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Part of the definition of pain is that it is "a sensory and emotional experience" - in other words, emotions of the negative kind are integral to the experience of pain. Is it any wonder that poets and authors have written so eloquently about the anguish of unrelieved pain? As I write this, I've been pondering the way "psychosocial" has been used when discussing pain, as if those factors aren't experienced by "normal" people, as if the way we feel about pain and the way people who struggle with their pain feel are two entirely different things.

Chris Eccleston, someone I admire very much, writes about a "normal psychology of chronic pain" and makes some incredibly useful points: that pain is a normal feature of human life. Pain is an everyday occurrence (watch kids playing in a playground - every 20 minutes kids communicate about pain, Fearon et al, 1996). In New Zealand one in five people report experiencing pain lasting six months or longer. Pain really is all around us - and it's normal and indeed part of the experience itself, to feel negative emotions such as fear, anger, sadness, anxiety, and such when we're sore.

So why have emotions been lumped in with "other factors" as part of the negative way psychosocial factors are interpreted today? I personally think it's partly a hangover, in NZ at least, from the way our stoic forebears viewed "weakness". There wouldn't be many families in New Zealand who haven't heard something like "man up", or "big boys don't cry", or "pull yourself together" with great All Blacks who played on despite broken ribs or arms - who didn't give in when they were injured being held up as examples we should emulate. At the same time pain isn't given much space in our health professional training programmes - and when it is, it's primarily viewed in a neuroanatomical way, as we're taught about spino-thalamic tracts, and nociceptors, and not much else. In fact, I think the gate control theory is still being taught as the main theory in some programmes (despite it being revised and replaced with more sophisticated models).

So what is normal? I really like Acceptance and Commitment Therapy, as you've possibly noticed. Amongst one of the many reasons I like it so much is its view of suffering. Within ACT, being psychologically inflexible is the problem - that is, working hard to avoid or control experiences we don't want, getting caught up in thoughts as if they're Truth instead of our mind's opinion of things, being attached to someone's idea of who and what we are, living in the past or predicting the future, and failing as a result to take actions that line up with what our personal values are. When we get stuck thinking there's only one way to deal with a situation, and when we forget about what's important in our lives because we're working so hard to avoid certain experiences - these aren't seen as pathological, but instead are just part of the way our mind/language and experience tangle us up. The beauty is that there are ways out of being stuck but they're counter-intuitive.

What do I mean? Well if we all have negative emotions about pain, why do only some of us struggle with that experience and get stuck? For some people it's because they're trying so hard not to feel pain that they spend time and energy doing things to control it and in the process stop doing things that matter. Think of the many appointments and the ups and downs of hope that it will all go away with this magic thing - then despair as it doesn't work. Just the amount of time people spend waiting for and attending appointments can take time away from being with family, working, living ...Now to me, this is not psychopathology. This is what normal minds do - try to fix a problem using strategies that have always worked in the past.

At the same time, given pain is a negative experience, doesn't it make sense to monitor what went on last time you tried to lift that box, go to work, drive the car... AND doesn't it make sense to anticipate what might go wrong if you try it again? This isn't about being depressed, anxious or any other kind of pathology - this is just what we've learned to do, and our minds are trying incredibly hard to make it work again.

When I mentioned that a solution might be counter-intuitive, what I mean is recognising that trying to control or avoid an experience that comes with us wherever we go because it's part of us, can trip us up. Instead, we might do better if we soften our attempts to control or avoid our experience of pain. Maybe spending time exploring pain and doing things alongside pain is possible - especially if the things we want to do are important to us. Don't believe me? Think about marathon runners - they feel the pain (hit the wall) and still keep running! Why? Because it's important to them to get to the end.

Now I'm not suggesting that ALL people will find this approach helpful, and I'm NOT denying that many people with persistent pain experience depression, anxiety, rotten sleep and generally feel demoralised. What I AM saying is that if we approach everyone with the misguided idea that psychosocial factors exist only in "those people", we're wrong. Any one of us will experience negative emotions if pain is present - and even more if pain persists. This is a normal response to a challenging and inherently aversive experience. Of course, if we've experienced depression, adverse life events, turmoil in our home and work life, and the stigma of not being believed, the potential to then become angry, depressed, and fed up is only greater. Let's not make a negative experience worse by stigmatising people with the notion that "psychosocial factors" makes them any different from anyone else.

Eccleston, C. (2011). A normal psychology of chronic pain. Psychologist, 24(6), 422-425.

Fearon, I., McGrath, P.J., Achat, H. (1996). 'Booboos': The study of everyday pain among young children. Pain, 68, 55-62.

Vowles, K. E., Witkiewitz, K., Levell, J., Sowden, G., & Ashworth, J. (2017). Are reductions in pain intensity and pain-related distress necessary? An analysis of within-treatment change trajectories in relation to improved functioning following interdisciplinary acceptance and commitment therapy for adults with chronic pain. Journal of consulting and clinical psychology, 85(2), 87.

Posted in ACT - Acceptance & Commitment Therapy, Chronic pain, Coping strategies, Occupational therapy, Pain, Pain conditions, Physiotherapy, Professional topics, Psychology, Research, Science in practice, Therapeutic approaches and tagged acceptance, biopsychosocial, Chronic pain, Clinical reasoning, function, Pain, pain management, Therapeutic approaches by .4 Comments

Last week I discussed some of the areas in the brain, and basic principles, that are currently thought to influence our pain experience. This week I thought I'd introduce one of my favourite ways of considering pain mechanisms, mainly because it helps me think through the four main kinds of mechanisms, and can influence our treatment approach. At this stage I want to raise my hand to acknowledge the following:

My gratitude to Dr John Alchin, longtime friend and colleague, who first pointed this paper out to me and has shared it with hundreds of people who go to see him at the local tertiary pain management centre.

We know this is a simplified, under-developed approach to mechanisms underpinning pain, but it's helpful nevertheless.

Most of our patients will have a combination of mechanisms involved in their experience, not just one.

This approach to mechanisms doesn't include the psychological or social - just the primary biological processes.

Throughout this blog, when I use the word "pain" I mean the experience we have once whatever mechanisms involved filter up through to our awareness. So while I talk about peripheral mechanisms, they're only experienced as pain once we become aware of them - and that process involves a whole lot of what I discussed in my last post .

Clifford Woolf wrote this paper in 2010, and although the research into mechanisms has continued unabated, I think it provides clinicians with a reasonable guide to considering how best to tackle treatment. He begins by dividing the mechanisms into "useful" and "useless" pain - ie pain that is useful for adaptation, survival, warning, alerts. Just as it's possible to have dysfunction or disease of our cardiac, pulmonary, gastro-intestinal, and skeletal systems, I think it's just as plausible that we can have something go wrong with our nociceptive system. In fact, because of its complexity, it seems probable to me at least that there are many different ways this system can fail to work properly. But more about that shortly! Let's begin with the useful pain.

Nociceptive pain - is considered to be pain that is, as Woolf puts it, our "early-warning physiological protective system". When we touch something super cold, super hot, or a chemical that can harm us (think chilli pepper!), or meet a mechanical force that activates mechano receptors, our high threshold nociceptors are activated - well in advance of tissue damage, I quickly add. This process activates withdrawal - even in simple single-celled animals - and saves us from harm. When combined with behavioural responses including vocalisation, grimaces and other pain behaviours, we signal to everyone around us that we're in danger, and others shouldn't do what we've just done (Melzack, Dennis, Kosterlitz & Terenius, 1980). For me, the cool thing about nociceptive pain is that once you've removed that stimulus (got rid of the chilli on your lips, let go of the ice-cube or the hot mug of coffee, or shifted in your seat to relieve your butt) the pain simply goes away. Just like that. How cool?!

Inflammatory pain - is also a useful pain to have. Unlike nociceptive pain, inflammation involves disruption to the tissues, triggering a release of a whole bunch of neurochemicals and cells that quickly lower the point at which nociceptors will fire (making you much more sensitive to mechanical, chemical and temperature input), and increasing the blood supply to allow foreign material, dead cells and spent neurochemicals to be whisked away. Inflammation is reasonably easy to see in the periphery (though not so easy in the internal organs because the innervation is more diffuse) and you'll all have had it - think sunburn (I know you're not meant to, but everyone gets sunburned at least once, especially in our NZ sun). With sunburn you're red, hot and often swollen, and you really know it when you step into the shower! That experience of ouch! to your usual shower temperature (and the ouch! when you towel down) is allodynia, or the experience of pain when a usually comfortable stimulus is applied. You'll experience hyperalgesia if your mate comes along and slaps you on your sunburned shoulders!

Now both of these mechanisms are useful because they alert us to threat, they make it more difficult to move around, and we often respond to them with changes in our behaviour that act as a signal to others around us. Let's turn the attention to two mechanisms where there is something gone awry with the nervous system - in other words, useless pain.

Neuropathic pain - is defined by IASP as " pain caused by a lesion or disease of the somatosensory nervous system." What this means is that there must be an identifiable lesion in the nervous system somewhere - something that can be imaged or tested to demonstrate damage. This could be in the periphery - think of radial nerve entrapment with its characteristic tingling, deep aching and burning over the distribution of the nerve. It could be in the spinal cord itself - think of a complete spinal cord injury where the person is unable to move from the lesion down, and who also gets the same tingling, aching, burning and electric shock pain over the same area. A simple example would be radicular pain where the nerve root is compressed - and this can be seen on imaging, and where the pain is experienced over the same nerve distribution. The final group in this nasty set of neuropathies is when someone has a stroke, where part of the brain is damaged leading to intractable, deep, aching pain with electric shock-like pain just to make it nastier. For a great paper reviewing neuropathic pain, Finnerup and colleagues wrote one published in 2016 (see below), describing a grading system to indicate possible, probable and confirmed neuropathic pain. The hallmark of this pain is that it doesn't represent tissue damage except in the area of the nervous system where the lesion is located. In other words, that pain down the leg is not where the problem lies in radicular pain - it's near the spinal cord. So this pain doesn't have a function for survival - it's just a horrid nuisance.

The final mechanism is poorly understood - even less well understood than neuropathic pain. This is where ostensibly the nervous system appears intact. The pain experience might be in multiple parts of the body, it could be just in the head (migraine, for example), or it could be just in the shoulder (frozen shoulder maybe?), or it might be everywhere (fibromyalgia). The name isn't even completely determined - it's called " dysfunctional" by Woolf, and he collapsed this and neuropathic pain into one mechanism, but I prefer to keep it separate because it's more helpful for management especially when a neuropathy might be amenable to surgery. Another term, and one I like, is nociplastic - referring to the idea that it's the unhelpful neuroplasticity of our nervous system that has over-responded to potential threat (Kosek, Cohen, Baron et al, 2016). Some would argue that this mechanism is partly a general tendency to a lower nociceptive threshold, maybe genetic, maybe behavioural (ie we've learned to monitor and respond to threat perhaps because of early life experiences), perhaps a diathesis-stress where the predisposition exists but it's not brought into expression until a stressor, perhaps a virus or an injury, exerts an influence on homeostasis.

Ultimately, pain is an experience that we've all had, and one that has individual meaning for each of us based on our previous experiences, predictions for the future, current goals, culture and biology. What a mechanisms-based approach to pain management might mean is better and more accurate management for each one. So we'd be looking to remove that bunion so people can walk more easily; reduce the inflammation in an auto-immune disease; decompress a squished nerve in neuropathic pain and look to altering plasticity in nociplastic pain. But pain is weird and as I said at the very beginning, it's entirely possible to have more than one mechanism involved - and because pain is not just biology, we'd be foolhardy to think that just by down-tuning the intensity, everyone so treated will go "back to normal". More on that next week!

Finnerup NB, Haroutounian S, Kamerman P, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016;157(8):1599-1606. doi:10.1097/j.pain.0000000000000492.

Melzack, R., Dennis, S. G., Kosterlitz, H. W., & Terenius, L. Y. (1980). Phylogenetic evolution of pain-expression in animals. Pain and Society, 13-26.

Woolf CJ. What is this thing called pain? The Journal of Clinical Investigation. 2010;120(11):3742-3744. doi:10.1172/JCI45178.

