I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We are humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing a path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.

Support

Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.

Takeaways

 

• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient centred care’ or PCC for short.

Now for a buzzword it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient or person?

Most of the available literature in this area discusses “patient centred care” but I much prefer “person” centred care as it turns the patient well ….into a person and a much more ‘real’ entity in a two way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlights the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What actually is PCC?

Maybe by definition PCC is tough to define for all? What is person centred for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centred care has previously been defined as:

"willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems" – Stewart 1995

"the physician tries to enter the patient's world, to see the illness through the patient's eyes'' McWhinney 1989

Two person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient centredness”

  • The biopsychosocial perspective (the patients life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC is NOT

There are some criticisms of PCC that seem to centre around the idea of consumer driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain problem
  • Present options
  • Discuss pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer decision
  • Arrange follow-up

 

What do people really want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel and ultimately need.

This is a really interesting paper regarding a two person perspective in back pain Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership with practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

'Understand me'

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen to me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   - Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction

Does It matter?

A question I often hear asked about person centred care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an affect on outcomes we don't know if PCC specificaly improves the most common outcome measures , but in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the persons experience in healthcare (which might be an outcome measure in itself).

 

The application of PCC

Maybe we should NOT see a person centred approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting with the end in mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding, is in my opinion the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system"  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” - Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person centred approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared decisions and responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to be have an influence on exercise outcomes "Autonomy: A Missing Ingredient of a Successful Program?" . Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally it is a therapists responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each others responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family and social pressures. One of the best ways to implement a BPS perspective is to realise that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort and sacrificing something else.

People don’t just need a something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from From'Non‐encounters' to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than healer can be really helpful for many!

Support & motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite to walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” - Holopainen 2018

 

Conclusion

 

  • Person centred care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down

 

 

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"Functional therapeutic movement is without a doubt one of the most practical, well referenced, clinically relevant, and beneficial continuing education courses I’ve taken. Ben has a lively presentation style that keeps you engaged, a good sense of humor, and clear mastery over his content. The course is relevant and valuable for young and experienced clinicians alike. Be sure to come prepared for discussion and plenty of critical thinking!"

DR Jarod Hall DPT USA

 

Key Learning points

 

• Develop GREAT rehab programs for even the most challenging patients


• Latest evidence and best practice guidelines for treating low back pain using an ACTIVE approach  


• Use a flexible, adaptable and simple to implement clinical framework to help navigate the uncertainty of clinical practice from patients with persistent pain to elite athletes.


A look at pain and exercise through a truly biopsychosocial lens.


• Take the complication and rigidity out of exercise prescription – Make it fun and engaging for YOU and your patient. Forget a physio tools or photocopied exercise sheet approach.


Take the mystery out of exercise prescription- when do you need to be specific? And when less so? Learn a comprehensive view of exercise that is more than just sets and reps.


How to sell your patients on exercise – A key factor in rehab success


Learn what you need to know about the psychology of pain and exercise without needing to become a psychologist.


• Learn about pain and how to talk about it without needing to be a neuroscientist. More patient focus and less biology!


Concise and practical reviews of the latest research into pain and exercise to save you time and energy! Perfect for the busy clinician who doesn’t have the time to wade through every piece of new information coming out


How to improve your subjective assessment. How to get all the information and ‘find the hook’ that guides patient beliefs, emotions and commitment to rehab.

 

This is NOT just another exercise course about sets and reps! It is about applying movement and exercise to people in pain. Exercise and movement are fantastic tools to help our patients but the complexity and uncertainty often present in clinical practice can make its application tough especially with painful problems!

What’s the best exercise? Will my patients enjoy or even do it? What if I underload, overload or even make them worse? What does the evidence say I should do? How do I communicate this with my patients?

Couple this with many of the current concepts in exercise & fitness simply not applying well to people in pain and this can be frustrating for therapists and patients alike. . The amount of information out there on this subject can be overwhelming, confusing and time consuming to process and we need to learn how to cut through the noise quickly to get to what really matters to help our patients.

Functional therapeutic movement enables you to navigate this uncertain environment by guiding you in making sense of the evidence around exercise and its application, in a way that will practically apply to your patients in clinic straight away. This can help discard unhelpful, outdated & often detrimental perspectives around movement that are often pervasive, amongst therapists and clinicians, and enable a streamlined, flexible and evidence based approach that is in line with the latest pain and rehabilitation research.  

One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the back bone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace? 

