Everybody wants a piece of the pain pie

Over the last week I’ve been travelling (with a small team from the company I work for) around the north island of New Zealand delivering in-service training talks to allied health professionals, (Physios, OTs, Psychs, counsellors, medical specialists) about the new Accident Compensation Corporation pain service that has been rolled out nationwide across NZ.

My involvement was the delivery of a 2-hour in-service, which included evidence based processes in facilitating pain education and sharing a few evidence based nuggets around graded exposure and graded activity that I use in my own clinical practice. I also introduced the concept of P.H.O.D.A. (Photograph Of Daily Activities) to my colleagues, none of whom had heard of this very useful model. My experience of PHODA was back in the NHS, although very interested in it, I never really used it due to time constraints. That has changed with the help of colleagues in the UK and NZ.

After a great couple of days, reflecting on the enthusiasm people had towards the new pain service, I was left with a bit of a sour taste in my mouth. Everyone was really eager to be involved particularly in the delivery of the pain groups but I pondered on whether some clinicians actually had the expertise in providing for the needs of a such a complex population.

Pain science is an exciting and fascinating area and we have a long way to go to truly understand the enigmatic nature of some persistent pain presentations (Eriksen, Kerry, Mumford, Lie, & Anjum, 2013). In particular, being able to identify the multi-dimensional nature of pain. I have been criticized in the past by other physio’s suggesting that I am too brain bound. I would like to argue this firstly by quoting Moseley, ‘nociception is neither necessary nor sufficient for pain’ and ‘no brain no pain’. Secondly to reference the numerous stories within Explain Pain (Butler & Moseley, 2003) and finally the numerous stories you hear everyday of people not experiencing pain after sustaining horrific tissue trauma.

So I say to those individuals who make these claims against me being too brain bound, is simply you do not understand the true nature of pain. I have never said that pain does not involve the tissues, it is just that the tissues are not the sole involvement for why someone will experience pain, which leads me to the sour taste.

This begs the question whether some clinicians are ready for the challenge of shifting peoples focus towards learning to live well with pain. That perhaps they remain too tissue based and are fearful to step outside a pathoanatomical model. A study from Simmonds, Derghazarian, & Vlaeyen (2012) suggest this may be the case identifying that ‘physiotherapists continue to have a limited awareness of psychosocial factors versus physical factors despite the knowledge that psychosocial factors are stronger predictors of disability than biomedical factors.’

It appears that many clinicians are familiar with the term multi-dimensional in that many factors make up a pain experience. Yet the difficulty is actually identifying how those factors fit in to why the patient presents to you at that time and that presentation is not a constant, it is highly variable! Clinicians that truly want to embrace the multi-dimensional nature of pain have to understand that a uni-dimensional approach is not sufficient. Unsurprisingly, Synnott et al (2015) highlighted this exact reason identifying that physiotherapy training did not instill the confidence in successfully addressing the multi-dimensional nature of low back pain (LBP).

Furthermore Moseley & Butler (2015) have also identified the misconceptions in managing pain through the use of cognitive behavioural therapy (CBT). CBT certainly shows promise particularly in the form of Acceptance and Commitment Therapy (ACT) (Hughes et al., 2016; McCracken & Vowles, 2014), however as Moseley & Butler (2015) highlight, pain has a biological process with an underlying fundamental relationship with meaning. So yes changing the thought may be appropriate here, however a biological adaptation such as central sensitization that denotes an upregulation of the nervous system cannot be soley addressed through changing thoughts. Thus it would seem (in my opinion) changing the thought associated with pain is once again a uni-dimensional approach to addressing pain.

Finally, I want to highlight the ongoing dogma that we all knowingly or unknowingly, inflict upon our fellow colleagues. Particularly the objection of other professions being involved in the delivery of pain education/management etc. Everyone who has an interest in working with people living with pain has the freedom to explore this area of research and science. It’s unprofessional to object to clinicians from an alternative therapies background to want to work with people living with pain. I have my own opinions of certain approaches particularly of those that have a lack of supporting evidence. However, I embrace those professions that respect the science and advocate an interdisciplinary approach to pain management. So don’t fight it, embrace it!

If we are to provide effective delivery of pain services there are a number of challenges that face clinicians.

1. Ditching clinical clout and dogma
2. Embracing critical thinking and uncertainty
3. Acting as a hybrid but knowing when to draw the line in the sand
4. Working collaboratively and respecting clinical knowledge
5. Being comfortable with being uncomfortable. Admitting that it’s ok if you don’t know or you need assistance.
6. Think outside the box and explore opportunity to make new discovery.
7. Acknowledge that learning is continual and exploring many other approaches to pain is a must.
8. To understand that pain is no a simple neurophysiological phenomenon it is also based upon psychological, social, philosophical, linguistic processes.
9. Embrace that other clinicians have an interest in pain, there’s no law to say they can’t, so don’t object to something you have no say over.
10. The most important person here is the person sitting in front of you, not you.

Thanks for having a read

TNP

References:

Eriksen, T. E., Kerry, R., Mumford, S., Lie, S. A. N., & Anjum, R. L. (2013). At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms. Philosophy, Ethics, and Humanities in Medicine : PEHM, 8(1), 11. http://doi.org/10.1186/1747-5341-8-11

Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., Mcmillan, D., & Hughes, L. (2016). Acceptance and Commitment Therapy (ACT) for chronic pain: A systematic review and meta-analyses. The Clinical Journal of Pain, Publish Ah. http://doi.org/10.1097/AJP.0000000000000425

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. The American Psychologist, 69(2), 178–87. http://doi.org/10.1037/a0035623

Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), 807–813. http://doi.org/10.1016/j.jpain.2015.05.005

Simmonds, M. J., Derghazarian, T., & Vlaeyen, J. W. S. (2012). Physiotherapists’ Knowledge, Attitudes, and Intolerance of Uncertainty Influence Decision Making in Low Back Pain. Clinical Journal of Pain, 28(6), 467–474. http://doi.org/10.1097/AJP.0b013e31825bfe65

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy, 61(2), 68–76. http://doi.org/10.1016/j.jphys.2015.02.016