Posted in Education, Pain, Pain conditions, Research, Science in practice and tagged biopsychosocial, Chronic pain, Health, Pain, pain management, Research by .1 Comment

From time to time I see a flurry of tweets or Facebook posts about pain and psychosocial factors. Many of them are informative, intriguing and empathic, but some are just plain wrong. The ones I most get upset about are those arguing that because someone has "psychosocial factors" their pain must be psychological in origin, followed closely by the idea that psychosocial factors equate to psychopathology. This is a series of back to basics posts where I hope to set these things right.

Pain, according to the current definition, is

"an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"[7] is derived from a 1964 definition by Harold Merskey,[8] and it was first published in 1979 by IASP in PAIN, number 6, page 250.

An associated note, which should be read alongside this definition is:

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

The final sentence in the note is important, distinguishing between the experience of pain and the biological apparatus transmitting information from the nociceptors, ending in a bunch of places in the brain. I personally dispute the sentence "many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons" because (recall when it was first written) science has moved on and we now have good evidence supporting the notion that abnormal processing is involved in cases such as migraine (Iyengar, Ossipov & Johnson, 2017; Pietrobon, 2017) and fibromyalgia (Schmidt-Wilcke & Diers, 2017; Tour, Lofgren, Mannerkorpi, Gerdle, Larsson, Palstam et al, 2017). As a side note, I love science because we can revisit beliefs and revise our understanding as more information is collected - whether we'll ever get to the "truth" is debatable, but we can get closer and closer as we continue learning (see Bhaskar).

Back to basics. It's evident that ALL pain is a psychological experience and therefore will be influenced by our current goals, past experiences and predictions for the future. And these aspects of attention, motivation, memory and decision-making are present in all of us and for every sensory experience. Take sound, for example. I'm sitting at home listening to a large truck rumbling away, dumping construction materials in the section two doors down. That sound is so like the deep rumble and thud of an earthquake that I'm aware I'm on edge because, after more than 10,000 earthquakes since the first one in the Canterbury region this day seven years ago, my nervous system has learned to be on high alert - who knows what could happen next?

Seven years of learning, 10,000 earthquakes-worth of learning, lots of emotions and lots of very real and scary outcomes. It affects people. In the same way, pain, which we learn about from birth, is influenced by personal experience, by other people's experiences, and by prevailing community attitudes. This is not psychopathology - at least, not for me though some people have experienced PTSD as a result of the earthquakes we've been through. You'd likely do that if you were trapped in a building with no way out, and countless aftershocks continuing while rescuers try to get to you. Most people in Christchurch, however, have simply learned to be aware of sights and sounds that signal a quake - and quickly get back to usual once the sounds have gone. Similarly, most people who experience pain, don't have a mental health problem - they've learned, as we all do, that pain is unpleasant, and learn to avoid situations where pain is likely to occur. In our society, experiencing pain is not viewed as "normal" and indeed, some people have called us "algophobic" - afraid of pain (Kugelmann, 2016). This means we've learned to look for ways to get rid of our pain, even if it's not very intense - because pain means something is "not right" with us.

And one of the functions of pain is to alert us to the potential that something is threatening our bodily integrity, and withdraw or avoid such situations (ie, to learn from them). And as a species we're designed to be social, so we also display behaviour when we're hurt that others can see - thus helping spread the word "don't do that dumb thing!" (Steinkopf, 2016).

To summarise: pain is an experience we've all had, and yet it remains something we don't fully understand. Irrespective of the modality of sensory experience, humans are hard-wired to make sense of, and act upon, experiences based on prior learning, current goals and future predictions, within a context that is inherently social. We're actively engaged in making sense of our experiences so we can remain safe and give and receive support from those around us. While the experience is psychological, the apparatus producing that experience is biological, filtered through our social and contextual experiences. Like taste, sound, and colour - pain is inherently subjective.

Next post - does this mean the biological is redundant?

Pietrobon, D. (2017). Lessons from familial hemiplegic migraine and cortical spreading depression. Neurobiological Basis of Migraine.

Posted in Pain, Pain conditions, Research, Science in practice and tagged biopsychosocial, Pain by .Leave a comment

The debate about cannabis and derivatives for persistent pain continues to grow in New Zealand, and elsewhere in the world. Many people I've treated and who are living with persistent pain say they like to use cannabis (in a variety of forms) to help with pain intensity and sleep, adding their voices to those wanting "medicinal" cannabis to be approved. In the few patients I've worked with who have managed to obtain a cannabis product (in NZ it has to be legally prescribed and will generally be in the form of Sativex or similar) the effect doesn't seem as profound as the real thing (whether smoked, vaped, or in edibles).

Here's my current position, for what it's worth. Right now I think cannabis legislation needs an overhaul. Cannabis doesn't seem to fit into the same class as synthetic drugs (often called "herbal highs" or synthetic "cannabis") - for one, the plant probably contains a whole lot of substances that have yet to be fully analysed, and for another, I have yet to see a death reported from cannabis use, yet in Auckland, NZ, alone this year there have been around 9 people who have died from taking the synthetic substance, whatever it is. Cannabis seems to cause less harm than legal substances like alcohol and tobacco, and in many places in the world it's been legalised with some interesting effects on use of opioids.

Ever since Professor David Nutt visited New Zealand a few years back, I've been convinced it's time for a rethink on cannabis laws, but at the same time I'm not ready to support wholesale legalisation of "medical" marijuana. Here are a few reasons why:

When a doctor prescribes a drug, he or she is able to rely on the manufacturer making a consistent product, with a consistent amount of "active" ingredients, and a consistent quality. At present, with the exception of the two versions available in New Zealand, this can't be guaranteed. Plants vary in the combination of active chemicals in them, and storage and age of the product influence the availability of those chemicals when inhaled or ingested. Just as we don't suggest people go and grow their own opium poppies because we know that opioids are effective analgesics, I don't think it's time to allow people to grow their own cannabis for medicinal purposes, such as treating pain. A doctor can't know just how much of a dose a person can get because in NZ we don't yet have a controlled environment for cannabis production.

When a doctor prescribes a drug, he or she is also guided by the indications for use. So, although some medical practitioners prescribe "off-label" use for medications (a good example is nortriptyline, an antidepressant used often for pain reduction), generally there are good double-blinded, randomised controlled trials to determine whether the active drug is more effective than placebo. When we read about cannabis use for medicinal reasons we hear of its use for cancer (mainly nausea, but also pain), neuropathic pain, and in the general media we hear of its use for migraine, period pain, abdominal pain, fibromyalgia, osteoarthritis - there's very few pain disorders that cannabis isn't seen to be appropriate. But the truth is, we don't really know which kind of pain (the underlying mechanism) will respond, and what pains don't respond. It's still a bit of a mystery - mind you, this is not any different from other medications for pain for which N=1 seems to be the mantra.

Why might I support a change to marijuana laws?
Well, an interesting study from the Northeastern United States, and published in the journal Pain, looked at the perspectives of people enrolled in legal medical marijuana clinics. It was quite a large study of 984 people, so should represent a good cross-section of those using the drug within a legal system. Participants were asked to complete an online survey, and their responses were analysed by a psychologist who was "not a cannabinoid expert", arranging the data into themes and subthemes. (As an aside, apparently this was carried out using a "Grounded Theory perspective" based on Corbin and Strauss - BUT essentially the researchers didn't follow grounded theory methodology throughout, and instead it should be called a thematic analysis using inductive coding. Pedant, yes!). The data was then examined to quantify the responses (another violation of GT methodology), and re-examined by another co-author for verification.

What they found was a group of people, over half women, with 2/3 indicating they'd been diagnosed with chronic pain by a medical professional. Diagnoses varied, but most (91%) had low back and neck pain, 30% with neuropathic pain, 23% with postsurgical pain, nearly 22% with abdominal pain, 20% with chronic pain after trauma/injury, 7% with cancer pain and 5% with menstrual pain. Most people smoked cannabis either by joint, pipe or bong; some used a vaporiser, some had edibles or a tincture, and least, some sort of ointment.

The participants indicated it was on average 75% effective at reducing/treating symptoms, which is extraordinary when you realise that traditional forms of medication for neuropathic pain may reduce pain by 50% in around 1 in 4 people (Woolf, 2010). Participants spent around $3118 each year, but this was skewed because concentrates cost $3910, while topicals were $814. Joints were more expensive than vaporised product ($260 different!).

Analysing the positives of cannabis, participants reported pain relief, or at least being able to tolerate the pain more easily; while sleep benefits was the next most significant theme. Participants were encouraged that cannabis doesn't have overdose potential, it's natural, there are a wide range of strains with different characteristics, and limited potential for dependence.

There were numerous other positive aspects to using cannabis this way, according to the participants: things like "feeling normal", "I am more active and able to do things I want", being "distracted" from the pain, "able to focus", and "able to relax".

Negative perspectives included the cost (too expensive - in NZ Sativex is around $1000 a month - not covered by NZ pharmaceutical subsidies); some people didn't like the smell, the effects on lungs and breathing, appetite changes (and gaining weight), and some emotional effects like anxiety or paranoia. Stigma and judgement by others also features, as did the difficulty accessing the drug, and conflict about the different laws applying to cannabis use - noting that the US has different federal and state laws.

Overall, the responses from these participants suggest a benign, mainly positive response to a drug, with negatives primarily around the social aspects - stigma from health providers, other people thinking of the participants as stoners, the legal situation and so on. For me, the limitations of this study really preclude any major judgement as to benefit or otherwise. We only know what this group of people believed, they have a vested interest in promoting benefits because negatives won't support their belief that this is a viable treatment option, we don't know the effect on function (particularly objective data), and we have no way of verifying the diagnoses individuals reported as the reason for prescription.

My conclusion?
It's way past time to discuss cannabis use, health risks and health benefits. To have an open discussion about use for medicinal reasons, we need to remove the current barrier: the legal situation. While people have a vested interest in promoting the benefits over risks or adverse effects, we're not going to have a very clear picture of what happens with ongoing use. I don't support the use of cannabis as a medicinal product - to me there are far too many unknowns, and I think we risk wedging open a gate that has, until now, been useful for limiting the risk from pharmaceutical harms. We need to subject cannabis to the same level of rigour as any other pharmaceutical product being introduced to the market.

On the other hand, I think removing legal barriers to recreational use is about balancing the benefits and harms of this substance against other substances used for similar reasons. Alcohol and tobacco are well-known for harmful effects. Prohibition of alcohol did not work. Tobacco smoking is reducing over time courtesy of a committed campaign documenting harms, as well as raising the price via taxation. We can't campaign around health harms for a product that isn't legal. We can't establish useful regulation over who produces it, who can buy it, where it can be used, the effects on work injury/vehicle injury, we can't represent the undoubted benefits, and we look, to many people, to hold a double-standard.

And sneaking cannabis use in under the guise of "medicinal" use just isn't on, in my humble opinion. Let's not put medical practitioners in an unenviable situation where they're asked to prescribe a product that is not yet examined to the level we expect for every other pharmaceutical product on the market. Let's spend some precious research funding to establish WHO cannabis helps, WHAT it helps with, and HOW it helps - and most importantly, let's look at whether it helps produce outcomes that surpass other approaches to persistent pain. We need to face it, currently our treatments are not very good.

Piper, B. J., Beals, M. L., Abess, A. T., Nichols, S. D., Martin, M. W., Cobb, C. M., & DeKeuster, R. M. (2017). Chronic pain patients' perspectives of medical cannabis. Pain, 158(7), 1373-1379.

Woolf, C: (2010). Review: Overcoming obstacles to developing new analgesics, Nature Medicine (Supplement); 16,11: 1241 - 47

Posted in Chronic pain, Coping strategies, Pain conditions, Research, Science in practice, Therapeutic approaches and tagged biopsychosocial, Chronic pain, coping, Health, healthcare, pain management, Research by .6 Comments

In a move likely to create some havoc in compensation systems around the world (well, at least in my corner of the world!), the International Association for the Study of Pain has worked with the World Health Organisation to develop a way to classify and thus record persistent pain conditions in the new (draft) ICD-11. While primary headache disorder has been in the classification for some years, other forms of persistent pain have not. Recording the presence of a pain disorder is incredibly important step forward for recognising and (fingers crossed) funding research and treatment into the problem of persistent pain. As the IASP website states:

Chronic pain affects an estimated 20 percent of people worldwide and accounts for nearly one-fifth of physician visits. One way to ensure that chronic pain receives greater attention as a global health priority is to improve the International Classification of Diseases (ICD) diagnostic classification.

The classifications are reasonably straightforward, with an overall classification of "chronic pain", and seven subcategories into which each type of pain can be placed.

