday I distinguished between cognitive behavioural therapy and a cognitive behavioural approach - while the therapy is often primarily concerned with ‘talk’ therapy followed by behavioural changes to improve mood for example, a cognitive behavioural approach is a broader concept that is based upon the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.

In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Today I want to move into two points: how an interdisciplinary team works (with a specific focus on role blurring and duplication of input), and more on the way in which occupational therapists can use so-called ‘psychological’ approaches to help people engage more fully in their lives.  BTW I think maybe other disciplines can use some of this too.

Interdisciplinary and multidisciplinary are two words bandied about a lot when it comes to pain management.  Sometimes they’re used almost interchangeably – but when it comes down to it, there are important differences between the two.

In a multidisciplinary team, each team member retains an independent, usually discipline-specific, approach or model for working with the patient.  Although the team works concurrently with the person, and there may be common goals, multidisciplinary teams do not necessarily need to integrate their treatment, nor have a common over-arching treatment model or approach.  Some poorly coordinated multidisciplinary teams can actually provide serial ‘mono-therapy’ – just the same as seeing several separate clinicians one after the other.

Interdisciplinary teams work differently.  Firstly they hold a common model or understanding of the problem.  In pain management, this means the team accepts the tenets of a cognitive behavioural approach as I outlined in yesterday’s post.  Then the team works with the person/client/participant to develop a combined understanding of the person’s problems or situation, and collaborate to generate shared goals.  While a newly formed team may function somewhat like a multidisciplinary team in some respects, over time each clinician develops a shared understanding of each other’s contributions - and very often can function at a basic level within some of the domains of concern of each other’s discipline.  They continue to provide discipline-specific input, but always with a view to the overall model and the client’s goals.

For example, after 18 years, I have some knowledge of medications and their side effects, so it’s not surprising that I can talk with someone about when to take medications and what the side effects might be.  I might do this because I’m working with the person to help them get up and schedule their day, and help with a better sleep pattern.  It’s also no surprise that the physiotherapist and the clinical psychologist, nurse and social worker can be heard discussing activity management – even asking how the person is going to apply skills in daily activities!

This can at times be somewhat disturbing, especially to new clinicians.  They might ask “How can I be sure these other team members know what to do? What if they do it wrong? Why are they doing what I should be doing? What if things get left out?”

As I’ve learned, two things help to make interdisciplinary teams work well – really good induction and mentoring as the new clinician settles in, and time.  It’s during the latter that communication needs to be open and robust discussion about why various approaches are used, and who might be the best person to have the main focus on a goal.  Role contributions change over time too, as team membership changes.

Does working this way lead to duplication? Yes, to a certain degree.  Provided that team members are consistent in what they say, ensure no goals are omitted, and focus on the case formulation, I’m not so sure that duplication is always a bad thing.  Maybe it’s better described as being consistent, providing back-up to each other, and more importantly, allowing the patient/client choice about who to approach to talk about topics. Most times, in an individualised programme, teams seem to work best with a combination of clinicians who can address psychosocial aspects, functional/physical aspects, and help the person integrate what is learned into his or her life.

A proviso – team members need to be competent in the techniques they use, and they must ensure the goals they can contribute most effectively to are being addressed. As someone pointed out, an occupational therapist or physiotherapist who dabbles in ‘a bit of CBT’ on the side is not likely to be helpful if they then omit something like how to schedule or plan a day, or progress activity levels over time. At the same time, I keep on saying, when is there a better time to elicit automatic thoughts and beliefs than when engaging someone in activity? When better to discuss whether the thoughts are helpful, accurate or helping the person achieve what is important and valued in life? And carried out with competence, working with thoughts, beliefs, emotions and behaviours in this way is both effective and efficient.

Mainly for occupational therapists, I want to turn to how it’s possible to integrate so-called ‘psychological’ approaches into occupation.  Be warned now – this may be continued!

If occupational therapy is about helping people engage more fully in valued occupations, I’d argue that we need to use the most effective tools to do so.  In pain management, a cognitive behavioural approach has consistently been demonstrated as effective – and occupational therapists, while somewhat silent on the publishing front, have been involved in most of the major pain management programmes.

Occupational therapy is not a ‘talk’ therapy – it’s all about doing.  It involves identifying what is important or valued in a person’s life, and helping them engage in those occupations.  While part of this involves talking and planning and ‘educating’, the purpose and outcome is for the person to then be equipped to engage in those activities or occupations themselves.