Its people not just pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system. 

We can see below from Engel's view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

Download 4

We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem.

Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.  

Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

"underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process"

One of the issues that is often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and there subjective experience? And it maybe better defined as a model of care rather than a model of treatment. Now this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problem. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself.

Just treat the pain?

I can already hear some readers shouting, “Just treat the pain - then you will not have any more problems”

Well that is the biomedical view in a nutshell!

Firstly we have been attempting top do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS model of PAIN

A pain oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel's model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

Screen Shot 2019 08 21 At 07.34.26

The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to becoming the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a uni directional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.

Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multi factorial pain treatment model, not the BPS model set out by Engel.

This has drawn critique, and rightly so, of the BPS model and it's interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach - Beyond the BPS model” (Thanks to the authors for the full text link!). This critique, I feel and highlighted by the authors, is not really of the Engel's model but instead the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Lets try to do that before we think beyond it.

Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here 'XXXXX'. Even the most uni-factorial biological one you can think of…lets say a fracture.

How does their perception and knowledge, sense making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight lines & trichotomies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel's work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what are termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a tri-chotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This maybe better termed a multi dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. Its about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

Its about BELIEF

Certainly we don’t want to demonise the idea of resting or taking it easy if things are too painful, that is not evidence based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people's opinions around what affects pain pain in the positive AND negative. .

Darlow 2014 - Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self reported perspective of what trigger back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare ups

Costa 2019 - What Triggers an LBP Flare? A Content Analysis of Individuals' Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 - Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple 'go to' blame physical activities (especially when other things are not considered), but when the flare up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

Its about POSITIVE messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short vs longer term

What we do seem to have some data on is that having low pain self efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster - 2010, we see that low pain self efficacy is related to worse disability outcomes at 6 months. The question is how do our own attitudes, and others peoples attitudes as well, towards our backs influence our behaviours? Food for though perhaps?

Key messages from advice to remain active

Hurt does not equal harm – Its OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

Exercise dosage in rehab is still one of the biggest areas of uncertainty in clinical practice. On one hand we have modern thinking that promotes higher loading & dosage for patients and on the other hand we have the traditional model of lower load and lower dosage that has probably evolved to minimise the risk of adverse scenarios such as increased pain and decreased patient confidence in the therapist.

Currently we have some basic dosage guidelines for rehab that focus on the physical qualities that we know can be a PART of rehab. But if we take the primary target of the majority of rehab, PAIN, and if we are being honest with our current knowledge base, we don’t really have the sets and reps, or other dosage parameters that we can use to achieve a reliable outcome on our patients pain.

If we look at the current research base for rehab exercise we regularly see that the confidence intervals around the mean effect for pain cross zero meaning that the possibility of a large, small, no or even an adverse effect are all still a possibility.

Rough current physical dosage parameters

  • Endurance 12+. 2-3 sets.
  • Hypertrophy 6-12, 3-6 sets.
  • Strength 6 or less, 2-6 sets
  • Power 1-2 reps, 3-5 sets.

Unfortunately NONE of these things relate well to pain and that makes a lot of sense but also throws in some confounding. We know pain is a multi dimensional experience so for one factor to reliably relate well to pain makes little sense, but the issue is that the one factor (exercise) may also have an effect on multiple dimensions associated with pain as well, so this becomes a little confusing : ). Maybe the key here is the word reliable?

So if we want to improve these physical aspects in rehab then we do have some parameters to work with. The question is can we simply port over what we know about exercise over to rehab exercise and pain?

I don’t personally believe so.

So Lets NOT say physical parameters are unimportant but also acknowledge that expecting a traditional view of exercise and exercise dosing to have a predictable effect on pain may not be prudent or correct.

A principle often discussed in relation to exercise programing is the SAID principle, Specific Adaptation to Imposed Demand, this means that the body will always adapt to the stimulus applied. Now this is a principle that will hold true always, although HOW the body adapts is still pretty individual and often not easy to predict.  

BUT the problem is that we expect the thing we can specifically target with our current dosing knowledge, lets say strength with a rep range of 6 or under and a load that reflects that, will have a predictable and specific relationship with ANOTHER therapeutic target, PAIN.

So we are not really being specific in this case at all as there is a disconnect between the targeted physical outcome, and associated dosing parameters, and the outcome of pain.

Rather than just physical adaptations, a modern view of rehab might start to think about some of the things that exercise might affect that have a positive impact on patients. To get a specific effect from these things we might have to think about programming specifically to achieve these outcomes rather than suggest our current rehab dosing will automatically improve them.

