The Blame Game

A person with persistent pain will usually have a long and complicated story to accompany their pain. They often carry this story around like a big battered, heavy suitcase containing all of the crap and misery that has gone hand in hand with their pain since it started. As practitioners we will often notice that anger and blame are pretty quick to spill over from the baggage, smashing on the floor and blocking the way for recovery. It might be the careless driver who hit their car while checking their phone, kickstarting our patient’s journey with whiplash. The uncaring boss who never took their concerns about safety seriously and appears to be complicit in covering up the workplace incident.   The surgeon who “stuffed it up”.   The insurance company who denied the claim. The doctor who didn’t believe them. The list is endless and varied but the common theme is that whilst blame is often totally understandable in the circumstances, it is also unhelpful and can stop a patient from moving forward.

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Why does it matter? Often the situations that are “to blame” are well and truly in the past – the people have moved on, may never have known they were “to blame” – but ultimately they don’t care! For the patient though, the power of that external blame can have a strong drive on how they view the world and ultimately view their pain. They can become so focused on the person or scenario they believe to be responsible, that they find it difficult to step over it and walk the road to recovery.

So if we recognize that blame is blocking the path, how do we address it? Often the blame can be a symptom of the fact that they feel that no one really cares or really believes their story, including all of the people who have come along subsequent to the blame. The antidote to this scenario can be simply to spend the time listening, fully getting an understanding of how things have come about. This takes time and it also takes some skill. If we can see that this listening component can be an integral part to getting better, we can start to dedicate it the time that it needs within the consult and also the training that we might need as a practitioner to get better at it. We can start to see this as an intervention in itself and place more importance on it.

 

Some of the key concepts that you might like to draw on to help this process are:

  • Allow the time in the first place. Recognise that examination, diagnosis and treatment don’t all have to be squashed into the first consult, especially for the distressed patient. Have longer initial consults, relax and allow the patient to spend the time they need to get the information that is important to them
  • Don’t interrupt too much. Trust that the bits that they will focus on are the bits that are important to them.
  • Demonstrate empathy. Practitioners can feel that this is artificial, uncomfortable or forced. You don’t need to cry with the patient for them to feel that you have got the gist of the ugly bits – simply rephrasing the key concepts to demonstrate that you have got it can do the trick. The odd “that sounds really upsetting” or “you are really brave to have gone through that and still be doing as well as you are” can also go a long way to showing you care.
  • Ask open ended questions – What makes you say that? What did you believe was going on at the time? Why do you think that is? Why is that?
  • Give body language cues to demonstrate that you are listening and you want them to continue- you probably don’t need to take notes at this point – you can summarise the important bits later. Face the patient, make eye contact and relax. Don’t freak out when they cry (and they will if you are doing a good job of creating a safe environment for them to talk). Simply pass them the box of tissues and carry on.

 

 

Once the patient has had a good chance to be heard, you will often find that a great deal of the work has been done. Addressing the blame can then be like a lock and key scenario to moving forward – The listening component acts like WD40 on a rusty lock. If a patient feels believed and heard, they have less of a reason to hang on so tightly to the blame.

 

One way to address it directly might be to follow the listening with some pain education. Depending on how you prefer to do this – formally, informally while treating the patient or drip feeding it through all conversations, ultimately one of the goals is to separate the sensation of pain from tissue damage. I also like to aim to help the patient change their focus from pain to function – having them use what they can or can’t do as their benchmarks for progress rather than their pain levels.

 

Having now got them on your side by demonstrating that you believe them, then helping them to reconceptualise pain in a way that is more helpful to recovery, the next bit might be to address the blame – especially if you feel that it is really driving the process. One of the ways that I find works is to say something along the lines of   “It sounds to me like you are still really angry with ………. – am I hearing that right?” If they are able to engage with these thoughts and they say that yes, they are, you might like to respond with something like this: “I can completely understand why you feel that way after everything that you have been through. It makes sense. In the past I have had people who have had really bad pain situations – a lot like yours, who have found that blame or anger has really held them back – that they were unable to focus on getting better because the blame was such a big deal. When they were able to let it go a bit, or at least recognize that it was unhelpful, they found they were able to focus on the future a bit more and on their progress. Once they did this, they found that things just fell into place a bit easier”  You could then just leave it to the patient to comment on that as idea, or you could ask an open ended question to see if they can engage with the concept.

If they “get it” , you can easily  go forward using an Acceptance and Commitment Therapy (ACT) approach. Whilst the blame is unhelpful, you don’t have to get rid of it in order to move forward. You can encourage the patient to acknowledge that the blaming thoughts are there again, allow them to be there without judging them or engaging with them and then let them go along their way. They will no doubt pop up again soon – these thinking processes become seriously engrained habits – so just repeat the process.

Over time, hopefully the patient can let go of the blame that keeps them in the past and engage more with the rehabilitation that looks towards the future.

A great resource to introduce these concepts to both practitioners and patients is this book:

There is also more information and an online course on the website

If you are interested in learning about how I use pain education in my clinical work, I am running small group seminars in Melbourne in the coming year – check the details on the website under the ‘upcoming seminars’ tab.

Classical Conditioning and Pain – A synopsis of the research done by Dr Tory Madden

In the second of two blog posts inspired by the Paincloud convention, I am going to attempt to describe some of the research produced by Dr Tory Madden, who finished her PhD with the BIM group in Adelaide, Australia.