During planning and ‘educating’, it’s common for the person to raise objections to doing things differently.  These objections are – yes really – automatic thoughts!  In other words, they’re cognitions or beliefs, or maybe even attitudes or rules about how the person thinks things ‘should’ be done.  Robinson, Kennedy and Harmon seem to construe this situation as one in which what the client believes should be accepted without question.  I argue that unless the belief supports the person engaging in occupation, it is a valid target for an occupational therapist to address. While the belief may be part of the person’s ‘lived experience’ to date, it’s amenable to revision and change so he or she can see themselves and their opportunities differently, and re-engage in what is important.

When using a problem-solving process to review how a person has managed a new set of occupations, or way of approaching an occupation, feedback and evaluation is a vital component. It’s at this point too that an occupational therapist can review how helpful thoughts and beliefs are – and help the person look at the situation (and beliefs) in the light of new evidence.  They can then be helped to generate new beliefs and change their behaviour (or engagement in occupation).

I’ve gone over the word limit again today, so yes, there will be more tomorrow on this important topic.  I hope it’s generating food for thought and that what I’m writing serves as encouragement for ‘non-psychologists’ to learn more about how to work with thoughts and beliefs as they work with people.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

“Pain Management. A Handbook of Psychological Treatment Approaches” (1986) edited by A. D. Holzman and D. C. Turk.Pergamon Press

“Come to me, all you who are weary and burdened, and I will give you rest.” (Matthew 11:28)

Have you ever been so tired that you did not even have the energy to watch TV? Think about that. How much energy could it require, and how much poor concentration is needed to sit in front of a TV set? Yet I’ve found myself even that exhausted, to the point of not enough energy for the mindless entertainment of television.

Sometimes God will speak to you in your spirit, just a small voice that you must listen closely to hear. Recently I was praying to God and saying, “Lord, today I need You to carry me for I have no strength.”

The Lord surprised me by responding, “I’ve been carrying you today and every day.”

I burst out laughing because it was so very true. God had been carrying me through the many days when I had no strength.

My “Chronic Fatigue Syndrome” needs a name change to “Constant Fatigue Syndrome.” I’m continually exhausted and finding myself with no strength. Yet the Lord has helped me to somehow get through.

We each face diverse things. For me fatigue is a major issue, and for you it may be something completely different.

You may have plenty of energy but find yourself in a wheelchair or limited in movement by arthritis. We may need different kinds of rest and relief, but one Lord supplies all of our needs by His love and grace.

Today you may find yourself in dire need of God’s rest for your soul. Our Jesus is a living God. He is master of the universe and master of our lives. We each face much adversity, but we never face it alone. Turn to Him for rest for your weary soul.

Prayer: Dear Lord, when weariness saps at our will to go on, give us rest and strength to move forward again. Amen.

About The Author
Karlton Douglas lives in Ohio with his lovely wife. He has both Chronic Fatigue Syndrome and Crohn’s Disease.

Here we are just another day right? Not to us who have pain to deal with each and every day.You would think we would get used to the pain. Not likely what we get used to learning to live with it.

How many times have you hear ” after awhile you must get used to it.” These people have probably never had a pain in their life or if they did it was never chronic pain.
Everyone of us know someone like this. Share your stories with us.

I HATE HOSPITALS AND BEEPING DOCTORS, there I got it out, growl, mutter, mutter, growl.

Just got back from Hospital with My knight and I really do hate the doctor she is an evil unfeeling bitch, I wish bad things on her  and hope someone is as uncaring as she was today. . the last few weeks have been some of the hardest I have seen for my knight pain etched onto his face,  Pain with every movement.

we have a letter from the hospital to say he had this and that and some of that and lots of that wrong with him and when we seen her next we would work through them sorting them out, Now when we were there this time she talked about Chronic Pain Syndrome and we had to sort that out as he had pain every where then the rest would follow.  It was not my pain she was talking about but how I took it was he needed to sort him self out, get up, get moving and be positive or thing would be worse for him and it would be his own fault, WTF.

and it was completly curable and he would be back to walking around pain free in no time at all. WHAT THE F**K, hello he has ME/CFS and Rheumatoid arthristis and Osteo something or other. before the hips, ankle, knee and spine damage he has. Of course he will be walking around when she fixes it. TWAT of a woman. I  said to her my knight was in so much pain he tried to kill him self since your last letter bcause of the pain,  ok, ok, ok well lets say it will go away sometime you just have to think positive and it will go away with help. which I can’t give you but as part of your team we can all help you.  Every word that came out of her month was backwards front wards, one thing then another, nothing made sense she know’s my knight has Me?CFS so why talk in riddles it was hard for me to understand and I don’t have brain foggy.