Now there will be those who are uncomfortable with labelling a symptom (an experience, aporia, quale) as a separate diagnosis. I can understand this because pain is an experience - but at the same time, just as depression, which is an experience with clinical and subclinical features, so too is pain. There is short-term and useful pain, serving as an alert and warning, and typically an indication of the potential or actual threat to bodily integrity. Just as in depression which has short-term and usually useful episodes of sadness, withdrawal and tearfulness (as in grief). At the same time, there are periods when sadness becomes intractable and unhelpful - and we call this depression. Underlying both of these situations are biological processes, as well as psychological and social contributors. Until now, however, persistent pain has remained invisible.

The definition of chronic pain, at this time, is the IASP one from the 1980's:
"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Often, pain serves as a symptom warning of a medical condition or injury. In these cases, treatment of the underlying medical condition is crucial and may resolve the pain. However, pain may persist despite successful management of the condition that initially caused it, or because the underlying medical condition cannot be treated successfully. Chronic pain is pain that persists or recurs for longer than three months. Such pain often becomes the sole or predominant clinical problem in some patients. As such it may warrant specific diagnostic evaluation, therapy and rehabilitation. Chronic pain is a frequent condition, affecting an estimated 20% of people worldwide. This code should be used if a pain condition persists or recurs for longer than 3 months."

Chronic Primary Pain is defined as "...chronic pain in one or more anatomical regions that is characterized by significant emotional distress (anxiety, anger/frustration or depressed mood) and functional disability (interference in daily life activities and reduced participation in social roles). Chronic primary pain is multifactorial: biological psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate independently of identified biological or psychological contributors unless another diagnosis would better account for the presenting symptoms. Other chronic pain diagnoses to be considered are chronic cancer pain, chronic postsurgical or posttraumatic pain, chronic neuropathic pain, chronic headache or orofacial pain, chronic visceral pain and chronic musculoskeletal pain. Patients with chronic primary pain often report increased depressed and anxious mood, as well as anger and frustration. In addition, the pain significantly interferes with daily life activities and participation in social roles. Chronic primary pain is a frequent condition, and treatment should be geared towards the reduction of pain-related distress and disability." (definition are found here)

The definition doesn't require identified biological or psychological contributors - so people with primary pain would be those who have fibromyalgia, persistent low back pain, perhaps even "frozen" shoulder. The main requirement is that the person is distressed by it, and that it interferes with life. Now here's a bit of a problem for those of us who have learned to live well with our persistent pain - I experience widespread pain, but generally I'm not distressed by it, and seeing as I've lived with it since my early 20's, I find it hard to work out whether I'm limited by it, or whether I've just adjusted my life around it, so it doesn't really get in the way of what I want to do. Technically, using the draft definition, I might not be given the label. Does this mean I don't have chronic primary pain?

Why did I suggest compensation systems might be interested in this new classification? Well, in New Zealand, if a person has a pre-existing condition, for example they have osteoarthritic changes in their spine even if it's not symptomatic (ie it doesn't hurt), and then lodges a claim for a personal injury caused by accident, they may well find their claim for cover is declined. What will happen if someone who has fibromyalgia, has an accident (say a shoulder impingement from lifting something heavy overhead), and the problem fails to settle? I think it's possible they'll have their claim declined. Low back pain is probably the most common primary pain disorder. Thousands of people in New Zealand develop low back pain each year. Few will have relevant findings on imaging - and even if imaging shows something, the potential for it to be directly related to the onset of low back pain is open to debate. Especially if we consider low back pain to be a condition that doesn't just appear once, but re-occurs thereafter (1-7). What will this mean for insurers?

I don't know where this classification will lead insurers, but from my perspective, I can only hope that by incorporating chronic pain into the ICD-11 we will at least begin to show just how pervasive this problem is, and how many people need help because of it. And maybe, just maybe, governments like the New Zealand government, will begin to take persistent pain seriously and make it a national health priority.

1. Dunn, K.M., Hestbaek, L., & Cassidy, J.D. (2013). Low back pain across the life course. Best Practice & Research in Clinical Rheumatology, 27(5), 591-600.

2. Artus, M., van der Windt, D., Jordan, K.P., & Croft, P.R. (2014). The clinical course of low back pain: A meta-analysis comparing outcomes in randomised clinical trials (rcts) and observational studies. BMC Musculoskeletal Disorders, 15, 68.

3. Vasseljen, O., Woodhouse, A., Bjorngaard, J.H., & Leivseth, L. (2013). Natural course of acute neck and low back pain in the general population: The HUNT study. Pain, 154(8), 1237-1244.

4. Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., Bain, C., . . . Buchbinder, R. (2014). The global burden of low back pain: Estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases, 73(6), 968-974.

5. Campbell, P., Foster, N.E., Thomas, E., & Dunn, K.M. (2013). Prognostic indicators of low back pain in primary care: Five-year prospective study. Journal of Pain, 14(8), 873-883.

6. Axén, I., & Leboeuf-Yde, C. (2013). Trajectories of low back pain. Best Practice & Research Clinical Rheumatology, 27(5), 601-612. doi: http://dx.doi.org/10.1016/j.berh.2013.10.004

7. Hoy, D. G., Smith, E., Cross, M., Sanchez-Riera, L., Buchbinder, R., Blyth, F. M., . . . March, L. M. (2014). The global burden of musculoskeletal conditions for 2010: an overview of methods. Annals of the Rheumatic Diseases, 73(6), 982-989. doi:10.1136/annrheumdis-2013-204344

Posted in Chronic pain, Clinical reasoning, Health, Research and tagged biopsychosocial, Chronic pain, Clinical reasoning, Health, healthcare, Pain, Research by .6 Comments

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Part of the definition of pain is that it is "a sensory and emotional experience" - in other words, emotions of the negative kind are integral to the experience of pain. Is it any wonder that poets and authors have written so eloquently about the anguish of unrelieved pain?

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Patient education leaflet

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Patient education leaflet

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A clinician's perspective on treating patients in pain

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A clinician's perspective on treating patients in pain

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Insights on pain science and importance of psychosocial understanding

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Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it

SUMMARY

full article 10000 words

Pain is not just a message from injured tissues to be accepted at face value, but a complex experience that is thoroughly tuned by your brain. The results are often strange and counter-intuitive, like quantum physics, but the science is clear: every painful sensation is 100% Brain Made®, and there is no pain without brain.

Does that mean can we think pain away? Just how much power does the mind have over pain? Can confidence and education cure?

Articles on this topic are now common, but most of them tease readers with the tantalizing idea that pain can be treated with the mind... while failing to explain how. In this article, I get specific about what's realistic and practical with "mind over pain." There's bad news, but there's also good news - if you understand how pain actually works. 1 Many discoveries about the physiology of pain 2 3 have been painfully slow to reach the public, or even health professionals. This is useful stuff, and it needs to be shared.

Mostly we need to stop thinking of pain in terms of single causes or cures: "It's all coming from the ____, I know it!" It almost never is. 4 Pain is not reliable sign of what's really going on. Chronic pain is a witch's brew of different factors, complex by nature (not just coincidence or bad luck). At the very least, pain always has a layer of brain-generated complexity. At the worst, the pain system can malfunction in several colorful ways, causing pain that is much more intense and interesting than just a symptom - sometimes the pain is the problem.

Watch it! 2 great videos on this topic

This well-produced short video neatly summarizes many of the key points of the content of this article. I have quibbles with the advice they give - some nitpicking on that below.

Another fine video "summary" of a different sort: this hilarious TED talk about a snake bite and pain neurology. No, really, you will actually laugh! It's like stand-up comedy. Australia's Lorimer Moseley, Professor of Clinical Neurosciences and tireless pain researcher, is one of the best public speakers I've ever seen - a must-watch for anyone with chronic pain, and the professionals who care for them. Does he say "groovy" just a couple times too many? Maybe! But it is groovy ... mate.

Ramachandran's excellent phrase

Ramachandran said that "pain is an opinion" - which sounds like a flaky New Age mind-over-matter theory. But Ramachandran is no mystic or guru: he is a neurologist and scientist. This passage is mainly known for the first few words, a pithy statement of the modern understanding of how pain works:

He then tells the story of an extraordinary cure of a man with phantom limb pain, tortured by agony in a clenched fist that was not there. With a clever arrangement of mirrors, Ramachandran created the illusion that the man's amputated arm was restored - a sort of "virtual" limb. The mere appearance of his phantom hand opening and closing normally cured his agonizing "spasms." He felt better because of the illusion that he was better - because he thought he was better. The mirror-cure of phantom limb pain is one of the most curious anecdotes in all of pain science. In all of medicine, in fact.

Since then, "mirror therapy" has been studied and applied in many ways. A good quality 2007 study showed that mirrors aren't actually necessary to achieve this effect. 5 Mirror therapy is probably just a "fun" way to visualize healthy movement - which also works quite well without a mirror! 6

Stranger still are tales of severe pain without injury, illustrating that pain can be entirely in the mind. (Technically, it always is.) One of the strangest of these was reported in the British Medical Journal in 1995:

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

JP Fisher, senior house officer, DT Hassan, senior registrar, N O'Connor, registrar, accident and emergency department, Leicester Royal Infirmary 7

His pain was a "nocebo" - the opposite of a placebo. 8 Extreme examples like this are rare, but probably not as exotic as you might think. More to the point, even if they are rare, for every case like this there must be hundreds more where the injury is real but the patient is convinced that the damage is much worse than it really is - with proportionately exaggerated pain. Happily, it also works the other way, and people may feel much less pain than they "should" when they don't realize how bad the damage is.

Injury and pain are not in lock step with each other. And yet that is exactly what nearly everyone assumed for a long, long time. And many professionals, even though they may "know" better, often seem to forget how powerfully pain is influenced by perception.

The perception of the perception of pain in olden times (and not so olden times)

For most of the history of medical science, pain was believed to work more or less the way the French philosopher René Descartes described it: a simple signalling system.

1. The flesh is wounded. ("It's just a flesh wound!")

2. Nerves send an unambiguous message to the brain about the damage. The intensity of the message is directly proportionate to the severity of the injury.

3. The brain interprets that message at face value - that is, if the message says, "There's some bad damage here," we believe it.

Based on this model, almost everyone still - today, in 2017 - still assumes that any message sent to the brain by a certain kind of nerve will always cause pain. Health care professionals everywhere still believe that the nerve is "sending pain," that the signal is pain - and therefore these nerves are habitually called "pain fibers" and their messages are called "pain messages," an equivalence between signalling and pain baked right into the language. This is wrong! And it's worse than an oversimplification.

The labeling of nociceptors as pain fibers was not an admirable simplification, but an unfortunate trivialization under the guise of simplification.

The relationship of perceived pain to afferent nerve impulses, by Patrick Wall and SB McMahon, 254-255

For several decades now, it's been clear to pain scientists and neurologists that this simplistic, pain-fiber model is hopelessly inaccurate. In fact, they call it " the naïve view"! 9 Even microscopic worms with only two trouble-detecting nerves, compared to our billions, have richer pain experiences than that, with ways in which their pain is an "opinion" - an interpreted experience, with some surprising sensitivity to context. 10 And of course it makes complete evolutionary sense. Pain is clearly more useful as an experience when it is "smarter."

So the way pain really works is much more complicated, interesting, and in some ways useful. A nerve should never be call a "pain" nerve. It doesn't detect "pain." It only detects some kind of stimulus in the tissue ... and the brain decides what to make of it, how to feel about it, and what to do about it, if anything.

What goes up, must come down

Pain is less painful when we are confident that we are safe. This was demonstrated early in the history of pain research by a famous paper about wounded soldiers in WWII, which showed that they experienced surprisingly little pain considering the severity of their injuries - probably because they were so glad to be off the battlefield. 11 Ever since, researchers have been trying to understand just how that actually works. Although many questions remain to be answered, we do seem to have a rough outline.

The brain is not just a passive, gullible receiver for whatever messages the peripheral nerves send upstairs. And, if you think about it, it's kind of strange that we would ever have thought of it that way, because this is, after all, the brain we're talking about: seat of consciousness, the generator of your reality. The brain critically evaluates every danger message it receives - considering it in context, sizing it up before deciding whether or not to take it seriously.

Once a danger message arrives at the brain, it has to answer a very important question: "How dangerous is this really?" In order to respond, the brain draws on every piece of credible information - previous exposure, cultural influences, knowledge, other sensory cues - the list is endless.