 

Tory hails from Cape Town in South Africa, studied physiotherapy and worked as a physiotherapist for five years, including time in a rural South African region.  She decided to do a PhD and in creating a list of potential supervisors, she aimed high and placed Professor Lorimer Moseley at the top of the list.  Her strategy paid off and when she began negotiations to begin her PhD, she had to start with one small but important bit of research  – where on earth was Adelaide?  Her move to Australia was not a completely easy or smooth process as these round the globe transitions can sometimes be (I can attest to that!) and it was confounded by the fact that she had started dating a rather delightful fellow named Matthew just 6 weeks prior to the move!  To her mother’s delight, Tory was able to smash out her PhD in 3 years and return home to her man, who subsequently became her husband.  Back in South Africa she now works as a post doctoral research fellow at the University of Cape Town.

Tory’s research was on classical conditioning and was designed to test the idea that many clinicians hold to be true – that not only can pain occur in the absence of nociception, but it can be brought on by non noxious stimuli such as tactile stimulation or movement. The theory might be that these non noxious cues may have been frequently occurring at the same time as the nociceptive event in its initial phases.  When the initial event resolves and the tissue heals, but the pain has hung around despite there no longer being nociceptive input, is it possible that the non-noxious stimuli that were associated with the initial injury are triggering the pain? This pairing of non noxious and noxious stimuli could be seen as an example of classical conditioning.  My laypersons way of describing it would be to say – When “Thing 1”, which is non nociceptive, occurs at the same time as “Thing 2”, which is nociceptive and results in pain, “Thing 1” and “Thing 2” might be described as being paired together.  So if we remove “Thing 2” and just expose the person to “Thing 1” (which shouldn’t normally cause pain), we may be able to create a pain response.  The most famous example is commonly known as  ‘Pavlov’s dogs’ experiments.  There has been a fair amount of research into classical conditioning in relation to fear and this research has provided some effective evidence based ways for psychologists to help a person reduce fear and anxiety.  Additionally,  classical conditioning has been demonstrated to be involved in the maintenance of fear of pain (1).

In order to better understand what clinicians thought about this scenario, she started with a survey to determine just what people thought was going on and how well backed by research they thought this was.  She found that overwhelmingly clinicians did indeed think that pain can be a classically conditioned response to a non-noxious stimulus and that they believed this was backed by evidence (2).  She and the team then undertook a systematic review to establish what the literature said about evoking pain with a non-noxious but associated stimulus (allodynia) and about amplifying pain with an associated stimulus (hyperalgesia).  They found evidence to suggest that classical conditioning could amplify pain but not enough evidence to draw a conclusion about its role in the eliciting of pain (3).

 

Armed with this information, the team set out to design an experiment to see if they could pair a non- noxious stimulus, in this case a vibration sensation on the back, with a noxious stimulus – a thermal probe.  Their initial results showed that after a pairing process between the two stimuli, they were not able to elicit pain with the non- noxious stimulus (4).

At this point they went back to the drawing board and thought a bit more about the design process and with some tweaking, came up with a model that they thought would better be able to capture the effect of pairing the stimuli to see if they could create a classically conditioned response.  In this second round of testing they paired a vibration stimulus at one location with a painful laser stimulus, and a differently placed vibration stimulus with a non painful laser stimulus.  After the pairing process they used an “at threshold” laser stimulus – which was designed to be right on the border of pain – and they found that when they cued the participant with the vibration location that had been paired with the painful stimulus, the participant was more likely to report the laser to be painful, than when they cued them with the other vibration location.  Thus demonstrating that pain thresholds can be influenced by non-nociceptive sensory stimuli, via a classical conditioning effect (5). This is not quite the same thing as pain being elicited solely by a non-painful stimulus, because the participants still received an at-threshold test stimulus – but it’s a step in the right direction.

Phew…. tricky stuff isn’t it? So what does it mean?  Well, probably that the clinicians who answered her survey were onto something, despite there being a lack of evidence for their assertions.  Perhaps  associative learning in subacute pain can play a role in the transition to chronic pain in the absence of tissue damage? Understanding this better can help us to direct treatment of both early pain states and chronic pain.  This research also provides a foundation for future studies to look at patients with existing pain states, as it provides information about how a healthy nervous system behaves.

As well as her published academic papers, Tory has written some cracking blog posts on the BiM website – you should check them out.

 

 

Tory and I getting our selfie on at the Paincloudconvention

1. Meulders A, Vansteenwegen D, Vlaeyen JW. The acquisition of fear of movement-related pain and associative learning: A novel pain-relevant human fear conditioning paradigm. Pain 2011, Nov;152(11):2460-9.

2. Madden VJ, Moseley GL. Do clinicians think that pain can be a classically conditioned response to a non-noxious stimulus? Man Ther 2016, Apr;22:165-73.

3. Madden VJ, Harvie DS, Parker R, Jensen KB, Vlaeyen JW, Moseley GL, Stanton TR. Can pain or hyperalgesia be a classically conditioned response in humans? A systematic review and meta-analysis. Pain Med 2016, Jun;17(6):1094-111.

4. Madden VJ, Russek LN, Harvie DS, Vlaeyen JW, Moseley GL. Classical conditioning fails to elicit allodynia in an experimental study with healthy humans. Pain Med 2016, Sep 28.