Therapeutic exercise targets:

  • Pain (the big confounder)
  • Specific functions (physical qualities are a part of but not all of this)
  • Fear avoidance & psychological measures (proving very important in outcomes & prognosis)
  • Confidence & motivation
  • Freedom of movement/relaxation
  • Movement strategy
  • Adherence

Exercise Research

If we take recent work by O’Neill HERE that looked at acute analgesia (instant pain relief) we see that the set dosage used in this study, looking at individual responses, produced variable responses on pain, even INCREASING pain, especially if the patients baseline pain was already high. 5

Another paper HERE looks at different exercise types  effect on pain and an interesting recent paper HERE discussing mechanisms and individuality with pain responses to exercise.

Lets take a look at some exercise comparison studies where pain was part of the primary outcome measure. We see that different programs with different dosing parameters have similar outcomes.  We also have to be aware that if we are looking at the mean effect of exercise on pain this may mask the low and high responders to the differing dosage levels.

This study HERE compared low and high load exercise programs for rotator cuff tendinopathy

This study HERE compared high (deadlifts) and low load (motor control exercises) for back pain. The conclusion from this group’s research was that higher load was more applicable for those with lower pain.

This study HERE looked at different loading programs for Achilles tendinopathy

Tolerance

Exercise for pain perhaps should not always be seen as something that will reduce pain in the short term, as we might see with the concept of exercising/moving to change symptoms. Instead it might be moving with a TOLERABLE amount of pain that increases pain self efficacy and keeps the body moving during pain is an equally important scenario.

 Remember tolerance should really be PATIENT DEFINED. Exercise has the potential to increases our patients pain as well as reduce it and anyone in clinical practice who has flared a patient up with exercise knows this! The concept of optimal loading is really about tissue/physiological adaptations, but perhaps we also need to apply this optimal loading concept to pain adaptations, increases in pain, staying within current symptomatic levels and also decreases in pain.

We know that exercising WITH pain does not produce worse outcomes HERE. I have previously written about this HERE

Current state of the patient

So within the concept of tolerance we have to consider the current state of our patient with regards to dosage. It is tough to reconcile the concept of tolerance within a model of changing strength, ROM etc for me, as this does not consider things that might affect our patient’s tolerance to exercise.

Things that might affect our patients pain tolerance

  • Current/previous levels of exercising
  • Stress levels
  • Sleep behaviour
  • Anything that is associated with increased pain sensitivity to stimulus

One of my favourite clinical reasoning tools is the SIN analysis from Maitland. Lets not go too much into the Nature (type of pain), but severity (how much it currently hurts) and irritability (how long it hurts vs stimulus applied) really equal the modern concept of sensitivity. One of the key factors in ‘sensitivity’ is disproportionate stimulus and response (level and duration of pain or severity and irritability). This then would inform our clinical reasoning by reducing the stimulus or exercise dosage in line with current levels of sensitivity.

Rate of perceived exertion  (RPE)

One of the measures I use to gauge dosage is effort level via the borg scale. This is far more subjective than using sets and reps in a traditional fixed sense and remember pain is a pretty subjective experience!

Borg

One of the hardest things is to keep our exercise dosing within tolerable limits in the beginning, or dose titration, when we have limited or no knowledge of our patients response. I tend to use a pain VAS (yes I know it’s a crap measure!) vs RPE. So if VAS is high then I make sure effort level is lower. I tend to find this keeps responses within tolerable limits, but of course not always.

I call this the rule of 10, so both numbers add up to…..you guessed it 10! Example would be if pain is a VAS of 7 then I would keep RPE to a 3. If pain was low, say 3 on the VAS then I would maybe take the RPE up to 7.

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But if you feel your patient is highly stressed, fearful or under slept then any of these things might have to be factored in to the dosage thought process if you want to keep the dosage within a tolerable response.

Monitor response to dose!

The most important thing is to monitor the response to the dose. Lets say we play it sensible and keep RPE low because of a higher VAS, and the patient finds it easily tolerable well then we know we can push it a bit harder and load em up.  If we get an adverse reaction even though we kept the effort or load down then we may have to drop it even further. 

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Be OK in the grey

We will never really know what the dosage should be until we actually apply the dosage and then monitor the response. So its OK not know what’s going to happen, just use your ‘loaf of bread (head)’ and be OK with sometimes getting it wrong. Don’t panic, just adjust the dosage and educate that this is normal, it’s definitely not an exact science and often trial and error.