Pain really is in the mind, but not in the way you think, Moseley ( TheConversation.com)

As if that didn't complicate things enough, once your brain has made up your mind, it also sends messages downwards that actually affect the sensitivity and behaviour of the nerves. 12 Thus everything that hurts involves a conversation, a sort of debate between the central and peripheral nervous systems. It could be dramatized like this:

NERVES

Got problems here! Bad problems! Red alert!

BRAIN

Yeah? Hmm. Okay, so noted. But you know what? I have access to information - sorry, it's classified, you'll just have to take my word for it - that suggests that we don't have to worry about this much.

NERVES

I'm telling you, this is serious!

BRAIN

Nope, I don't buy it.

NERVES

Look, I may not have access to this "information" you're always talking about, but I know tissue damage, and I am not kidding around, this is a credible threat, and I am going to keep telling you about it.

BRAIN

Actually, you're having trouble remembering what the problem is. You're going to send me fewer messages for a while. Also, these aren't the droids you're looking for.

NERVES

Uh, right. What was I saying? Gosh, it seems like just a second ago I had something important to say, and it's just gone. I'll get back to you later I guess ...

The brain can boss the nerves around, tell them how sensitive to be. When anxious, the brain might request "more information" from the peripheral nerves, ordering them to produce more signals in response to smaller stimuli. Or it might do exactly the opposite. There is extensive recent evidence that the peripheral nerves can even physically, chemically change, perhaps in response to brain requests, tissue conditions, or both. To extend the analogy, this isn't just twiddling the volume knob, but changing the equipment, changing the signal before it even gets to the "amplifier."

(Just for fun, have a look at the complex version of that diagram. SHOW )

In short, messages don't just go up to the brain, they go down. This two-way functionality in the pain system is the main difference between modern pain science and old-school pain science.

But most of the modulation is probably central: we only feel what our brains allow us to feel. Even "loud" sensory messages can be filtered down to almost nothing by the central nervous system ... or, conversely, "quiet" sensory messages can be amplified. The quality and intensity of the final experience is clearly the product of an elaborate set of neurological filters.

Perhaps many patients whom doctors treat as having a nerve injury or a disease have, instead, what might be called sensor syndromes. When your car's dashboard warning light keeps telling you that there is an engine failure, but the mechanics can't find anything wrong, the sensor itself may be the problem. This is no less true for human beings. Our sensations of pain, itch, nausea, and fatigue are normally protective. Unmoored from physical reality, however, they can become a nightmare ... hundreds of thousands of people in the United States alone suffer from conditions like chronic back pain, fibromyalgia, chronic pelvic pain, tinnitus, temporomandibular joint disorder, or repetitive strain injury, where, typically, no amount of imaging, nerve testing, or surgery manages to uncover an anatomical explanation. Doctors have persisted in treating these conditions as nerve or tissue problems-engine failures, as it were. We get under the hood and remove this, replace that, snip some wires. Yet still the sensor keeps going off.

So we get frustrated. "There's nothing wrong," we'll insist. And, the next thing you know, we're treating the driver instead of the problem.

Scratching an itch through the scalp to the brain, by Atul Gawande

Explain Pain: myths and misconceptions

Many moons ago I started trying to understand and explain pain, gradually producing this article, only dimly aware as I worked that I was re-producing some much more mature ideas. I knew that modern pain science and treatment has deep roots, insights and research going back to the 1960s and Melzack, gate control theory and cognitive behavioural therapy, but my explaining was eerily similar to a recent and popular "packaging" of pain science known as Explain Pain ( EP), from Drs. Lorimer Moseley and David Butler: "a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself." 13 There's a book of that name - Explain Pain - and many other interpretions and riffs on the key ideas (like this article). It's not that I invented my own version of Explain Pain independently, I was just trying to explain pain, you know? Lowercase!

Explaining Pain according to Dr. Moseley is about "wanting people to actually understand how and why they can be in horrible pain yet not in horrible danger." According to me, explaining pain (might) help to reduce it, and it's inherently fascinating even if it doesn't do a lick of good.

There have also been a lot of misunderstandings. Because explaining pain is tricky. (There are still plenty of unanswered scientific questions, too.) And because Explain Pain as a "brand" might be a little bit of an over-hyped upstart, maybe given too much credit by too many people too soon - especially the idea that it actually reduces pain, which remains highly speculative. Nevertheless, for the record, here are some key misconceptions about EP...

Explaining pain is not about managing or coping with pain. That's another (important) kettle of fish.

It's not just about chronic pain. Acute pain needs splainin' too.

Explaining pain does not encourage people to move despite their pain - it's just about teaching them that pain is often "overprotective." Just because the brain worries too much doesn't mean it's wrong.

It's not about the regulation of "pain messages" or "pain signals," because there are no such things. It's about the regulation of danger messages, and how only the brain can amplify or mute pain.

The point is not to reassure people that pain is "just" a perception and not real (ugh) - it's about reassuring people that the danger implied by pain may be exaggerated.

Many people seem to think that Explain Pain ignores biology, biomedical, and structural factors in pain. Nope: the point of explaining pain is to explain the "it's complicated" relationship between these things and pain. Tissue damage is real, and pain arising from it is real... but it's complicated.14

It's not just about central sensitization (for which there is no known cure). Sensitization is an important sub-topic, but it's important to explain unsensitized pain too.15 And the explain pain movement is actually rather optimistic (maybe even too optimistic) that learning the right things can actually change pain - even when it's the product of sensitization.

But the mother of all misunderstandings is the popular idea that if pain is an output of the brain, then we must be able to think our way out of it. It's such an important and difficult topic that most of the rest of the article is devoted to it.

Can we think pain away?

If all this is true... and it is... 16

100% of the time, pain is a construct of the brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

...does that mean can we think brain-built pain away? If the brain can build pain, can it un-build it? Yes and no, because, as Dr. Moseley explains, "Pain really is in the mind, but not in the way you think." 17 It's a good news, bad news kind of thing. Let's get the bad news out of the way first.

Pain is a motivator. It exists to get us to act. We hurt when our brains reckon we should do something differently, for safety...but safety is not always possible. The nature of the danger isn't always clear, or avoidable.

And the brain worries too much: from hangnails to fibromyalgia, it overstates the danger.

And the brain can't be manipulated simply by wishing, force of will, or a carefully cultivated good attitude. The brain powerfully and imperfectly controls how we experience potentially threatening stimuli, but I'm sorry to report that you do not control your brain. Consciousness and "mind" are by-products of brain function and physiological state. (Deep, eh?) It's not your opinion of sensory signals that counts, it's what your brain makes of them that counts - which happens quite independently of consciousness and self-awareness.

As Todd Hargrove put it, "Pain is sometimes immune to logic," because pain is handled by a part of the brain that is not easily over-ruled by other brain "modules" - like an optical illusion that you can't "un-see" even when you understand it. 18 As he put it elsewhere:

Your brain modulates pain based on factors that are completely out of your control, osr rather difficult to control, or even just impractical to control.

This is why many wise, calm, confident optimists still have chronic pain.

For instance, if you view a painful hand through a magnifying glass, it will actually get more swollen and inflamed - that is, if you make it look bigger, it will feel like a bigger problem. 19 And the reverse is true too! Use optics to make it look smaller, and swelling will go down. Incredible, right? Jedi pain tricks! But ... do you have a de-magnifying glass handy? Where do you buy even one of those, let alone a big one? (They really are hard to find. How about looking backwards through binoculars? Not a great solution. 20) And what happens if the pain isn't in a place that's so easy to de-magnify, like your low back?

The de-magnification trick is dang interesting, but it's not a practical approach to most pain. The effect is real under the right circumstances, but trying to use it as a treatment is like trying to take a magician's trick home with you.

Although it is technically the brain's prerogative to ignore painful signals from your tissues, that doesn't mean that it will - if there is a destructive disease process going on, for instance, the brain will usually not ignore those signals! The pain system evolved to report problems, and you can count on it to do so most of the time.

Here's a weird example

Power of the central nervous system, exhibit A, three-legged cat Isaac, trying to scratch himself with his missing leg:

That has got to be super frustrating! The pathetic futility of Isaac's scratching does not stop his brain from trying. Poor little guy. His brain has a picture how things should be, and acts accordingly. The impulse is like a freight train, even when it's blatantly ineffective.

So it is often is with pain: if the brain believes there's a threat, you're going to hurt, no matter how pointless it is or how intensely you focus on trying to have more reasonable and rational sensations. It's mostly just not up to you.

But that doesn't mean that we're completely powerless. Mind has some influence over brain. Below I suggest some ways that you can "hack" pain neurology.

Quibbles with the advice in the Australian video

At the beginning of the article, I shared this lovely Australian video about chronic pain. Its main messages are mission critical stuff, and overall it gets an A-grade from me. But I am concerned that some of its advice is a little too trite and dumbed down - and it's a good example of a common problem with this topic.

It's certainly extremely important to emphasize the psychology of pain, but the video comes dangerously close to advising patients to " don't worry, be happy" and the dreaded "all in your head" - and that's really not what we want here.

Yes, pain is a brain thing, but this must not be simplified so much that people have no idea what to do with it or, worse, feel blamed for it. People with chronic pain feel bad enough already! 21 This is tricky! "There's fun stuff in pain science and neuroimmunology that's slippery to adapt to practice without reaching too far" ( Sandy Hilton, Physical Therapist).

To the extent that the video is encouraging, I fear it's for the wrong reasons: it portrays pain as a problem with a dysfunctional brain that can be "retrained," which is definitely too optimistic. Brains are not terriers. Although it makes sense to try, there is no good evidence that it actually works, and it is virtually certain that it often does not. There are many possible reasons why.

For instance, stressors and mood disorders (depression, anxiety) can be virtually invincible. Most people with chronic pain aren't just a little stressed, they are a lot stressed, and often by major life challenges and social problems that they literally cannot solve. 22 Even when their problems are theoretically more manageable, most people find it extremely difficult to troubleshoot their own mental health. So while it's correct to tell patients to "learn to reduce stress" and "consider how your thoughts and emotions are affecting your nervous system," that advice is impractical without more and better information. "Consider" is just not concrete enough.

The video's low point is a recommendation to "recognize deeper emotions" - even more impractical, to the point where many patients will dismiss it as a flaky talk, far too touchy-feely. I understand what they were going for, and it's the tip of an iceberg of an important concept - healing by "growing up" - that I will discuss below, but the video simplifies it to the point of absurdity.

I certainly applaud the emphasis on psychological and social factors, but it's also really important to keep it real and make it practical. Because, properly approached, in some ways it is possible to "think pain away," to the extent that stress, fear, and anxiety about a painful problem can actually be reduced.

It's time for the good news.

How do we convince people in pain that we understand that they are in pain but it's not just about the tissues of their body? A key conceptual shift that we think is really important is that you can understand that pain is the end result, pain is an output of the brain, designed to protect you ... it's not something that comes from your tissues.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

Science says confidence cures

One of the top five questions I am asked by email, about any condition, is simply Is there hope? The answer is nearly always the same: yes, there's hope. There's never a guarantee, but there's always hope, and recovery from most kinds of severe chronic pain is not only possible but fairly common. Unless you have a known serious aggravating factor - a major trauma, for instance - there is almost never any reason to fear that recovery from any chronic pain problem is impossible. For the same reason that pain can be absurdly persistent and out of proportion to any clear cause - because it is so brain-tuned - it also never rarely loses the potential to finally shift and evaporate.

For instance, just a change in confidence can make a big difference.

There's been a lot of indirect evidence about this for a long time, but one of the first really good, direct scientific tests was finally published in 2013 by Vibe-Fersum et al. 23

Classification-based cognitive functional therapy (CB-CFT, or just CFT) for low back pain is a "body/mind approach to understanding and managing this complex problem" that "targets the beliefs, fears and associated behaviours" of patients (what I have called the "confidence cure" for many years). The big idea of CFT is that the cycle of pain and disability can be broken by easing patient fears and anxieties, specifically "reframing the persons' understanding of their back pain in a person-centred manner, with an emphasis on changing maladaptive movement, cognitive and lifestyle behaviours contributing to their vicious cycle of pain." Translation: pretty much anything strategy that restores confidence.

CFT was tested on 62 patients with moderate back pain, and compared to 59 who were treated with manual therapy and exercise. Three months and a year later, the CFT group was much better off. 24 CFT was "more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than manual therapy and exercise." As the authors put it for BodyInMind.org, "Disabling back pain can change for the better with a different narrative and coping strategies."