5. Madden VJ, Bellan V, Russek LN, Camfferman D, Vlaeyen JW, Moseley GL. Pain by association? Experimental modulation of human pain thresholds using classical conditioning. J Pain 2016, Oct;17(10):1105-15.

Cognitive Functional Therapy – from the horse’s mouth

I recently had the pleasure of hanging out with a bunch of very clever pain people at the Paincloud Convention in Norway.  Among the group  were two researcher/clinicians  that I have long followed in the pain research world – Dr Tory Madden, who gained her PhD within the Body in Mind team in Adelaide, Australia, and Dr Kjartan Vibe Fersum, who worked with Professor Peter O’ Sullivan and his Pain Ed team.  Both were delightful to meet in real life and each presented their research at the convention.  I am going to give an overview of both presentations over two blog posts.

Having quoted his research so very many times throughout my masters degree, read everything that has been published on the subject and attended a two day workshop presented by Peter O’Sullivan, I was  excited to meet Kjartan Vibe Fersum and had to stop myself from displaying any fan girl behaviour!  Kjartan and his wife Anine, both Physios were a delight to hang out with – grounded and down to earth.

A quick ‘fan girl’ selfie of KJartan and myself 

As it is with meeting many of these well known researcher/clinicians, you often walk away thinking that they are such personable people – and you can’t help wondering if the positive results that they demonstrate in their clinical trials have a lot to do with their ability to quickly create a rapport with anyone they are chatting with.  If you have ever had a chance to chat with David Butler or Lorimer Moseley you might have had this experience also.  This is probably not an accident – the science is slowly starting to paint us a picture that this stuff matters – creating a strong relationship with patients in the clinic seems to be more important than pretty much anything else that you do within that therapy time – many studies have demonstrated that the stronger that alliance with the patient, the better the outcomes they will get from that therapy (1-3).

Back in the mid 2000’s, researchers like Peter O’Sullivan and Wim Dankaerts were starting to move away from the popular theories of the time that revolved around instability and lack of motor control being the cause of low back pain.  The biopsychosocial model of pain was being investigated and acknowledged more and more, and the multidimensional nature of the contributors to back pain were being talked about by researchers and clinicians.  The Cochrane Back Review Group at the time recommended that on the basis of this, classification of low back pain into subgroups was likely to be helpful in directing both research and treatment.

O’Sullivan had produced what he believed was such a system – one that took into account the need to understand the patient and their beliefs about their pain well enough to be able to decide if faulty or unhelpful beliefs or social factors might be playing a role in the maintenance of back pain.  As well as this, he felt it was important to look at what movements or postures were able to reproduce their pain, and how often throughout the day they tended to adopt those postures or movements.  He published his proposal with some case studies to demonstrate the different approaches used for different patient presentations (4).  Shortly after that, Wim Dankaerts published a paper showing that when 13 clinicians had been trained to identify the movement patterns described in the classification system, they were able to come to almost perfect agreement when presented with test cases to identify (5).

At this point, Kjartan took up the reins and designed a randomized controlled trial to test the theory and check that the results that were being produced, weren’t just due to those strong alliances created by this very charismatic, curly haired, Kiwi/Aussie

The process took five years and was done in Norway at the University of Bergen. During this time, Kjartan and his wife had two daughters.  The results of the trial were a success (6). Even the most skeptical among us tends to sit up and take notice when we see results like this in a recalcitrant condition like chronic low back pain.

 

 

 

As you can see – the nearly 50 subjects in the Classification Based Cognitive Functional Therapy group (CB-CFT) did a lot better than the 43 subjects in the Manual Therapy and Exercise group (MT-EX) in disability and pain. This was also the case for all the other parameters that they measured.  Importantly, there were big differences in patient satisfaction between the groups, the CB-CFT group being much more satisfied.  They also displayed dramatically lower care seeking (utilisation of health care) after the intervention – the implications of which were not lost on me – in a system where you are going out of your way to ensure that you reduce distress, reduce fear of movement and increase self efficacy, it follows that the patient will be both very happy with the process and outcomes, and less likely to need further help in the future.

 

If you are interested to learn more about Cognitive Functional Therapy, you can check out some of these youtube videos, the Pain-ed website or get along to any of the courses run by the Pain-ed team.  I can highly recommend it.  The link to the article above is here.

If you are sad that you missed the Paincloud Convention (you should be!), check out their website to see the program. Then purchase the video package of the presentations when it becomes available – you won’t regret it – it was a wonderful, well rounded weekend of clinically applicable, entertaining and engaging presentations.   See some photos below.

1. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Phys Ther 2010, Aug;90(8):1099-110.

2. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther 2013, Apr;93(4):470-8.

3. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: An experimental controlled study. Phys Ther 2014, Apr;94(4):477-89.

4. O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther 2005, Nov;10(4):242-55.

5. Dankaerts W, O’Sullivan PB, Straker LM, Burnett AF, Skouen JS. The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment. Man Ther 2006, Feb;11(1):28-39.

6. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain 2013, Jul;17(6):916-28.

 

 

Some of the presenters chill out in the Norwegian mountains at a retreat before the Paincloud Convention.  L to R: Sivgar Garfors, Matt Dennis, Tory Madden, Sandy HIlton, Ole Morton Salte, Alison Sim, Bronnie Lennox Thompson

The conference organisers Sigvar and Ole on top of the world.