She sent him away reluctantly with some Tramadol to keep him quiet and a harsh letter to the our doctors. Evil bitch she was

watching my knight in so much pain is a knife to my heart, then I get angry because why should I waffling on about myself because what I am feeling is nothing comapaired to my knight.  I feel selfish going out and leaving him here alone in bed, while I run around the place. Guilt that I can do some much when he can do so littler without being in pain. Useless that i can’t fix him or at least take his pain away.

I hate tears and showing weakness as you all know, but I sit sometimes and just sob my heart out with the bloody unfairness of it, My lovely husband in so much pain for so long and it just gets worse not better nothing makes it go away, and my lovely Seahorse broken with ME/CFS and a broken heart and head.  I do as much as I can, so they can rest and relax but it is never enough I can’t take there pain away I know it is silly to think I woud  be able too. But oh please I’m asking all those above and below take there pain away even if only for a day and  Why can’t some evil twisted child abuser have it, or some bad person ( see i’m so angry I can’t even swear) I know life is not fair but come on cut them some slack please. …

Ok rant over, waffling done stop feeling bloody sorry for my self. Sorry all.

I was nervous last night.  Two of my fingers on my left hand swelled up, and I couldn’t bend them. The pain in my fingers was throbbing and burning, while the swelling made my veins look like they were going to pop any moment. This was reminiscent of some of what I had endured prior, but all over my body, and I feared it was beginning to return.  As I lay in bed last night, feeling the pulsing pain, I remembered that earlier in the day I had strained or pulled the fingers on my left had while chopping some ice outside.  Later on I was scrubbing something with my hands, which must have exacerbated already sore fingers.  A sigh of relief came over me. Interestingly the pain, still severe, began to lessen slightly, which I attribute to my body relaxing as I let go of the fear and nervousness.  I closed my eyes and fell asleep, awakening this morning to fingers that could bend, still a bit sore and swollen, but on the mend.  Today is gong to be a GREAT DAY!

I feel much better.  The pain has lessened a good bit… almost down to a dull roar.  I’m still quite tired and sleeping a ridiculous amount.  Really… I’m sleeping a lot.  Hoping this next week will mean more energy.  Will be waking up earlier and earlier each day, trying to transition to a more “adult” sleeping schedule again.   Wish me luck…

Also hoping to become more active and leave the house.  I’ve grown accustomed to staying in the house every day, but I know I need to get out.  I’m planning on going swimming one day soon.  And maybe hanging out with a friend.  The idea of that causes me so much anxiety.  Being actively social.  Meh.

Each day, I am more and more convinced this pain is nerve pain.  Or a very badly pulled muscle.  I am starting to stretch to kind of “restart my batteries” post-op.  Over and over, I keep feeling pain in the same muscle while stretching–it’s like I pulled my groin/leg/etc. or something.  I’m not sure how else to describe it…

So… I’m sleepy.  Here.  This makes Peter and I feel less strange… Charles is a carbon copy of all of these dogs.

Delighted to see an article in The British Medical Journal

http://www.bmj.com/content/342/bmj.c7167.full

Common clues suggesting joint hypermobility syndrome

In children and adolescents
Congenital dislocation of the hip

Late walking, with bottom shuffling instead of crawling

Recurrent ankle sprains

Poor ball catching and handwriting skills

Tiring easily compared with peers

So called growing pains or chronic widespread pain

Joint dislocations

In adults
Non-inflammatory joint or spinal pain

Joint dislocations

Multiple soft tissue (including sporting) injuries

Increase in pain or progressive intensification of pain that is largely unresponsive to analgesics

Progressive loss of mobility owing to pain, or pain avoidance through movement avoidance

Premature osteoarthritis

Autonomic dysfunction, such as orthostatic intolerance (dizziness or faintness) or postural tachycardia syndrome (in this form of dysautonomia, in 60° upright tilt the blood pressure remains constant while the pulse rate rises by a minimum of 30 beats/min)

Functional gastrointestinal disorders (sluggish bowel, bloating, rectal evacuatory dysfunction)

Laxity in other supporting tissues—for example, hernias, varicose veins, or uterine or rectal prolapse

At The Green Clinic, in Edgware, and the Green Clinic at The Gingerbread House, in Shenley, we have years of experience in treating children and adults with hypermobility.