There were some blemishes on the study methods, but nothing dire; the results can be safely regarded as quite promising while we wait for replication from bigger studies.

Just learning about this could be therapeutic, but how else can you apply this good news? How else can you CFT yourself, and otherwise get your brain to downgrade your pain?

Whilst the problem is superficially a physical one, the real challenges faced by someone with chronic pain are mental. Mental state is the biggest modulator of physical pain. Things hurt more when you're stressed or sad, and the increased pain makes you both stressed and sad. The way out of this vicious circle is a wholesale change to how you perceive fear, suffering and setbacks.

How chronic pain has made me happier, by Rob Heaton

Jedi pain tricks! What are the practical applications of this knowledge?

Pain is "another *%[email protected]!! growth opportunity" - another provocation to mature as a person, and a particularly intense one. For many people with severe and chronic pain, learning coping skills is a necessity. But personal growth is probably a much greater opportunity than merely coping with pain. We may not control our brains, but we do have considerable indirect leverage. We can't micromanage every sensation, but we can tinker on a large scale. We change the context and direct our experience of life on a large scale. For instance ...

Huff, puff, and blow your pain down. We can alter our physiology with deep, vigorous breathing, instantly creating new feelings - and your brain will go along for that ride, and perhaps re-interpret your experience of pain. For more about this odd idea, see The Art of Bioenergetic Breathing.

Create new social contexts by doing something as simple as playing a team sport - because other people are counting on you, the painful consequences of intense exercise are usually re-contexualized as tolerable, even desirable, and you can put up with quite a lot more. You can't think your way to that kind of pain tolerance - but you can place yourself in a situation where it is a likely outcome. This is why Haven - a counselling school, which many people go to just to learn more about themselves - uses "experiential" workshops, putting people through a lot of interesting and intense experiences together. They tinker with your social context, because humans beings are so interested in each other that our social experiences utterly dominate our consciousness. Change your social experience, change your brain!

Reduce fear and anxiety, increase confidence, especially with education. Fear and anxiety probably have more power to aggravate pain than any other emotional state, and acquiring knowledge and perspective are superb treatments. A confident and happy brain amplifies danger signals less than an anxious, miserable brain. This explains lots of interesting results in pain research (not to mention clinical observations), like the cognitive functional therapy results in the last section, and the fact that the most powerful factor predicting how soon people return to work after an episode of low back pain is whether or not they expect to return to work, 25 and the fact that education alone probably helps to resolve neck pain. 26 27 So do not let health professionals get away with any fear-mongering. 28 Seek out as much information as you can find, because nothing causes more anxiety than uncertainty. These are real defenses against pain.

Early intervention is critical to prevent acute pain from turning into chronic pain. 29 It is clear that chronic pain involves significant neurological changes, both in nerves and in how pain is processed in the brain. Once those changes occur, recovery is much more difficult, at an incredible cost in suffering and medical expenses. Persistent pain should not be ignored. Deal with it sooner, not later.

The brain cells that produce pain get better and better at producing pain. They become more and more sensitive...

Lorimer Moseley, pain researcher, Why Things Hurt 14:33

Firmly reject the self-hating idea that your pain is "just" psychological or merely psychosomatic. Paradoxically, even though pain is strongly regulated by your CNS, it is certainly not "all in your head." The idea has always been been disrespectful to pain patients, but now it is also scientifically obsolete and can be thrown out with yesterday's trash. Any health professional talking like that should just be ignored. We know better these days: pain does not have to be driven by easily diagnosed tissue damage to be "real" and serious, and it can have major psychological dimensions without being just psychological.

Be kind to your nervous system. Create pleasant, safe sensory experiences - positive inputs. Seek comfort. Be a hedonist. If your brain thinks you're safe, pain goes down - and pleasure feels safe. So be "nice" to your CNS in every way that you can think of. Make your life - or a joint - feel safer, gentler, more pleasant. Do it in general ways (soak the whole system in a hot tub), but also more specifically: pleasantly stroke a sore knee, give a screaming shoulder the "comfort" of a sling for a while, or cautiously but thoroughly move a troubled joint to demonstrate to your brain that it's okay. ( See, brain? We can do this! No big deal!) Lorimer again ...

Change something - almost anything! - about how a painful area feels. Make it as feel different as you (cheaply) can. Sensation is one of the factors the brain uses to set pain levels. If you can make a body part feel significantly different in any way, it may help (but especially if you can make it feel safe, protected, stabilized). In fact, this probably explains why many treatments for pain problems are popular and seem to help sometimes, despite being unreliable and generally minor. 30 Classic examples: taping, bracing, strapping, splinting, salving, vibrating, heating, icing. Regardless of how they supposedly work - there are many overly complex explanations - most of these methods mostly just change how a body part feels. 31 The benefit of novel sensory input is probably not much more profound than being distracted by a loud noise ... but we can add it to the toolkit, with reasonable expectations. Use any cheap, convenient, creative method - there's little reason not to.

Fix the fixable in your life - and be honest about what is fixable. Most people aren't quite as stuck as they think they are. Many problems really aren't fixable, of course, but some of your worst and oldest problems probably are - we tend to be our own worst enemies. And those problems are usually the source of most of our stress, anxiety and depression - which means that they also have a direct impact on how much we hurt. There are many examples of difficult problems that can usually be fixed with some hard work and maybe some leaps of faith: bad marriages and toxic friendships, bad jobs and bad bosses, a house or city or climate you don't like, poverty, addiction, insomnia and many more. Finally taking action to fix such problems is the most direct route to easing a brain's interpretations of pain.

Positive movement - One of the big ideas in evolutionary psychology is that our minds have many specific skills, rather than an all-purpose intelligence. If the part of the brain responsible for pain - the pain "module" - isn't easily swayed by the thinking module, are there other modules that might have more influence? Todd Hargrove: "The movement modules would be first on my list." 32 "Positive movement" may be more potent than "positive thinking." And what is positive movement? Moving as if you are more comfortable than you are: build up your confidence with whatever movement you can reasonably handle. Move in ways that are as pleasant, fun, and/or inspiring as possible. Pain limits movement - so push against those limits gently, creatively, playfully.

Don't dramatize your pain. This one needs a whole section...

Don't be a pain drama queen!

"It feels like a jagged, flaming, poisoned sword ripping through my body over and over again."

People really talk like that, when they are in pain. (My father talks like that. And I have the impulse - perhaps genetic - to talk like that.)

But beware of colourful and extreme descriptions of your pain. They are tempting. There are quite a few reasons to exaggerate pain. For instance, pain is such a private experience - so often minimized or even denied by health professionals - that patients are often tempted to dramatize the pain to make it seem more real. But it's a trap! Before you know it, you'll believe your own story. When you exaggerate and dramatize your pain, you directly exacerbate the neurological end of the chronic pain problem.

The pain scale is the imperfect replacement for flaming, poisoned swords. If you have chronic pain, you've probably been asked many times to rate your pain, and probably on a scale of 1 to 10, and maybe with a visual aid like this:

On the one hand, the pain scale is an essential pain research and clinical tool, with proven value - it's the main way that we measure the effect of therapies, to see if they really work. On the other hand, the opportunities for abusing the pain scale are legion, and the pain scale is a source of perpetual confusion in health care offices throughout the land. It sounds so easy: just rate your dang pain! But people are often stumped by the question, or they overthink it, or they wildly exaggerate.

Many times I have seen pain-scale discussions nose dive into philosophy. Is #10 reserved for the worst pain we have ever experienced, or the worst pain we can imagine? "I don't know, I can imagine quite a bit." Can we ever really know what someone else's pain feels like? ( No.) If pain fluctuates, do we take the average? For really horrible pain do we go off the scale? Or recalibrate?

The thing is, people like to go off the scale. Drama is fun. Hyperbole is fun.

"Definitely a 15. Having a baby, yikes, that was like a 19 with spikes to 38."

The irony is that the pain scale is supposed to help you think more objectively and rationally about your pain, but it often just creates another opportunity for melodrama. So use the pain scale, but use it wisely. Use it as a tool for getting a little more real about your pain.

Speaking of hyperbole, this pain scale business was hilariously lampooned by Allie Brosh of the brilliant, scribbly blog Hyperbole and a Half. Look back at #8 on the pain scale chart above. Does that look like a #8? According to Brosh, #8 seems to be thinking: "The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed." So she did her own. Here's her take on #8:

Now that's more like it! No ambiguity there! Brosh's pain scale is so funny that you will spray milk out your nose. (Assuming you drink some milk first.) Read the whole thing. But get the joke!

What's the difference between "pain is an opinion" and "it's all in your head"?

I've already pointed out a couple times that none of this means that pain is "all in your head," but we should make it much clearer. Unfortunately, it's tricky to tell patients "sometimes pain correlates poorly with tissue damage" without them hearing "it's all in your head." It's a hazard baked right into modern pain science, and I think it's a serious problem. I have experienced it myself as a patient, and seen lots of other evidence of it.

For example, here's the beginning of an amazing, uplifting back pain story, told by Dr. Jerome Groopman in his book, The Anatomy of Hope, about his own experience with super severe chronic low back pain:

Dr. Rainville planted the MRI scan of my spine on a lighted box on the wall and systematically inspected the film, vertebra by vertebra. Seemingly satisfied that he had reviewed all the relevant data, he turned and stood before me.

"You are worshiping the volcano god of pain," he declared. "The volcano god of pain is your master."

I had been warned that Rainville was a brash, in-your-face clinician who held contrary views. But what on earth was he talking about?

The "volcano god worship" lecture Groopman gets from Rainville is really great: an intense, dramatic version of the central idea of this article, that pain can get totally disconnected from reality. Despite the artfulness of the explanation, Groopman struggles with the implications like any patient:

And what was he really saying, in cold biological terms, not flamboyant metaphors of volcano gods? That changing my beliefs could dampen flaming circuits of pain? Was I some mystic or yogi who could walk barefoot over hot calls or lie down on a bed of nails?

So here's the difference:

Pain that's "all in your head" is pain primarily driven by hypochondria, a form of anxiety disorder, a mental illness.

Chronic pain without obvious tissue damage is a systemic malfunction in which the nervous system produces more pain experience that is out of proportion to actual tissue trouble, sometimes dramatically (as in Groopman's case). But, crucially, the problem usually began with tissue trouble and there's still usually some tissue trouble remaining.

What if there is tissue trouble?

The ideas presented in this article are so clinically important and interesting that, in many discussions, they have begun to drown out the boring-but-basic fact that tissue trouble still usually leads directly to pain. Pain and tissue damage are positively and strongly correlated. Just because that correlation can get messy and break down does not mean that it doesn't exist, in spades. Pain is volatile, but it's not totally out to lunch!

Pain perception is subject to strong distortions, but these are mostly rare and hallucinatory. We can make pain up out of thin air, but we rarely do. And we can have painless trauma, but we rarely do. There are famous and fascinating examples of such cases (described above), but they are famous because they are somewhat exotic. Pain perception may be volatile, particularly with complex and chronic cases, but it's still mostly a consistent and predictable warning system about tissue danger.

It has to be reliable: that's why it exists.

Unexplained chronic pain is common, and the relationship between pain and tissue damage often gets weirder and murkier as time goes on, which can get totally confounding for patients and professionals. We need to simplify. When there's no known damage, there are two possibilities (other than hypochondria):

1. either there is tissue insult (a source of nociception) that just can't be identified (surprisingly common I think), or

2. the relationship between tissue insult and pain has broken down (also quite common).

And these scenarios are not mutually exclusive: you can have both tissue damage and a wonky, disproportionate relationship to pain.

Point one is an important source of reassurance for many people. I'm speaking both professionally and personally here, because I suffered exactly that fate in the last year: a persistent pain with no apparent cause, so much so that I was told by a few professionals that my only problem was "pain dysfunction," or experiencing pain without tissue damage. But then, rather better late than never, the %#!!$& source was found and removed and that was the end of my pain. Ta da!

So I suffered a year of serious chronic pain with no apparent source that absolutely was positively, strongly correlated with a tissue insult. Just a sneaky one!

I know similar things have happened to plenty of other people too.

So sure, technically, all pain is indeed all in your head...but so are those nectarines, bumblebees, and nebulae. That is the nature of consciousness. Most experiences have strong roots in the world. Or your body.