People will always want some kind of directions

One of the issues can be that people want to know how much to do and have some kind of direction. This usually end ups as 3x10 once a day (be honest, you have said this!) and I can understand why this is given as it is really quite difficult to be more specific. This is why explaining that it is a bit of trial and error with some good reasoning and also helping the patient to understand what a flair up might be/mean is important.

Conclusion

  • We currently don’t have an exercise dosage for pain
  • Pain does not respond consistently to current dosing parameters
  • There are other therapeutic targets apart from physical aspects
  • Exercise data does not support current dosing ideas in rehab
  • Think about the current state of the patient with regards to dosing levels
  • Use clinical reasoning
  • Be OK in the grey

This is the first in the series of a few mini/micro blogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being banded about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists we often have a bunch of why’s, ROM, strength and other outcome measures that are often not really very well aligned with the patients WHY.

 Put yourself in the other person’s boots - why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to peoples WHY. Well I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!
Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.  

Rehab should tap into the meaning to that person’s life and what they gain from doing it, not just doing an exercise because someone told me too.

The problem has been one of therapeutic exercise about finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built in to the process.

The challenge with persisting pain maybe the motivation is not so clear cut, we need to dig a bit deeper as pain can narrowed peoples focus and reduced the amount of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

Whether rehab exercises should be painful or not has become a recent topic of much discussion. As we have started to value the role of (optimal) loading in rehab, and that we can get patients back to moving and loading pretty early in the rehab process, we have also got to appreciate that this is unlikely to happen without experiencing any pain.

If you have any type of understanding about pain then the simple question of “should we use painful exercise?” suddenly might not look so simple!

Rather than a simple yes or no, there are a bunch of questions to be answered, such as how much pain is OK? Who may or may not benefit? And what is the best way to manage the process? Especially if all does not go to plan!

Research

From a data standpoint it would be great if we had have something that we can use to guide us here. Low and behold we do, and its open access.

Smith et al looked at this question in 2017.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

This systematic review and meta analysis looked at 9 trials in which varying degrees of painful exercise were used. They found that painful exercise did NOT result in statistically worse outcomes across a short, medium or long term follow up. There was a small statistical benefit in the short-term for painful exercises as highlighted by the standardised mean difference of around 0.2 (SMD = effect size for a meta analysis). So from a research standpoint this is positive news.

One thing to note here from a clinical standpoint is, that using painful exercise is no GUARANTEE that it will have a positive effect for your patient. All statistical tests only give us the PROBABILITY of an effect, so the likelihood is that it will, but when we look at the confidence intervals (measure of variability) for the mean SMD for painful exercise, for the majority of the studies we can also see that they cross into a negative effect and in some of the studies quite substantially.

The variable effect of exercise on pain (although over a shorter time frame) was also shown by O Neill et al's recent look at the acute effects of isometrics *Here*. Although, of course, isometric exercise and painful exercise is not the same thing, the point here is the highlighting of the variable effects from exercise. For patients with higher baseline pain isometrics actually increased their pain post exercise and this is the benefit of looking at individual responders within a study not just the group average. Those with lower pain at baseline seemed to receive more analgesia from isometric exercise.

BUT at the very least I think we can say that the likelihood is that it will not have detrimental effect. So as rehab can often be painful we can be reasonably confident but without seeing painful exercise as some sort of fire and forget panacea and also appreciate the individual nature of pain.

We could debate the mechanisms of HOW painful exercise might work from pain habituation to conditioned pain modulation and perceptual mechanisms but in essence we don’t really know at this point in time and this might be different or in different combinations for different people.

Benefits

The benefits can be both physical AND psychological.

Firstly, it allows patients to get in MORE exercise. If they are not being limited by pain (or pain contingent if we are being fancy :) then they can get a greater dosing than if they stopped due to it being painful. It is important to add though that we currently don’t know what optimal dosing is for exercise having an effect on pain!

Secondly, it sends the message that hurt does not equal harm. The problem can be painful and still settle down if managed in the right way. This may give people a new insight into their pain and how they can manage it.

Pain self-efficacy may also be built experientially, so using painful exercise as a tool might be an option to help do this.

Clinical application

So it’s great to have some objective data on this subject, but as we know getting that into clinical application is not always straightforward.

Firstly don’t be afraid of some pain! The likelihood is that it won’t cause a worse outcome. But as we are dealing with thinking, feeling HUMANS, it is OF COURSE not as simple as this, but more on that later.