L to R: Ole Morton Salte, Sigurd Mikkelsen, Kjartan Vibe Fersum, Alison Sim, Sandy Hilton, Tory Madden, Bronnie Lennox Thompson, Jason Silvernail, Sigvar Garfors, Tim Marcus Valentin Hustad.

Kjartan Vibe Fersum tells us that posture doesn’t have much to do with pain and that telling people otherwise probably does more harm than good

 

Jason Silvernail spoke about how it might be helpful if we as therapists placed less emphasis on the physiology side of pain science and more on the human side – understanding who our patient is and creating a connection with them.

 

Sandy Hilton speaking about graded exposure and graded imagery in pelvic pain populations – plenty of penis and vagina talk with a good laugh thrown in – but some great information about serious topics.

Cannabis for Chronic Pain

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Legalising marijuana for either recreational or medical use makes lawmakers very popular

Canada is about to legalise marijuana.

 

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Really?  Does he need any more help?  

When it comes to the facts about  whether the use of cannabis for chronic pain is effective and worth some of the troublesome accompaniments that go with it, the lines can get a bit blurred.   Here in Oregon, where I am currently based, marijuana was legalized for recreational use just over a year ago but has been legal for medical purposes for more than 10 years.  A report in the local paper – The Oregonian,  suggests that one year on, the tax generated from the sale of pot accounted for just under $15 million, from sales of around $60 million, an impressive boost to the public purse for this relatively low population state.  However they also recognized that there had been a significant increase in people driving under the influence of marijuana, as well as calls to the poisons centre and visits to the emergency room for people who have over indulged.  The other obvious fears around such a move to decriminalize the drug – increases in psychological illness in adults who have been exposed to the drug in adolescence,  and the possibility of abuse or addiction, are yet to be examined due to the longitudinal nature of the studies needed to provide this data.  In Colorado, where marijuana was legalized in 2012, it was noticed that calls to the poisons centre went up by around 30% and that people self-reporting  to treatment centers increased by around 66%.

From the social side of the things, what I have found interesting living here is the reduction in stigma around the drug – the notion of which came wafting in my direction at a school fundraiser and social event that I recently attended.  Its just not a big deal.

For many countries or states trying to decide whether or not  to introduce the drug for medical purposes, it is hard to sort out the emotion from the science.  The emotive arguments can sometimes come across as if a lifesaving drug is being deliberately withheld.  There are certainly clinicians who report amazing and life changing results from observing patients using the drug for treating multiple sclerosis and nausea associated with chemotherapy.  However, like any drug used to treat a condition, we first of all need to know if it works, how well it works, and if the side effects or other issues associated with the drug outweighed by the benefits .

For treating chronic pain with medical marijuana, it seems like the answers are not straight forward.  The stigma and illegality of the drug certainly makes studying it trickier than it otherwise might be.  There is some evidence starting to trickle through – solid clinical trials showing good levels of efficacy.  However they are confounded by many problems – high drop out rates, difficulty in the standardization of the components or chemical make up of the product and  side effects, for example the inability to drive.

Two recent papers on the topic shed some light onto the effectiveness of the drug’s use in the treatment of chronic pain.  This study from 2015 combines data from both synthetic cannabis as well as herbal cannabis  (1).  The synthetic cannabis drugs that have been included in the review are dronabinol, Nabiximol and levonantradol, which are prescribed in some countries for the treatment of nausea associated with chemotherapy, wasting syndrome associated with AIDS, spasticity with MS and chronic neuropathic pain.  Overall this review suggests that there was moderate-quality evidence to suggest that cannabinoids (either herbal or synthetic) were effective at reducing pain in chronic pain states and treating spasticy, however the data for reducing nausea and improving appetite to prevent wasting in HIV whilst promising, was of a lower quality.  The review combined data from both cannabis that was smoked or eaten in a preparation with data from clinical trials on the synthetic cannabis, which it should be noted, have generally poor efficacy when reading their individual outcome studies.

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Herbal cannabis has up to 573 constituents  (2).  THC is the main psychoactive component which tends to cause the euphoria or relaxation effects as well as potentially contribute to anxiety and paranoia which can sometimes be experienced.  Other compounds that have an effect on the physiology are metabolites of the breakdown of the primary components.  The other notable component is cannabidiol (CBD), which does not cause psychotropic effects on its own and  is suggested to work to attenuate the anxiolytic effects of the THC  (3).  It should be noted that most of the synthetic forms of cannabis are purely THC based.  These include dronabinol and nabilone which have been trailed and used in the treatment of nausea associated with chemotherapy and spasticity associated with MS.  The small effect sizes that they have on these conditions doesn’t warrant much excitement (1).  Nabiximol, a synthetic mix of both THC and CBD analogues, is available for prescription in Canada and parts of Europe for treating pain, nausea and spacticity.  Again, the results are not that exciting and the side effects play into the decision for other countries not to license the drug.

A 2016 discussion paper suggests that the use of herbal cannabis (smoked, eaten or oil based)  in chronic pain settings (both nociceptive and neuropathic) resulted in VAS score reductions of 50% and 33% with numbers needed to treat (NNT) of 2 and 3.5 respectively.  These results were far superior to placebo and similar to reductions seen with the use of strong opioids  (4).  A difficult condition to treat,  drugs used to treat neuropathic pain, opioids and gabapentin,  have reported NNTs of 4.3 and 7.2 respectively  (5), well below the efficacy demonstrated in the above medical cannabis trials.   Another 2016 study also suggested that in states of the USA where medical marijuana has been legal for some time, there appears to be an associated statewide decrease in opioid use and thus a reduction in opioid associated deaths  (4).  These are probably statistics that should make us sit up and take notice. Opioid related deaths have increased dramatically in the last 10 years, alongside the increased prescription rates of opioids.  Additionally, opioids account for 75% of all overdose deaths in the USA  (6).  It is easy to see why some people are excited by the possibilities that cannabis seems to present.