Everything is in the brain, but when we want to learn about the universe, we look through telescopes, not brain scanners.

~ Dr. Rob Tarzwell of One-Minute Medical School. (Ironically, when Dr. Rob wants to learn about people, he looks at them with a brain scanner.)

If you want to know about nectarines, you mostly study nectarines, not brains. If you want to know about that nebula, you use a telescope, not a brain scanner. And if you want to know how back pain works, you are going to have to study back injuries and pathologies and the creative and colourful ways that brains play with pain perception. But brains are still usually playing with the perception of something that is actually going on in the "world" of your back, in your tissues.

Concluding advice for Professionals

I'll keep this simple. Physical therapists, massage therapists, chiropractors and anyone who works with hurting bodies: please consider not trying to "fix" patient's flesh. It's possible that it's impossible. 33

Instead, address the nervous system. Be kind to it. Help patients remember what it's like to feel safe and good. Be the source of a positive sensory experience. Educate to reassure, and avoid giving patients any new cause for alarm or worry.

Appendix: more examples of pain weirdness

Pain weirdness example #1: Insight from eyesight, Spring of 2011

I had corrective eye surgery a month ago. Today my eyesight gave me good insight into how pain works. The laboratory of my own body has yielded results yet again. I swear, I should just start injuring myself and having surgeries just for the academic experience. (Hm, on second thought, no. But you know what I mean.)

Recovery is going swimmingly. My left eye is so good it's practically bionic now. My optometrist - an excellent one in downtown Vancouver,Dr. Graham Foster, info Performance Vision Optometry, downtown Vancouver. who loves eye-science tangents - basically can't find any sign that anything even happened to my left eye. No laser tracks. No remaining signs of recovery. It's done!

The right eye? Total slacker.

The right seems blind! ← subliminal political message

The left eye is so good that the right eye actually feels bad. It aches a bit. In reality, the right is also healing well and is either on recovery schedule or slightly ahead.

And yet my bionic left eye is so far ahead of healing schedule that the right actually literally suffers by comparison. It seems awfully blurry, and there has been mild pain for a couple weeks now, and this was freaking me out a little. Get a load of what my optometrist said (paraphrasing) when I told him about this:

People's eyes often hurt when they think there's something wrong with them.

Really? So ... I should probably resist this punning, but I just can't ...

Pain is in the eye of the beholder!

So, if you think there's something wrong with your eyes, they may well start to hurt. This demonstrates that "pain is an opinion" rather well. That is, pain intensity depends surprisingly heavily on how dangerous/scary/disturbing the situation seem to us, on our "opinion of the state of the organism." If you think the organism (you) is safe, pain will be dulled. If you think you're in danger, then pain will be more painful.

This is clearly not the same thing as being "all in the head." It's pain being affected - dialed up or down - by what's in the head, both consciously and unconsciously.

My optometrist described the following scenario (paraphrasing):

Someone can "discover" an eye problem they've had for twenty years and start hurting. They accidentally cover one eye while watching television, happen to notice that the vision in the free eye is a bit off. It's been off all along - almost everyone is at least a wee bit astigmatic, but the brain completely takes care of that when both eyes are open. But if they notice it with an eye covered, a week later they're in my office complaining of blurred vision and an ache.

Fascinating. And exactly like the mind game in low back pain. As with back trouble, I reckon that the idea of eye trouble is just a bit more freaky, and thus usually more sensitive to psychological factors.

Not only is worry generally excessive and unnecessary, we can see here that it is actually counter-productive and painful. (Which is worrying!) It's really quite a thing: here I was getting anxious about my right eye when it's only problem was being less awesome than my left. Good grief.

Honestly, I really became a little obssessed with it in the last couple weeks. I "discovered" that it wasn't as good as the left, and started checking it constantly.

And so it started to ache.

I am impressed again by how easily I am fooled by the illusions of neurology, even when I am well aware of them. It is becoming clear to me - if I look at it with my left eye, anyway - that we need to know the basics of pain neurology quite well indeed in order to acquire the confidence required to see through those illusions. I was able to quickly focus on the nature of the problem when it was explained to me ... but despite all my knowledge about musculoskeletal problems, I was blind to it without a bit of help.

Pain weirdness example #2: Metal rod embedded in arm painless for fifty years

Sensation and pain are nothing if not mercurial. On the one hand, we can be driven half out of our minds by a bit of beef wedged between a couple teeth. Or, stuck right in the other hand, a large piece of metal can be painless for 50 years. Like a turn signal lever.

Art Lampitt got one of those embedded in his arm in a car accident long ago. What with all the other injuries, no one noticed. It didn't give him any trouble until recently. His arm began to ache and swell and an x-ray revealed a strange, thin third arm bone.

"I was hoping it might be shiny still," he said in an interview with CBC Radio One's "As It Happens," but it was badly corroded - perhaps the reason it finally caused some symptoms, but who knows.

I love medical marvels that challenge our preconceptions about what will hurt. It's noteworthy that it didn't hurt for decades - because if that's possible, just imagine how unpredictable the symptoms of a little arthritis can be - but it's also noteworthy that it did start to cause trouble eventually. It's a great example how pain is weird.

- Added Lorimer Moseley's superb TED talk about pain, Why Things Hurt , and a couple of good quotes from it.

Related Reading

"Pain really is in the mind, but not in the way you think," a webpage on TheConversation.com. In this not-too-technical article, the endlessly quotable Lorimer Moseley summarizes the role of the mind in chronic pain, especially low back pain.

"Scratching an itch through the scalp to the brain," a webpage on NewYorker.com. This is a particularly wonderful article, which uses a fascinating and awful medical story - about a woman who scratched through her skull (seriously) - to explain how pain works, just as this article does. It's a point that a lot of experts are making in a lot of different ways, and more all the time, but this is the best I've seen yet: great storytelling and superb reasoning, from Atul Gawande, one of the best medical writers alive today.

Why Things Hurt on YouTube.com.. A genuinely funny and entertaining TED talk about a snake bite and pain neurology. No, really, you will actually laugh - it's like stand-up comedy. A must-watch for anyone with chronic pain, and the professionals who care for them.

Understanding Pain and what to do about it in less than five minutes on YouTube.com.. Beautifully produced short video that neatly summarizes most of the key points in this article.I do have a few quibbles with the treatment advice provided, discussed above.

PS Pain Relief from Personal Growth - Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness

PS Does Acupuncture Work for Pain? - A review of modern acupuncture evidence and myths, focussed on treatment of back pain & other common chronic pains

PS Anxiety & Chronic Pain - A self-help guide for people who have both anxiety and chronic pain

PS Therapeutic Options for Pain Problems - A guide to therapies and medical professionals for injuries, chronic pain and other musculoskeletal problems

All in my head: an epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache, a book by Paula Kamen (book review). Like PainScience.com, this book offers an unusual combination of both humour and information about pain. Kamen is a completely engaging writer, and tells her story with both journalist rigour and personality.

pro An excellent scientific paper by Lorimer Mosely: "Reconceptualising pain according to modern pain science"

pro "Central sensitization: Implications for the diagnosis and treatment of pain," an article in Pain, 2010. Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called "central sensitization" because it involves changes in the central nervous system (CNS) in particular - the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also "echoes," fading more slowly than in other people. For a much more detailed summary of this paper, seeCentral Sensitization in Chronic Pain.

Notes

1. The complexity of pain makes it much harder to beat overall, but it also means that some factors are more treatable or manageable than others - but only if you have a modern understanding of how pain works. You cannot hack a system you don't understand. I can hardly imagine a better argument that we need a more biologically literate society! BACK TO TEXT

2. Modern pain research was kicked off in the late sixties by the work of Dr. Ronald Melzack and Dr. Patrick Wall. BACK TO TEXT

3. All the dumbed-down pain science in this article is presented in a more scholarly form by the erudite Lorimer Moseley, an Australian pain scientist, in his excellent article "Reconceptualising pain according to modern pain science". Dr. Moseley's article is a perfect companion to this one: it is both much more detailed and scientific and yet still fairly accessible compared to, say, a neurology textbook. BACK TO TEXT

4. The most common kind of presumed cause of musculoskeletal pain - a "structural" or biomechanical problem, like a slipped disc, or a short leg - is one of least likely actual explanations. The failure of such explanations for pain to pan out over the last 20-30 years is also evidence that there's more to pain than just screwed up tissue. See Your Back Is Not Out of Alignment. BACK TO TEXT

5. BACK TO TEXT

6. ABSTRACT

Despite widespread support of mirror therapy for pain relief in the peer-reviewed, clinical and popular literature, the overwhelming majority of positive data comes from anecdotal reports, which constitute weak evidence at best. Only two well described and robust trials of mirror therapy in isolation exist, on the basis of which we conclude that mirror therapy per se, is probably no better than motor imagery for immediate pain relief, although it is arguably more interesting and might be helpful if used regularly over an extended period. Three high quality trials indicate positive results for a motor imagery program that incorporates mirror therapy, but the role of mirror therapy in the overall effects is not known. Obviously, more robust clinical trials and experimental investigations are still required. In the meantime, the relative dominance of visual input over somatosensory input suggests that mirrors might have utility in pain management and rehabilitation via multisensory interactions. Indeed, mirrors may still have their place in pain practice, but we should be open-minded as to exactly how.

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7. Fisher JP, Hassan DT, O'Connor N. Minerva. BMJ. 1995 Jan 7;310(70).
This source is tough for readers to confirm. It's widely cited, downright popular, because it's a great anecdote, but of course that doesn't mean much. Is it for real? It is indeed. If you are determined, you can verify the citation with a free trial membership for BMJ.com: the story is just one item in the full text of the "Minerva" column, which is a compilation of snippets of interest.
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8. "Nocebo" is Latin for "I shall harm" (which I think would make a great supervillain slogan). It refers to the harmful effect of ... nothing but the belief in or fear of a harmful effect. Give someone a sugar pill and then convince them you actually just fed them a deadly poison, and you will probably witness a robust nocebo effect. A common funny-if-it's-not-you nocebo in general medicine is the terror of "beets in the toilet": people eat beets, and then think there's blood in the toilet, and call 911. Nocebo is a real thing, and not to be messed with. It is one of the chief hazards of excessive X-raying and MRI scanning, for instance: showing people hard evidence of problems that often aren't actually a problem. Which is one of the main reasons it can valuable to learn about all this. BACK TO TEXT

9. See Gawande: "New scientific understanding of perception has emerged in the past few decades, and it has overturned classical, centuries-long beliefs about how our brains work-though it has apparently not penetrated the medical world yet. The old understanding of perception is what neuroscientists call "the naïve view," and it is the view that most people, in or out of medicine, still have. We're inclined to think that people normally perceive things in the world directly. We believe that the hardness of a rock, the coldness of an ice cube, the itchiness of a sweater are picked up by our nerve endings, transmitted through the spinal cord like a message through a wire, and decoded by the brain." BACK TO TEXT

10. See Sensation on a Small Scale. BACK TO TEXT

11. BACK TO TEXT

12. Jackson M. Pain: The science and culture of why we hurt. Trade paperback ed. Random House; 2003. BACK TO TEXT

13. A cogent formal summary and update on how this "explain pain" thing is going so far (pretty well). Moseley and Butler are always quite readable, even when writing for journals (imagine), but see also their blogging about the same thing.
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14. This misconception comes straight from some overzealous advocates of Explain Pain, who too aggressively promote the idea that pain is unrelated to tissue damage. It's true and very important than the correlation between tissue damage and pain is often quite poor, but it is still quite strong for most people most of the time. BACK TO TEXT

15. The central message of explaining pain is that pain often exaggerates the danger that tissue is in. In central sensitization, the exaggeration is pathological and entrenched: danger signalling is consistently and severely exaggerated. But that's an extroardinary situation. Pain is also routinely out of proportion to the danger even when there is absolutely no sensitization going on at all. BACK TO TEXT

16. It's not academic hair-splitting. It doesn't mean that pain isn't real, or that tissues can't genuinely be in trouble. What it means that is that all pain, always, no matter what, is a seriously unreliable and weird interpretation of information coming to your brain from your body. Just like your brain "constructs" what you see, it builds pain. BACK TO TEXT

17. TheConversation.com [Internet]. Moseley L. Pain really is in the mind, but not in the way you think; 2013 Jul 20 [cited 14 Jan 6]. BACK TO TEXT

18. www.bettermovement.org [Internet]. Hargrove T. Why Your Body is a Hypocrite; 2017 September 7 [cited 17 Sep 7].
As usual, Todd goes deep to find insight into pain science, this time mining evolutionary psychology and the modular theory of mind. (I am glad he did this reading and thinking so that I didn't have to. Dense source material! But neat.) The article is about how different parts of your brain don't necessarily cooperate much.
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19. ABSTRACT

The feeling that our body is ours, and is constantly there, is a fundamental aspect of self-awareness. Although it is often taken for granted, our physical self-awareness, or body image, is disrupted in many clinical conditions. One common disturbance of body image, in which one limb feels bigger than it really is, can also be induced in healthy volunteers by using local anaesthesia or cutaneous stimulation. Here we report that, in patients with chronic hand pain, magnifying their view of their own limb during movement significantly increases the pain and swelling evoked by movement. By contrast, minifying their view of the limb significantly decreases the pain and swelling evoked by movement. These results show a top-down effect of body image on body tissues, thus demonstrating that the link between body image and the tissues is bi-directional.