One of the issues with always looking to be pain free with exercise or continually treating pain, is what does that say ABOUT pain? On one hand we are telling people hurt does not mean harm but our actions might not be saying the same thing. If pain is OK, if it is normal then in the process of getting it better we might have to endure a little bit of it.

But how much is OK is a key question? Studies that have allowed painful exercise have ranged from not increasing baseline symptoms during or post exercise up to 5/10 on the VAS.

We know the limitations of the VAS as a REALLY subjective scale so perhaps we could introduce the idea of pain being tolerable or intolerable rather than a numerical score.

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Now tolerable might be a bit sore but it does not really get in the way. Intolerable might be thought of as getting in the way of our daily activates, maybe having an effect on our sleep and generally making life a bit miserable. This is going to be different for different folk so hence why the concept of tolerable becomes important.

We would also like to know how the pain is settling down. So pain that is not really calming down after the exercise stimulus or keeps on getting progressively worse over a number of days as the exercises are performed is probably not a great idea. We would like to see a nice stimulus response with only slight increases above baseline (tolerable remember : ) that calms down gradually over 24-36 hours, quite similar to delayed onset muscle soreness (DOMS)

So on the issue of DOMS, it is important to identify if the increase in pain is actually the same as the original symptom. Post exercise soreness is quite normal but for those that are unaccustomed to exercise this might not be recognisable especially for a currently painful area. Defining what is pain and what is soreness might be a good sense making exercise for some patients. Although we don’t know that progressive overload is required with exercise in rehab, it probably ia a good idea, so having some sort of tolerable baseline for patients to progress or regress from is a great idea too. This is also might have an effect their self efficacy using exercise too which, of course, is a bonus.

Pain is not the only issue

Potentially the most problematic area with painful exercise, and one that is really under discussed, may be more about the psychological aspects that are associated with the pain and how they can affect the person. One of the best prognostic factors for recovery in a number of body areas appears to be pain self efficacy, *here* is a recent paper from Chester et al and also from Foster et al *here*  Pain self efficacy, something I have written about before also *here*, is the ability to carry on normal functioning despite of pain. It is important to note that those with higher pain self efficacy also tend to adhere to exercise better.

So someone’s pain self efficacy is going to be a KEY factor in whether they are able to tolerate having pain and being able to carry on functioning which maybe a fundamental skill at the heart of painful exercise especially if it can take 24-36 hrs to settle.

Predicted outcome is another key prognostic factor and if someone believes that increased pain will result in a negative outcome then this could have a negative effect on the actual outcome.

Jack et al *here* found that the number one reason for poor adherence to exercise programs was that people did not want to make the problem worse. So painful exercise coupled with negative beliefs about pain, low pain self efficacy and a poor predicted outcome may not sit well together.

A qualitative piece “Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy” from Sandford et al also found that a fear of making the issue worse was a key factor in reduced adherence to exercise.

What can we do?

Firstly you could screen people for these factors if you feel they are required. We have tools such the Pain Self Efficacy Questionnaire  (PSEQ) and the shorter version the PSEQ-2.

One caveat with using questionnaires, in my opinion : ), is it does allow us to get a score to assess confidence and resilience in managing pain but it perhaps does not tell us about things that are specific to our patients. So being able to weave this into a good subjective that teases these more personal parts of the narrative out is a must.

Also ASK about their expected outcome from the treatment and what would it mean to you if it was painful

“Do you feel like this exercise will work for you?”

“Do you have any concerns about doing this exercise?”

It might be that someone tells you that they have tried exercises before and they did not work or that they feel it might make the issue worse, especially if it hurts.

It might also be important to discuss with ALL patients what their beliefs are around pain. These might be that pain indicates they are doing more damage to their bodies or they will not be able to work because they have pain or implications for future functioning. It can often be what the pain MEANS to the patient that is the real issue rather than just the sensation of the pain itself.

A key factor to remember is regardless of whether painful exercise is positive or no worse than non painful exercise, a negative belief may stop your patient from exercising

Education

One of the most powerful tools we have at our disposal is EDUCATION, I am not always a huge fan of this term as it can imply a teacher pupil relationship. But in order to provide effective education to people we first have to build rapport and then understand what they may need to know more about.

We can educate on a range of things from the effectiveness of exercise for many issues, that painful exercise is often not detrimental, that pain self efficacy is an important prognostic factor and what pain may actually mean and its relationship with physical damage. It may also be worth talking about the process and what to expect, and often that it is a process of trial and error to get the right level and desired response.  