Some clinicians are not convinced that the gains to be made are worth the hassle to overcome the problems associated with medical use of marijuana.  Dr Michael Vagg, a medical practitioner working in the field of pain in Geelong, Australia, wrote in his article in “The Conversation, AU” that the lack of research and heterogeneity of products leaves significant gaps in the decision to pursue the implementation  of medical marijuana.  He argues that the current state of evidence for the drug is not compelling enough to overcome the safety and quality and regulation issues.

So is the juice worth the squeeze?  Are we just swapping one set of side effects with another?  Is it the missing piece in the chronic pain puzzle that we have been waiting for?  The jury is still probably out and until we have a bigger evidence base to draw from we may not know.  It is certain that there are patients who will benefit from using this drug, but it is not without problems – do we swap opioid related deaths for DUI traffic deaths?   Many questions to be answered……  much pondering to be done…….  On that note, I might pop out and make the most of the greenery that Oregon has to offer.

I’m going for a walk in the forest, not to smoke a cheeky one!  😉

If you are interested in learning more about the studies of cannabis and chronic pain, as well as other pharmacological approaches to chronic pain, there is a 1 hour lecture available to purchase on our online teaching site here.  

 

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1. Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA 2015;313:2456-73.

2. Savage SR, Romero-Sandoval A, Schatman M, Wallace M, Fanciullo G, McCarberg B, Ware M. Cannabis in Pain Treatment: Clinical and Research Considerations. J Pain 2016;17:654-68.

3. Ahrens J, Demir R, Leuwer M, de la Roche J, Krampfl K, Foadi N, et al. The nonpsychotropic cannabinoid cannabidiol modulates and directly activates alpha-1 and alpha-1-Beta glycine receptor function. Pharmacology 2009;83:217-22.

4. Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain 2016;17:739-44.

5. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162-73.

6. Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother 2013;13:1201-20.

Home birth – a discussion from my soapbox

Mention home birth in social discussion and depending on the social circle you are mixing with you may get extremely polarized opinions.  In the UK, government funded and supported home birth have been part of the NHS for many years.  It is seen as a great way to reduce the burden on hospital systems and allows women to labour and birth in a place that is relaxed and comfortable.  For low risk pregnancies it is safe option because of the infrastructure and systems incorporated into the process.

In Australia, the practice seems to be strongly discouraged by both the medical systems, and the government.  This means that the services available to the midwives facilitating home birth in the UK that make it a safe system, are not offered to mothers and midwives who chose to birth at home in Australia. A woman can still choose to birth at home, however the path is not smooth or easy.  Ultimately, without access to well facilitated hospital transfers, open and accessible sharing of medical records and welcomed co-management by the medical system, choosing a home birth in Australia is certainly not the path of least resistance.

For low risk pregnancies, a home birth with good medical backup and a shared care approach is a fairly safe option.  However for those choosing to go down that pathway in either  a higher risk category, or who are not able to access things like full medical records and easy systems to transfer to hospital when things aren’t going well, a home birth put both mother and baby at risk.  When both of these factors are at play it is a scenario for disaster – one that many might say is both entirely unnecessary.  I was recently promoted to read the coroners report in this tragic case in Melbourne in 2012 – an extremely distressing and sad tale that encapsulates many of these issues.

Knowing that no mother would ever deliberately put herself or her child at risk, what prompts a family to choose a scenario where the risks are perhaps questionably high compared to the benefits?  I believe that in these cases, the answer lies in a sense of injustice, disappointment, trauma and emptiness following an upsetting hospital birth scenario.  Emergency caesarians, situations where a woman and her partner are left feeling emotionally distraught, a perceived lack of support from busy midwives on the ward,  tiredness kicking in, breastfeeding issues, a sense of not being heard regarding medical care – the list could go on.    Even the very “best” birth and post partum experiences can leave a new mum feeling lost and confused.  Throw some traumatic experiences into the mix and a woman can leave hospital feeling angry, regretful, and resentful about her hospital experience.  Its not a big leap to see then that blaming the place and the people associated with those feelings is a potentially natural next step and walking away from those systems in subsequent pregnancies is somewhat understandable.

The main problem with this scenario is that the things that lead to the unpleasant scenarios in that birthing experience, potentially mean that any subsequent labour are predisposed to slightly higher risks.  If you had a post partum haemorrhage the first time, you have about a 14% chance of it happening in a subsequent pregnancy.  So, whilst it makes sense to not  want to go back to the place where all of this unfolded in the first instance, the body of evidence, says that this is exactly there you need to be.  I feel really strongly also, that in some instances, this  information is not taken full into account by both a pregnant woman and her partner when making an informed choice – ultimately, for informed consent to be truly that, a full understanding of the risks versus benefits needs to be thoroughly explored.  This has to include a discussion of the  follow through of potential consequences for the partner and extended family – if a mother dies giving birth in a high risk home birth, do the partner and family believe that the risk benefits ratio fits with their situation – are they prepared to bring up the child or children on their own.  This decision is not just about the woman’s desires  but the whole family.