For further information please view our websites:
www.edgwarephysio.com

http://www.radlettphysio.co.uk/physiotherapist.htm

or view our video: http://www.vimeo.com/17161181

Delighted to see an article in the British Medical Journal.

http://www.bmj.com/content/342/bmj.c7167.full

Summary
Joint hypermobility syndrome (JHS), is inherited, and can lead to joint pain, severe soft tissue injuries, and joint instability.
There can be proprioceptive impairment, leading to clumsiness, and frequent falls or sprained ankles;
it can lead to premature osteoarthritis;
there can be poor movement along the intestinal tract leading to IBS type symptoms such as abdominal cramps;
there can be other fragile tissues, causing hernias or uterine or rectal prolapse.

Symptoms are often mild, but 24% of patients with joint hypermobility attending the UCH Hypermobility Clinic already had
an chronic pain. They were experiencing serious pain, disability, and impairment of their quality of life, some patients
becoming chairbound or even bedbound.

How common is it?
Joint hypermobility is very common, occurring in 10-20% of populations of Western countries, and higher still in those in Indian, Chinese, and Middle Eastern groups.
There can be people who are hypermobile without symptoms.
The true prevalence of the syndrome is unknown.
In surveys in London and in Santiago, Chile, patients referred to general rheumatology clinics have found prevalences of joint hypermobility syndrome as high as 45%;
the syndrome is higher in females and non-white people.
Therefore many patients presenting to their doctors with common, everyday, noninflammatory, painful, musculoskeletal conditions probably have unrecognised joint hypermobility syndrome.

Why is it missed?
In a recent survey among members of the Hypermobility Syndrome Association , largely due to missed diagnosis, 52% of patients waited over 10 years from the onset of symptoms to get a correct diagnosis.

Doctors may be unaware of the prevalence of the condition, its effect on quality of life, or its multisystemic nature and may not routinely look for hypermobility in the clinical examination;
the condition rarely forms part of the curriculum in medical schools or in postgraduate training programmes for general practitioners, specialists, or physiotherapists or occupational therapists.

Why does this matter?
If joint hypermobility syndrome is missed, the following problems may arise:

Inappropriate and potentially harmful labelling or treatments may be applied on the basis of an erroneous diagnosis such as rheumatoid arthritis.

Over zealous physical manipulation may cause avoidable damage, such as (a) precipitating subluxation or dislocation of intervertebral or peripheral joints, (b) inflicting rupture on ligaments, joint capsules, muscles, or tendons, or (c) precipitating pathological fractures in fragile bone. Exercise therapy may be either excessively forceful or ineffectual.

Anecdotal evidence exists that orthopaedic operations may be done without the surgeon knowing that the patient has an underlying connective tissue disorder, and this may lead to poorer outcomes.

Chronic pain may sometimes lead to a potentially reversible downward spiral of immobility, deconditioning, dependency, and despair.

How is it diagnosed?
Diagnosis is entirely clinical as currently no biological or imaging markers are available.
The musculoskeletal symptoms mainly derive from a vulnerability to injury resulting from fragile tissues (tendon, ligament, muscle, bone, cartilage, and skin). In patients with joint pain or post-injury musculoskeletal pain, screening blood tests and/or appropriate imaging are needed to exclude conditions such as inflammatory arthritis and fractures.
The Beighton score identifies joint hypermobility but is too insensitive for diagnosing joint hypermobility syndrome.
Diagnosis requires the application of the Brighton criteria.

At The Green Clinic, in Edgware, and the Green Clinic at The Gingerbread House, in Shenley, we have years of experience in treating children and adults with hypermobility.

For further information please view our websites:
www.edgwarephysio.com

http://www.radlettphysio.co.uk/physiotherapist.htm

or view our video: http://www.vimeo.com/17161181