This has to start with understanding the patient, their history and belief structure.

Where you start is not where you have to finish

Do we have to jump straight into painful exercise? I don’t think so. It is not REQUIRED but it is also not harmful.

An important point to make is that for someone with very negative beliefs about pain, reduced pain self efficacy and poor beliefs about the outcome, challenging them right off the bat with painful exercise might not always be the best thing to do. As they build trust in you and confidence in their bodies then pushing into pain progressively might sometimes be a better route.

We know that giving people the option to avoid pain can actually maintain pain avoidance, so whilst not advocating avoidance behaviour confronting these things may take a little time, confidence and education, especially if the person has a lot of negative pain and avoidance based beliefs.

Those that persist in doing painful things that have NOT provide a therapeutic effect may benefit from non painful exercise for a while too. If you feel that pushing into pain has not given the desired response when looking at their history then a break or change in dosage could be just the ticket.

Those with higher levels of pain at baseline on average seem to have worse clinical outcomes so this might also lead me to reason that maintaining this level of pain through exercise might not always be a good idea.

There are no real hard and fast rules here only individuals and individual considerations.

What if it all goes wrong???

This is where self efficacy may come into its own. Empowering your patients to self manage maybe valuable in the exercise process.

As we hopefully have told the patient BEFORE they embark on an exercise program I can often be trial and error. Have we enabled our patients to adapt their exercise dosage if it goes a bit wrong? *Here* is a short piece on dosage in rehab  

So do your patients know what to look out for in terms of symptoms?

Do they know how to adjust the dosage? This could be in exercise frequency, intensity and time, sets and reps (volume).

Are they able to contact you to ask questions? Do they know this?

I think these are all required aspects of pushing into pain.

A patient I saw last week had religiously persisted at pushing into his painful rehab exercises every 48hrs. He believed if he did what he was told he would get better (the trust!). But after 3 months there was not the desired outcome. In this case he was given no indication what to do if this happened, just blind faith on all sides that he would get better.

Key points

  • Painful exercise DOES NOT produce worse outcomes from the research we have
  • Research does not guarantee your patients response to painful exercise
  • It is not just about the PAIN sensation! What does the pain mean and how does it affect behaviour such as exercise adherence?
  • Pain self efficacy and predicted outcome are important psychological measures and can be discussed and measured
  • Think about education around the exercise and the pain response
  • It does not need to start with painful exercise!
  • Empower your patients to self manage

The world of the science of pain or ‘pain science’ as its better known can definitely be a polarising topic when it gets discussed. These recent commentaries twitter/social media debates really highlighted this.

The truth about pain science, exercise and movement

The REAL Truth About Pain Science and Body Mechanics: A Response to Criticism

P.s the second one is better - Todd Hargrove is a great writer ; )

I would like to point out that I am by no means a pain researcher and really just a lowly blogger and clinician. It has been suggested this makes my opinions less valid and I am OK with that. So you have been warned!

Before we get into it there are two points I would like to make.

Firstly, the importance of understanding more about pain, from both a clinical standpoint and also a patient perspective should be highlighted.  There can be great value for everybody in this area but one that is still evolving and has more to it than one or two dominant voices.

Secondly, pain can be seen a bit as a ‘special interest’ area. However if someone is working with those in pain and has not received some education on the current concepts around pain, at least to some degree, then a parallel maybe like being a chef who does not know much about the ingredients they cook with! The science of pain is one of the primary areas that clinicians, and anybody working with people in pain, should have some proficiency in.

Stuck on the Biological?

The term biopsychosocial gets thrown around a lot in healthcare. In my opinion there is no more important place for a BPS perspective than when it comes to our understanding of pain. It could be argued however, that the current dominant views and messages within ‘pain science’ in many regards have not really moved beyond the biological.

I would like to say explicitly the point of the this piece is not to say ditch the biological but instead consider that this might be insufficient to truly understand pain and its ramifications on peoples lives. There are also clinicians already advocating for this and combining both aspects.

The vast majority of the information and slogans we have about pain are specifically focused on the biology and anatomy, and the education mainly is grounded in these elements. Although in fairness the intention maybe that this biological message has an effect beyond biology and into behaviour, but the focus seems to be less on the behavioural aspect itself.

The most important message to come from this might be that:

"Hurt does not equal harm"

So that the sensation and its magnitude, severity or however you want to describe it, does not have an ‘isomorphic’ (fancy way of saying simple, direct or 1 to 1) relationship with tissue damage. For many this has been an informative and empowering message but for others may not resonate with their pain experience in the same way.