Whilst the desire to walk away from hospital and medical systems  makes some sense in these instances, I believe that the scenario could be avoided  with a relatively cheap, low risk, no side effect intervention in the weeks that follow birth- a session or two with someone from those hospital systems (preferably someone involved in the birth)  who can offer a listening ear, reassurance, education and a plan going forwards.  I believe that the missing link in many of these scenarios is just that sense of not being heard, combined with a lack of full understanding of what took place and why, and what the future consequences might be.  This is not to say that the existing systems don’t understand this, or try to implement such an approach, but recognises that resources are often limited and the capacity to offer such a service is limited.

Research tells us that not being heard is one of the primary complaints of patients utilizing  medical services.  The same series of studies also tells us that reassurance and education in itself can offer fantastic outcomes with regards to reducing distress and improving other outcomes.  We need to start seeing the time spent both listening and educating patients as a clinical entity in itself, and in doing so allowing the time and funding required to deliver it.

Shingles and Post Herpetic Neuralgia

Post Herpetic Neuralgia

The varicella zoster virus, also know as the chicken pox and shingles virus, is a type of herpes virus.  In younger people, it  causes the chicken pox.  The virus will then lay dormant in the dorsal root ganglion (bundles of nerves close to the spinal cord).  Most young adults who are tested will demonstrate seropositivity to the virus –  meaning that they carry the dormant virus and are at risk for it developing into shingles in older age.  Our immune system will tend to keep the virus in check, however as we age, the number of circulating antibodies that are specific to the virus tends to drop, and the virus can reactivate.  This results in a painful, blistering rash in a unilateral, single dermatome.  Acute pain in the distribution of the dermatome usually precedes the rash by 7-10 days (1-3).

screen-shot-2016-09-29-at-12-50-07-pm

The rash will tend to heal in 2-4 weeks, but roughly 10- 27% of sufferers will go on to develop a condition known as post herpetic neuralgia (PHN) (4). This is a nasty, painful conditions that proves very difficult to treat.  The pain is described as being dull and constant or burning in nature, with many describing sharp, shooting pains as well.  Some people also find the area to be intensely  itchy.  This is not a fun condition and the burden of disease is huge.

The literature tells us that there are a few factors that can predict the likelihood of someone going on to develop PHN following the herpes zoster infection.  These include older age, a worse rash in terms of pain levels and severity of the rash, diabetes and involvement of the eye (3, 5).

Treating PHN is notoriously difficult.  Success is generally defined as a 30% reduction in symptoms, however only about half of people treated for the condition  will actually achieve this level of relief.   (1, 2, 6, 7).  The literature suggests that best treatment options are amytriptiline, gabapentin, lidocaine patches and perhaps even opioids.  Many times, a combination of several medications is required to achieve better outcomes (1).

Prevention is always better than cure and preventing PHN seems to come down to several factors.  Oral antiviral medications are effective at reducing the duration and severity of the shingles virus.  There is insufficient evidence to suggest that they are effective at reducing the development of post herpetic neuralgia, however there are some newer drugs on the market which are yet to be extensively investigated for their capacity to prevent the progression from acute pain to chronic pain  (8). The problem in the real world with such an intervention is that it needs to be taken within 72 hours of the rash appearing to be effective.  Patients may not present to doctor within that time, or the rash may be misdiagnosed.

The most obvious way to prevent PHN, is to prevent the population from getting shingles in the first place.  The shingles vaccine has been shown to reduce the occurrence of the virus by about 50%  in a vaccinated population.  Further, those who do get the disease following vaccination tend to have a milder rash and less pain  (8, 9).

Public health recommendations generally don’t support vaccination for people under 60.  This is based on data that says that it is not cost effective – the costs of vaccinating a population under 60 do not outweigh the costs associated with not vaccinating (treatment, medication and ongoing costs in the event of post herpetic neuralgia).  This is not the case in the population over 60 and it is generally recommended that people over that age get the vaccine   (4, 10).  However, we need to remember that public health decisions are exactly that – made for the public.  For the individual, the opportunity to reduce the chances of getting shingles and the subsequent change of that hanging around and becoming PHN, the choice is a no brainer – get the vaccination, even if you have to pay for it.

For primary healthcare practitioners, this is an easy chat to have with a patient over 50 that could save a lot of suffering for that individual.

1. Hadley GR, Gayle JA, Ripoll J, Jones MR, Argoff CE, Kaye RJ, Kaye AD. Post-herpetic Neuralgia: a Review. Curr Pain Headache Rep 2016;20:17.

2. Argoff CE, Katz N, Backonja M. Treatment of postherpetic neuralgia: a review of therapeutic options. J Pain Symptom Manage 2004;28:396-411.

3. Boogaard S, Heymans MW, de Vet HC, Peters ML, Loer SA, Zuurmond WW, Perez RS. Predictors of Persistent Neuropathic Pain–A Systematic Review. Pain Physician 2015;18:433-57.

4. Drolet M, Oxman MN, Levin MJ, Schmader KE, Johnson RW, Patrick D, et al. Vaccination against herpes zoster in developed countries: state of the evidence. Hum Vaccin Immunother 2013;9:1177-84.

5. Forbes HJ, Thomas SL, Smeeth L, Clayton T, Farmer R, Bhaskaran K, Langan SM. A systematic review and meta-analysis of risk factors for postherpetic neuralgia. Pain 2016;157:30-54.

6. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006;174:1589-94.

7. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet Neurology 2015;14:162-73.

8. Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014:CD006866.

9. Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2016;3:CD008858.

10. Le P, Rothberg MB. Cost-Effectiveness of Herpes Zoster Vaccine for Persons Aged 50 Years. Ann Intern Med 2015;163:489-97.

Students and New Graduates: leading the charge.

Get a few pain people together to talk about how we can change the face of healthcare to embrace a more current understanding of pain and reliably the conversation will head towards a consistent answer: students.

Reaching out to existing clinicians to get them on board with a more modern view of pain is tricky for a  few reasons:

  • Some of them don’t go along to appropriate professional development courses, choosing to fill their CPD quota with business marketing courses and therapeutic courses that fall well short of what I believe the public expect of government registered practitioners to fulfill every year.
  • Some of them have ventured into learning about pain science and find it too much of a paradigm shift because:
    • It invalidates their way of practice (it doesn’t necessarily)
    • It devalues their contribution to previous therapeutic successes (it doesn’t – it just my change their understanding of why such success was obtained)
    • It is a threat to business (it doesn’t have to be – we all need to move with the times.  Be thankful you are not a taxi driver in a city with Uber!)
    • It can feel to them like they are learning that the earth is flat.  The cognitive dissonance kicks in and they turn their back on it.
    • Having said that, not everyone is getting left behind. Clinicians are paying attention and pain science is is becoming more and more present in the mainstream.

But students and new graduates are the obvious way forward to create a generational change and shift in the way we deliver healthcare – one that fits a little more closely with our current scientific understanding.

Having been in contact with both students and new grads from universities in Australia and the USA in both osteopathy and physical therapy professions, I am confident that the wheels are in motion.  Students are embracing a biopsychosocial model in their early years and are clever enough to navigate a system where they are learning about social and psychological factors that influence pain in one class  and biomechanics based treatment approaches in the next class.  They are the first generation to be integrating this understanding from the get-go – and I envy them!

New graduates are equally important for us to be focusing our attention and mentoring skills towards.  No clinician can forget those early days going home after a crappy day thinking: “ I am just not doing it right – my patients are not getting better”.  That crushing feeling that your manual skills are just not up to scratch because you had this idea that you should be able to fix everything with your hands!  Despite having a better understanding of this as the “bio” bits of a biopsychosocial approach, it can still be difficult and in the event that they seek counsel from a clinician with a very “bio” understanding of pain, they can end up seriously disillusioned.  The weight of words from experienced and well respected clinicians can be enormous – especially, for example, when they are telling people that X-rays for an asymptomatic patient with a common spinal anomaly are needed.  Or perhaps even running courses that advocate such understandings.  How do we help a  new grad navigate this?  Some suggestions:

  • Mentor them – if you employ a new graduate in your clinic it is your responsibility to help shape their understanding, handle the tricky cases and integrate their knowledge with clinical pearls of wisdom.
  • Help them set out their professional education calendar for the first few, very influential years
  • Run a journal club with your own clinic or other local practitioners
  • Make observation of other practitioners a regular part of your clinic – we can all learn from each other and the feedback and scrutiny for the treating practitioner can be fantastic.
  • Sponsor or mentor a student – have them in regularly for a chat and some observation.  Pay for them to go along to courses that you think will benefit them.

A manual therapist NEVER needs an MRI to manage low back pain

This was written by Monica Noy and Alison Sim

A manual therapist NEVER needs an MRI to manage low back pain

– an opinion(ated) piece backed by research!

MRI findings will not change your management strategy

  • There is very little correlation between pain and findings on an MRI or other imaging. Vast numbers of pain free individuals have disc bulges or spinal degenerative changes present on MRI. (Brinjikji, Leutmer, Comstock… et al, 2015; Jensen, Bran-Zawadski, Obuchowski… et al, 1994; Suri, Boyko, Goldberg… et al, 2014)
  • If there are no red flags but you suspect a disc bulge or any form of spinal degeneration or osteoarthritis, an MRI might confirm (or not) those suspicions, but shouldn’t change your management strategy.
  • If there are radicular signs and symptoms (sensory changes in a dermatomal distribution, weakness, loss of reflexes) without progressive worsening, an MRI that has already been conducted tells you where the disc bulge is, or how big it is, but should not change your management strategy.
  • Best practice management in most back pain cases is conservative as illustrated by this handy, up to date guideline of management of acute low back pain with radicular signs and symptoms.
  • Red flags WILL change your management strategy. If there are red flags or if there are no changes to radicular signs and symptoms after 2-4 weeks of conservative approaches, or if there is a continual worsening of symptoms, a referral to the appropriate medical professional is required. They will decide if an MRI is an appropriate course of action to help them make the decisions that need to be made and if more invasive treatments might be warranted.

MRI findings can make people worse

How can a non-invasive imaging modality make someone with LBP worse?

One word – FEAR. Images of jam donuts with bright red jelly exploding out the side, threats of surgery, crumbling, crusty spines, horror stories about uncles, friends or cousins who ended up in wheel chairs or damaged by surgery, or not getting surgery.

Medical and manual therapy culture, and subsequently society at large have alarming things to say about disc bulges and osteoarthritis. But those alarming warnings about slippages and crippling dysfunction do not apply to the majority of LBP sufferers. Still, the myths are pervasive, and have a lot of staying power. The higher the fear, the worse the outcomes.