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20. That's creative problem solving, but I think it only makes the impracticality point stronger: the very narrow field of view of binocs probably undermines the illusion significantly. Seeing an exaggeratedly remote looking arm through a peephole may not have the same effect. Not that it isn't worth trying, but for this to work the brain must actually be fooled. BACK TO TEXT

21. Toye F, Seers K, Allcock N, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829-41. PubMed #24351499.
This paper reviewed qualitative research on musculoskeletal pain to shed light on what it's like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces causes patients into the awkward position of having to prove the legitimacy of their condition: "if I appear 'too sick' or 'not sick enough' then no one will believe me." Many end up doubting themselves and questioning their own identity and wondering who is "the real me." Many lose hope and feel lost (or lost by) the health care system.
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22. For instance, it is next to impossible for impoverished single mothers of children with serious health problems and inadequate social services to support them to meaningfully "reduce stress," and advising them to do so borders on insultingly naive paternalism. BACK TO TEXT

23. BACK TO TEXT

24. CFT patients got a 13-point boost on a 100-point disability scale, and 3 points on a 10-point pain scale. Those are not amazing results, but enough to be considered clinically significant, and they beat manual therapy and exercise handily (those patients improved by only 5.5 and 1.5 points on the same scales). BACK TO TEXT

25. Schultz IZ, Crook J, Meloche GR, Berkowitz J, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004 Jan:77-85. PubMed #14715392.
This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: "The key psychosocial predictors identified were expectations of recovery and perception of health change."
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26. This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with "whiplash associated disorders" (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.
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27. Bodyinmind.org [Internet]. Moseley L. The therapy might work, but does it work in the manner you think it does?; 2012 Jun 18 [cited 15 Jul 15].
We know that "explaining pain" seems to reduce it, but how? Do we really know what's going on? "The theory behind explaining pain is that it decreases pain by changing the underlying schema about what pain actually is." Dr. Moseley methodically applies a validity test to that theory, which it passes with flying colours, meaning that it is a reasonable, working theory about how pain education works (not proof that is does work - a technical but important difference).

For contrast, note that in a follow-up article, he concludes that graded motor imagery does not satisfy the burns test - a nice demonstration of the integrity of his reasoning.
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28. Why would they do that? Unfortunately, it's pretty common for health professionals to unwittingly reinforce nerve-wracking ideas about what might be wrong with you. One of the not-so-harmless aspects of alternative medicine is that it tends to generate a lot of this. BACK TO TEXT

29. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000. BACK TO TEXT

30. Often we see inexplicable and "weird" changes in painful conditions, good and bad, and often in response to an attempt at treatment - and yet at the same time it's incredibly rare to find good evidence that any particular treatment works better than placebo. What could account for this? Using a wide paintbrush: it may be that input changes output, that nearly anything that happens to the body has the potential to affect how the body feels and works. Pain is an "output," and so is a lot of wet, messy biology. Tissue state is just chemistry, and the chemistry of everything is constantly micromanaged and hyper-regulated. Dysregulation and uncomfortable trade-offs and compromises in these processes are routine, but it's still full speed ahead, all the time, damn the torpedoes, a chemical balancing act that doesn't quit until we die. Any input may change the equation - the problem is that it's incredibly difficult and maybe even impossible in principle to predict what inputs will help, or make any difference at all. BACK TO TEXT

31. Obviously bracing a knee with a ruptured ligament is a different case, and straighforward. Similarly, you can certainly tape up a sprained ankle for pure stability - not a sensory effect. But bracing is often prescribed for much less clear reasons, and taping gets even weirder, like the absurd colourful tape that was so faddish in the 2011 Summer Olympics. These approaches to rehab often have wildly speculative rationales, when most likely they are all just creative ways of changing sensation. BACK TO TEXT

32. Hargrove 2017, op. cit. I'm paraphrasing and riffing off of Todd's thinking here - almost just a synposis of his idea, really. BACK TO TEXT

33. I'm understating that, because I don't want to blow too many minds. The idea that there might be little or nothing that anyone can do to "repair" tissue in any meaningful sense is a radical concept for a lot of professionals. I suspect there are a handful of possible examples, but the point is that almost all forms of manual and physical therapy, most of the time (whether we know it or not) are almost exclusively inputs to the nervous system. And "results" are the CNS responding with a new story. The tissue state remains the same, or only trivially changed. Flesh is remarkably good at staying just the way it is. (With a gradual, inexorable drift back towards homeostasis after injury.) BACK TO TEXT

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Pain is Weird: A Volatile, Misleading Sensation

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full article 10000 words Pain is not just a message from injured tissues to be accepted at face value, but a complex experience that is thoroughly tuned by your brain. The results are often strange and counter-intuitive, like quantum physics, but the science is clear: every painful sensation is 100% Brain Made®, and there is no pain without brain.

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Self-confidence and self-efficacy in sport

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Self-confidence and self-efficacy in sport

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Self-efficacy is an important attribute in sport performance. Athletes and coaches call it self-confidence and associate the concept with successful performance. This chapter presents the theory of self-efficacy in sport, including sources of self-efficacy information and consequences of high and low self-efficacy beliefs.

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A collection of articles on psychosocial factors in LBP

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A collection of articles on psychosocial factors in LBP

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The purpose of this special issue of is to present and integrate research evidence about the influence of psychosocial factors on presentation of symptoms of pain and disability (function) in physical therapist practice. We have focused primarily on low back pain, as it is the most widely researched musculoskeletal condition. We have included a number of perspective articles, specifically elicited from established researchers, but we also have taken the opportunity to include several empirical studies that have been submitted independently to PTJ. These empirical studies have allowed us to illustrate (and hopefully illuminate) facets of the overall conceptual framework presented in this special issue.

As guest editors, we were at times fairly specific in the requests and recommendations we made to our colleagues, in terms of breath of topic, depth of analysis, and overall style of presentation. We attempted the difficult task of developing articles that are able to "stand alone" but that also can be viewed as complementary parts of this special issue. We have retained the considered opinion of the authors while also trying to accommodate the issues raised by our external peer reviewers as part of the normal review process. As a precursor to the articles included in this issue, we briefly offer a number of reflections on why we embarked on this endeavor.

Current Education and Practice Model for Physical Therapists

We offer an initial theoretical framework ( Figure) that sets the context of this special issue. In the Figure, management of low back pain is depicted as a continuum of physical and psychosocial factors, with varying amounts of each. At one extreme of this continuum, the primary influences on symptom presentation are physical factors, and, at the other extreme of the continuum, the primary influences are psychosocial factors. These extremes are matched with the corresponding patient management model in the Figure. For example, "standard practice" based on a biomedical model is centered on the treatment of physical factors, whereas "mental health practice," based on psychological or psychiatric models, encourages treatment of psychosocial factors-and psychological factors in particular. The opposing sides of the Figure represent the current management approach of most physical therapists for low back pain. The implication is that, despite the continuum of physical and psychosocial influences on symptoms, psychosocial factors are either inadequately addressed or ignored within standard practice (left side of the Figure), or they trigger referral to mental health practitioners (right side of the Figure). The result is suboptimal management. In the concluding article of this special issue, we present an updated theoretical framework for physical therapist management of low back pain. 1

Why Should Physical Therapists Care About Psychosocial Factors?

Most physical therapists probably acknowledge the importance of psychosocial factors, and many would assert that they recognize them as part of their clinical practice. However, as Bishop and Foster 2 have documented, simple identification or knowledge of such factors does not lead to a change in focus or style of patient management. Yet, there is persuasive evidence for the influence of a patient's beliefs, emotional responses, and pain behavior on response to pain, treatment participation, and outcome. 3 Furthermore, the costs of ignoring or inappropriately managing psychosocial factors potentially leads to unnecessary patient suffering, restricted participation in valued activities, loss of productivity at work, and a waste of valuable health care resources. 4 We recognize the importance of differentiating "normal" from "abnormal" psychological processes and of knowing when to refer patients with significant mental illness, but, except in multidisciplinary clinics, this effectively removes the patient from access to musculoskeletal management. In the concluding article in this special issue, we suggest a "middle way" for physical therapists. 1

The Challenge

The major challenge for this special issue is to persuade biomedically oriented physical therapists of the need for a shift in focus in their management of low back pain. Standard practice for physical therapists involves biomedical treatment approaches that target the correction of physical impairments through various means. We suggest that it is appropriate for physical therapists to enhance their professional skills in the management of low back pain by including consideration of psychosocial factors (ie, pain beliefs, attitudes, emotions, and behaviors) as potential obstacles to reactivation and as worthwhile treatment targets in their own right. In fact, if the current research trends continue to support the efficacy of directly addressing psychosocial factors, the sort of philosophical shift we recommend will be essential for the ongoing development of evidence-based practice.

Matters of Definition

Within the research literature, the term "psychosocial" is used to cover a range of perspectives, ranging from reference to highly specific psychological or social factors to a much broader umbrella that includes almost everything apart from biomedical factors. In this special issue, we have not wholly resolved the question of overlap, but we have used the term "psychologically informed practice" to refer primarily to the inclusion of a specific focus on psychosocial or psychological factors (both clinical and occupational) insofar as these factors are used for risk determination and as potential targets for intervention by the physical therapist. We have consigned the broader spectrum of social factors to "black flags," which-although possibly amenable to change by public health or work-place interventions and to that extent could fall within the definition-are not a focus for intervention at the level of physical therapist practice.

The Articles in This Issue

We have attempted to assist this shift in orientation by inviting contributions from established authors with both physical therapy and psychology backgrounds, with experience in different health care systems, and with a focus on both clinical and workplace environments.

In their training, physical therapists are not normally exposed to biopsychosocial models of pain perception and pain-associated disability. To address this shortfall, Linton and Shaw5 have identified, described, and appraised the key psychological processes considered to influence pain perception and to underpin the development of chronic pain and disability. They illustrate how these processes are featured in some of the major current theoretical models, and they provide a link to practice by offering a set of guiding principles, with implications for clinical evaluation and treatment.

The interpretation of the influence of psychosocial factors on outcome in a particular study can depend on how these factors were "implemented" in the study. Hill and Fritz6 highlight this important methodological issue by appraising the differing potential influences of psychological factors as prognostic factors, treatment moderators, or treatment mediators, and they discuss the potential clinical implications of identifying these different ways in which psychological factors can influence treatment and its outcome.

In the next article, Fritz and colleagues 7 provide data on the use of the Subgroups for Targeted Treatment (STarT) Back Screening Tool. 8 This screening tool originally was designed for use in primary care, but results from Fritz and colleagues' study suggest that it has potential for use in physical therapy settings.

Nicholas and colleagues 9 revisit the original development of the concept of "yellow flags" 10 as psychosocial obstacles to recovery and review the subsequent decade of research. They first consider the relationship of psychosocial risk factors with outcomes of treatment for acute and subacute low back pain. They then consider the worth of targeting such factors in interventions as a way of enhancing outcomes.

Bergbom and colleagues11 report a specific investigation into the relationship between pain catastrophizing and depressed mood in outcome of physical therapy treatment. Yellow flags typically are studied in isolation, but this article shows the potential value of creating patient subgroups with multiple psychological measures. The authors also highlight the potential importance of providing targeted treatment, as receiving standard physical therapy did not benefit the high-risk subgroup.