If we think about the words used to discuss pain such as alarms, nerves, brains, sensors and nociception, they really relate mostly to biology and the stimulus and response process, or essentially the SENSATION of pain. It could be said that the information seems to be of more primary importance than the person it is being applied to.

Pain does not just have a  sensory-discriminative aspect but also the affective-motivational one too that can be equally, and for some maybe more, problematic. The lived experience is more than just the sensation that we feel.

These are two interesting papers that discuss different perspectives on pain.

The sensory-discriminative and affective-motivational aspects of pain

Pain as metaphor: Metaphor and medicine

It might be that I am going to be accused of over complicating all this, and whilst there are simple messages that could have a positive impact, there is also an often-made point in the pain world that oversimplification has led to the discussion of  ‘pain pathways’ and ‘pain receptors’ that are rightly pointed out as problematic for the understanding of pain.  

So to think about pain as only a sensation or an ‘alarm’ may also be a touch incomplete when we view it outside of the biological and move into the psychological and social realms, perhaps this is a simplification of a complex multi dimensional problem? Maybe it cannot be conceptualised into one sentence such as “pain is protection” or “pain is an alarm”. While we cannot exclude the biological aspect of the pain experience, and we should not go down the the baby and bathwater route, the question is, is a biological perspective and explanation sufficient to fully explain how pain impacts on lives? I personally do not believe in many cases it is. 

We seem to be really good at talking about the sensation, how it comes about and the biological processes involved, maybe we are not so proficient at exploring and explaining how this sensation affects lives, emotions and motivation and the overall unique individual experience that we might consider as the wider psychological and social impact.

Looking more at pain through a BioPsychoSocial lens

The real transformation in pain knowledge moving forward and building on the great work already done, from both a clinician and a patient perspective, I believe may come in understanding the impact on the psychological and social aspects of the human experience. Disability and suffering could be described as social aspects of the pain experience rather than a part of the biological ‘alarm’ system.

That pain is normal and occurs often is a key ‘pain science’ message. What differentiates those that do not develop persistent pain and those that are also able to live well with persistent pain from those that are most negatively impacted by pain?

It appears that the people worst affected by pain are perhaps not affected by an increase in the intensity of the sensation but instead by how much pain impacts on their lives as a whole, the ability to work or interact socially and integrate with society as a whole in a positive way.  Now the interpretation of the sensation of course will be part of that but by no means all of it. Pain may have many meanings beyond just damage. Getting to this meaning and giving information that relates to that can be key.

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This fits with Engels wider BPS with biological aspects being at the centre but having much wider ramifications right up to a societal level.

BPS factors

We perhaps also use wider BPS factors, sleep, stress, beliefs etc more to explain the increase or decrease in the sensation and sensitivity, so essentially contributors to pain. 

The idea that the sensation of pain is a primary concern for patients has already been called into question with disability seemingly more important than pain intensity.

Factors defining care-seeking in low back pain – A meta-analysis of population based surveys

Wider BPS factors can, often be studied in relation to ‘pain sensitivity’ or ‘tolerance’. The increase or decrease in response to a prolonged or painful stimulus can be discussed with relation to the sensation or an increase in ‘sensitivity’.  The focus seems to be more on the effect of these factors on pain rather than the effect of these factors on the person and their quality of life. Shouldn't we be doing both?

Lets take sleep as an example.

Sleep has a bi directional relationship with pain and it is unclear which is the chicken and which is the egg. Poor sleep can really affect my job, my social interaction and quality of life, instead we can focus on this aspect to explain the sensation and then as a modulator of the sensation.

This has also been conceptualised as “pain is telling us something is wrong, we just don’t know what” with regards to a stress or ‘allostatic’ load view of pain.

So whilst pain is often described as being inaccurate in reporting on tissue damage, pain can be seen as reporting more accurately on wider factors that have been associated with pain. Although it does not seem it can tell us exactly what, so insert anything here, to blame for pain.

I will be honest in that I struggle with this concept and have also realised that I have maybe got myself into a mental pickle : ).

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In one sense we should see the ‘alarm’ as perhaps being something to not take so much notice of, the idea of being ‘time contingent’ rather than ‘pain contingent’ with exercise for example. Whilst when pain is ‘reporting’ on psychosocial stressors it should be taken much MORE notice of.

It could be, and likely is, that PS factors might be no more isomorphic with pain than tissue damage and our pain experiences to the same ‘stressors’ will remain highly individual. But this is taking a sensation dominant view of course and this is exactly what I am arguing against here.