MRI findings are a waste of money

Not only do these images place a huge financial burden on individuals, health and insurance systems, there is plenty of evidence to show that they drive up both invasive interventions and cost in episodes of low back pain, regardless of the presence of radiculopathy. One study found that having an early MRI cost an average of around $13,000 in subsequent healthcare costs, compared to not having the MRI. (Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013.)  Just imagine what else could be done with that money!!

If MRI images provide questionably useful information that has no bearing on management or outcome, then we have little to no reason to seek these images, or request that our patient seeks them. (Rainville, Smeets, Bendix… et al, 2011; Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013; Suri et al, 2014).

MRI findings are not a necessity

If you already reassure patients that their back pain is likely to get better, or assure them that an MRI isn’t necessary and/or follow other current guidelines for management of low back (Chou, Qaseem, Snow… et al, 2007) then your help is needed. We can encourage colleagues who still default to the idea that what they see in MRI or other imaging is going to inform their treatment to engage with the current scientific understanding of MRI imaging, symptom presentation, pain science and outcome management.

Continued discussions about whether the degeneration at L5/SI is causing pain are really unhelpful, for both patients and clinicians.

                       *****  It just doesn’t fit with the science *********

 

 

 

The Science

Images, information and further studies to help educate your patients on these issues:

https://ptbraintrust.wordpress.com/2016/05/09/patient-education-binder/

Brinjikji,W.,  Leutmer, P., Comstock B., … et al (2015).  Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

Chou, R., Qaseem, A., Snow, V., et al.(2007).  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal  Medicine, 147,478–91.

Suri, P., Boyko, E., Goldberg, J., Forsberg, C., &  Jarvik, J. (2014).  Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders, 15,152.

Jensen,  M.,  Brant-Zawadski, M.,  Obuchowski, N., Modic, M., Malkasian, D.,& Ross, J. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69–73.

Rainville, J., Smeets, R., Bendix, T., Tveito, T., Poiraudeau, S., & Indahl, A. (2011).  Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice.  Spine Journal, 11(9), 895-903.

Webster, B., Bauer, A., YoonSun Choi, M., Cifuentes, M., & Pransky, G. (2013).  Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. Spine, 38(22), 1939-1946.

Why the “WHY?” is so important

I’m sitting in a café, trying to mark exams (and stop procrastinating) and the ladies opposite me are having a fairly public and loud “nutrition consult”.  One is paying the other for her advice and is listening intently.  I promise I am trying hard not to listen… but it is so loud… and so….. interesting:

Client: So that is why my knees are giving me so much trouble?  Because of my diet?

“Nutrition” lady: Absolutely – your diet is so inflammatory, it is 100% causing your knees to get sore and probably also causing all sorts of other problems –  heart problems, digestive problems…..

Client: ooooooooooohhhhhh.  Woooooooooow!

“Nutrition” lady: you need to eat more Kale, melon, spinach, beans.  But NEVER eat raw broccoli and avoid pumpkin and cooked cauliflower – you can eat it raw but never cooked.  Eat blueberries and raspberries but NEVER strawberries – those babies are so bad for you………………  And it all must be organic…..

On and on it went.  The client left a little bewildered with a strange and random list, heading home via the organic shop to infuriate her family, friends and facebook friends with her new nonsense diet that was going to cure her knee pain and toxic liver.

Now can you see why I couldn’t concentrate?

The “why” behind our pain can tend to drive us to do some strange things – it is a big component of “the search” for the quick and easy answer to our pain.  If we can just find out the why, then we can do something about it and there is our answer.  Hooray!!!!!  If only it was that easy.

Looking for answers seems to be part of our culture – we are quick to blame, rather than attend to the problem in front of us.  My own example of this is my tension headaches – they come on occasionally, perhaps a couple of times a year, usually when I am burning the candle at both ends.  They tend to last a week or so and they suck!  They are a good empathy check for me to help deal with patients in pain.  My natural tendency is to go looking for a specific reason as to why they might have popped up this time – is it lack of sleep, stress, too much work on etc. Sometimes, I just can’t pin down a reason at all and I find this situation the most distressing – if I can’t even figure out what I have done to bring them on, how do I stop it from coming on again?  The desire to be in control in all aspects of my life is obviously a dominant one!   I have begun to reason with myself that perhaps I can’t be in control of these things – and that is OK!  I can generally keep doing what I need to do WITH a headache and I know it will go away in the near future.

Disengaging the patient away from looking for the “why” is a massive part of pain education.  Its also often the hardest part to shift – people have usually latched onto a “why” that may be incorrect but has meaning or makes sense to them.  They will often have fitted it into a rule type situation that looks like this:

When I _____________________________, ____________________________ happens.

For example,

When I  eat cooked cauliflower, my knees get really sore

Devil cauliflower

These are often incorrect and unhelpful understandings about a person’s individual situation.  Myth busting in these cases is an important part of pain education.  How we go about that is probably going to be the key to success or failure.  For example, laughing until you fall on the floor about the cauliflower probably isn’t going to work well as a rapport building exercise.  We need to remember that the desire to know why can be a powerful driver and disentangling that needs to be done delicately.  We also need to recognise that if we take away someone’s long held assumptions, we need to replace it with something that is accurate, tangible, reassuring  and helps them to look forward towards function, rather than keep looking for answers.  This is the essence of good pain education.