Nicholas and George12 describe how psychological principles can be integrated into clinical practice in the development of intervention strategies. Having identified lessons from the literature, the authors focus particularly on the integration of psychological factors into secondary prevention and illustrate how psychologically informed reactivation can assist in the identification and management of obstacles to recovery or improved function.

The workplace provides unique challenges for physical therapists managing low back pain, which has importance not only for workplace-based interventions but for clinical practice. Shaw and colleagues13 appraise the utility of a range of possible strategies specifically for evaluating and addressing occupational factors and consider the physical therapist's potential role in client assessment, development of activity and lifestyle recommendations, therapeutic exercise, communication with other providers, and summary reports. The authors conclude with a number of recommendations for guiding clinical practice.

Any sustained shift in the focus of clinical management will require change in current physical therapist education and practice. Foster and Delitto14 identify key challenges and potential opportunities in establishing an integrated biopsychosocial approach.

It is important, however, to investigate whether physical therapist training in biopsychosocial approaches actually alters patient outcomes in practice. Overmeer and colleagues,15 in one of the few randomized controlled trials on the effect of biopsychosocial training, report on the clinical outcomes from biopsychosocial training for physical therapists. Although the authors' hypotheses were not supported, this randomized controlled trial provides direction for future hypotheses and is an important model for future studies in this area.

Finally, Some Words of Gratitude

As guest editors, we would like to thank Rebecca Craik and Dan Riddle for their support in making this special issue a reality. Mark Bishop deserves special mention for his time and assistance in designing the figures used in the introductory and concluding papers. Carolina Valencia also assisted with development of the figures. Finally, we are truly appreciative of author and reviewer contributions to this special issue. The authors demonstrated true professionalism and courtesy when dealing with our faltering attempts to sculpt this issue, and the reviewers selflessly offered their expertise by providing timely and informative suggestions to the editors and authors.

References

Manuscript Reviewers for PTJ's Special Issue on Psychologically Informed Practice

Dr Rebecca Craik, Editor in Chief, and Dr Chris Main and Dr Steven George, Guest Editors, gratefully acknowledge the manuscript reviewers who contributed their time, expertise, and constructive comments to this special issue:

John Childs, PT, PhD, MBA, OCS, FAAOMPT

Joshua Cleland, PT, DPT, PhD, OCS, FAAOMPT

Chad Cook, PT, PhD, MBA, OCS, FAAOMPT

Roger Fillingam, PhD

Douglas Gross, PT, PhD

Mark Hancock, PhD

Merrill Landers, DPT, OCS

Mari Lundberg, RPT, PhD

Christopher Maher, PT, PhD

Mike Robinson, PhD

Kevin Vowles, PhD

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Psychosocial Influences on Low Back Pain: Why Should You Care? | Physical Therapy | Oxford Academic

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© 2011 American Physical Therapy AssociationThe purpose of this special issue of PTJ is to present and integrate research evidence about the influence of psychosocial factors on presentation of symptoms of pain and disability (function) in physical therapist practice. We have focused primarily on low back pain, as it is the most widely researched musculoskeletal condition.

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Thoughts on using psychosocial approaches in the Rx of CLBP

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Thoughts on using psychosocial approaches in the Rx of CLBP

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Psychosocial factors (PS) are described as the combination of an individual's cognitive, emotional and social status that can influence their health status (Singla et al., 2015) and they include: patients' beliefs that pain and activity are harmful, fear avoidance beliefs, negative behaviours, lack of support, overprotective families, physical condition, personality type, coping strategies and faith/religious beliefs (Overmeer et al., 2004). For the past two decades we've known that PS factors play an important role in the development and subsequent recovery of individuals suffering from chronic low back pain (CLBP) (Kamper et al. 2015; Synnott et al., 2015; O'Sullivan, 2011) and current literature and guidelines for low back pain (LBP) in the UK, Australia, New Zealand and Italy recommend that PS factors should be considered in addition to traditional biomedical factors (e.g. structural-anatomical signs and symptoms and imaging findings) when managing patients with LBP (Negrini et al., 2004; NICE, 2016; Synnott et al.,2015; Darlow et al., 2014). Despite the widespread recommendation of incorporating the biopsychosocial (BPS) model into clinical practice, qualitative research studies in New Zealand Australia and UK investigating clinical practice underlined the tendency of manual and physical therapy practitioners to adopt a biomedical approach when working with LBP patients. (Singla et al., 2014, Darlow, 2016). To explore the transferability of these qualitative studies, we decided to investigate personal beliefs, knowledge, experiences and the potential barriers of Italian physiotherapists in assessing PS factors in patients with CLBP (Zangoni and Thomson, 2017). The qualitative study used semi-structured interviews with practitioners to collect data. We then used a grounded theory approach to analyse the interview data and make comparisons of the differences and similarities between participants, so that the findings were a construction of the different perceptions and experiences participants had in relation to the PS factors in CLBP (Charmaz, 2016).

The data suggested that all participants attributed some importance to PS factors and recognised the need to consider these aspects when working with patients presenting CLBP, but there was uncertainty about how to do this in a specific and meaningful way. There was an awareness of the importance of social factors, stress and negative attitudes amongst physiotherapists in relation to CLBP. However, it was unexpected to find that just a few participants mentioned psychological factors such as depression or anxiety (Heneweer et al., 2007, 2010) and fear-avoidance behaviours of patients as important PS factors (Pincus et al., 2006a,b; Nicholas et al., 2011). Although physiotherapists in the study had a vague awareness of the BPS model, many perceived biomedical and psychosocial factors as being totally separate domains, rather than being part of the same BPS model designed to orientate the practitioners' assessment and treatment.

Exploring the main barriers that practitioners faced when assessing CLBP, we found participants held a general view that the role of physiotherapists was mainly as a manual therapist performing physical treatments, and many felt there was limited opportunity during their sessions to fully assess PS factors with CLBP patients. Further, physiotherapists reported concerns that exploration of PS factors could lead to a disruption in the therapeutic relationship (i.e. fear of "losing the patient"). This was considered an important barrier to exploring PS factors.

Limited education about PS aspects in university training and lack of standardisation in this area within the Italian physiotherapy professional education may be a possible reason for physiotherapists' lack of confidence, skills and knowledge of the importance of PS factors. Our research was congruent with the findings of similar studies conducted in Australia and the UK by Singla (2015) and Darlow (2016) which found physiotherapists recognising the importance of PS factors, but still tended to focus on clinical biomedical and biomechanical findings (such as numerical pain levels and joint range of motion) rather than on PS factors to inform their prognosis and treatment plan (Kent et al. 2009). This is a concern in view of the strong prognostic capacity of PS factors compared to physical/biomedical factors (Chou et al. 2007).

Finally, curriculum planners and educators likely face a balancing act when constructing a physiotherapy course aligned to the current evidence base. Traditionally, undergraduate physiotherapy education incorporates biomedically and biomechanically orientated clinical skills and subjects; however contemporary evidence suggests that subjects orientated towards psychology, sociology and even philosophy may be equally important clinically if not more. However, the current literature suggests lack of standardisation in this area within the physiotherapy profession and lack of BPS oriented nature of the training (Overmeer et al, 2009; Synnott et al, 2015). Physiotherapy educators in Italy and elsewhere, may look to enhance initial training and postgraduate education in PS assessment and management in patients presenting with CLBP. However, this also appears to be not so straightforward! Interventions to increase practitioners' provision of psychosocial interventions have had little effect on patient outcomes (Hay et al. , 2005, Jellema et al. , 2005, Overmeer et al. , 2011, Stevenson et al. , 2006). More recent attempts to train practitioners in a BPS approach have been more successful in physiotherapy/physical therapy (Asenlof et al. , 2009, Beneciuk and George, 2015, Hill et al. , 2011, Overmeer et al. , 2009, Sullivan and Adams, 2010, Vibe Fersum et al. , 2013) but it remains difficult to shift practitioners' attitudes towards back pain. Two recent studies showed practitioner attitudinal changes towards a more BPS management of their patients, one with participants following workshops and having clinical supervision (Synnott 2016) and one with participants taking an e-learning programme (Draper-Rodi et al. , 2016). These results are promising but the mechanism on how practitioner attitudes influence their behaviour is still unclear.

Our qualitative findings concerning physiotherapists' barriers to assessing PS factors and the tendency to adopt a biomedically oriented approach with patients presenting CLBP are not intended to represent the entire Italian physiotherapy profession; however, the data may have some resonance with individual practitioners and should be considered as an instrument to highlight some of the challenges that are currently limiting the best practice in chronic LBP.

About Giacomo Zangoni

Giacomo is a registered Osteopath and Physiotherapist, obtaining the Bachelor's degree in Physiotherapy at the University of Padua (Italy) and the Master's degree in Osteopathy at the British School of Osteopathy (London). Since 2012 he has been collaborating in Italy and now in London with sport societies and working in private clinics and rehabilitation centers. Giacomo is currently collaborating with the Research team of the British School of osteopathy on the evaluation of psychosocial factors in chronic low back pain and has recently published his master's degree final research in a peer-reviewed international journal.

About Oliver Thomson

Dr Oliver Thomson is a practicing osteopath and Senior Lecturer at the British School of Osteopathy where he leads the research teaching for the undergraduate and postgraduate osteopathy programs. Oliver completed his PhD in osteopathy at the University of Brighton, Clinical Research Centre for Health Professions, where he explored osteopaths' clinical decision-making. His research interests include clinical decision making and reasoning, professional identity and beliefs using qualitative research and has published extensively in these areas. He is an Associate Editor of the International Journal of Osteopathic Medicine and is on the international advisory board for Musculoskeletal Science and Practice.

About Jerry Draper-Rodi

Dr Jerry Draper-Rodi is an academic clinician: he is CPD Manager and Research Lecturer at the British School of Osteopathy, chairs Oxfordshire Osteopathic Network and practises in Oxfordshire. He was awarded a Professional Doctorate in Osteopathy in 2016. His research was on the acceptability, feasibility and likely impact of a biopsychosocially-informed e-learning programme for non-specific LBP on experienced osteopathic practitioners' attitudes to back pain. He has presented his research in numerous conferences and has published articles in peer-reviewed journals. Jerry is a reviewer for the International Journal of Osteopathic Medicine.

References

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Asenlof P, Denison E, Lindberg P. Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: A randomized controlled trial in primary care. Eur J Pain. 2009;13:1080-8.

Beneciuk J, George S. Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings:Two-Phase, Sequential Preliminary Study. Phys Ther. 2015;95:1120-34.

Charmaz, K., 2016. Constructing Grounded Theory. SAGE Publications.

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Darlow, B., Perry, M., Mathieson, F., Stanley, J., Melloh, M., Marsh, R., Baxter, G.D., Dowell, A., (2014). The development and exploratory analysis of the Back Pain Attitudes questionnaire (Back-PAQ). British Medical Journal Open, 4(5):e005251.http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4039861&tool=pmcentrez&rendertype=abstract.

Darlow, B., Perry, M., Stanley, J., (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. British Medical Journal, 4(5): e004725. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4039787&tool=pmcentrez&rendertype=abstract.

Draper-Rodi J, Vogel S, Bishop A. Impact of an e-learning programme on the biopsychosocial model for non-specific low-back pain on experienced osteopaths' attitudes to back pain: A mixed-methods study. Manual Therapy. 2016;25:e167-e8.

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Nicholas, M. K., Linton, S.J., Watson, P.J., Main, C.J., (2011). "Decade of the Flags", Working Group Early Identification and Management of Psychological Risk Factors ("Yellow Flags") in Patients With Low Back Pain: A Reappraisal. Physical Therapy, 91(5), pp. 737-753.

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Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K. Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study. J Physiother. 2016 Oct;62(4):215-21. doi: 10.1016/j.jphys.2016.08.002. Epub 2016 Aug 24.

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Zangoni, G., & Thomson, O. P. (2017). " I need to do another course"- Italian physiotherapists' knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskeletal Science and Practice, 27, 71-77.

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Assessing psychosocial factors in chronic low back pain

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Psychosocial factors (PS) are described as the combination of an individual's cognitive, emotional and social status that can influence their health status (Singla et al., 2015) and they include: patients' beliefs that pain and activity are harmful, fear avoidance beliefs, negative behaviours, lack of support, overprotective families, physical condition, personality type, coping strategies and faith/religious beliefs (Overmeer et al., 2004).

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Whole Person Healthcare | New Zealand MindBody Network

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An authoritative resource for both clinicians and patients to understand and use a whole-person healthcare approach to illness.