We also talk about the biology in a very general way. It’s the same for everybody essentially, but does this generic biology result in the same experience? I do not personally believe so.  It is getting from this biology to the lived experience that may prove tricky.

The burning question is how much biology do I need to get across and how much does mostly focusing on the biology help? Of course that answer may prove to be individual rather than a generic singular solution. 

 A common argument for the alarm system is evolutionary based

One of the arguments for the current view of pain is based in an evolutionary perspective. So the ideas of pain as an ‘alarm’ or ‘protection’ look at pain from the need for basic survival.

When we look at pain from a BPS perspective perhaps some of the ideas of protection do not fit as well as when we view them from a more basic evolutionary perspective.

At the most basic level nociception, I think, can be conceptualised as an alarm. The network of a high threshold detection system falls nicely into the bracket of an alarm. But we also know that nociception does not simply equate to pain (remember the oversimplification thing). Pain could arise with the further analysis, or maybe lack of analysis potentially, of the alarm system. So is pain actually our reaction to the alarm?

But I digress.

This conceptualisation of pain maybe focuses less on the impact of pain at a wider level. Whilst there is a ton of research in the psychological domain and some in the social, I don’t think it has really made its way into the most dominant pain messages that are discussed and used with patients. A multi dimensional view of pain does not JUST consider the role of biology and threat but also the wider impact of pain across the BPS spectrum and also the bi-directionality of this.

The alarm conceptualisation does not really give the picture of how pain effects human beings, their psyche’s and the wider societal effects.  Can we explain away disability, suffering and many of the other impacts of pain on our psychological and social functioning as the singular role of an alarm?

Maybe our biology has not kept pace with the changes in our psychological and social environments? The simple alarm system has not adapted to the meanings and emotions we give to it and the wider ramifications on our functioning in society?

What are future directions?

Now, in my opinion, it seems the current dominant approaches of pain science education focus on the biology and slowly works its way out to the psychological and social. Perhaps we should start at a broader point on the effects of pain on life and work our way back down to the biology if required?

Seek first to build rapport and understand the person and their situation before explaining it.

We can talk about pain with people and for some it makes a huge difference. Not for all however and as per all interventions will have individual effects.  

Maybe there is not a universal way to explain pain? There is no flash card set or single conceptualisation that is correct for every experience of pain.

Something I have discussed for a while is making it relevant to the person you are working with. Helping people make sense of THEIR experience and THEIR pain may make it more relevant.

Don’t just apply information to people and expect to their behaviour to change. Define behaviour change and use specific information and experiential approaches to specifically change behaviour, then monitor closely if this has been effective.

Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognises the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What is resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and psychological thing. It is important that we don’t separate the two however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefit.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”

Sustainability

Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Screen Shot 2018 10 26 At 07.32.40

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first line treatment for back pain being the advice to remain active and engage in your normal activities *HERE* .

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & flexibility

Resilience should not be seen like a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience maybe the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain relief vs resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience is PERSONAL

Valued activities may provide balance during stressful situations. Especially people that suffer with persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating  patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

  • Weightlifting
  • Capoeira
  • Yoga
  • Pilates
  • Boxing
  • Bike riding
  • Crossfit
  • Running
  • Walking
  • Bouldering
  • Various sports
  • Gymnastics
  • Dancing
  • Making things
  • Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied  from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming  an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counsellors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb my pain would escalate 10 fold. I persisted and after 30 mins or so off cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can't control and you put energy and focus into those things you can control/accept”

“Resilience is I get up everyday and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job maybe to help with this process.

What components make up resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & positive emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and without doubt both viewpoint will interact within the 'third space'.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

  • Are you a generally optimistic clinician/person?
  • How optimistic are you about a positive outcome?
  • Do you discuss what a positive outcome might look like, especially in regards to improved function?
  • Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain acceptance & sustained engagement in valued activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen's *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk factors

Pain catastrophisation & avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience or vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnerable. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems this relies on clinical reasoning to apply the right care at the right time.

Screen Shot 2018 10 26 At 07.40.13

Take homes

  • Resilience IS NOT TOUGHNESS
  • Resilience is about adaptability and physical and psychological flexibility
  • Resilience lies on a continuum
  • Resilience looks and feels different to different people
  • Optimism is key
  • Sustained engagement in valued activities is key
  • Pain catastrophization and avoidance behaviour are risk factors