MedWorm provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest medical blog items that have been tagged with 'behavioural'. Sat, 03 Sep 2011 02:14:09 +0100 http://www.medworm.com/index.php?rid=5159895&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F08%2F23%2Fself-management-a-very-vexing-definition%2F Self management is one of those terms that is used to describe the aim of cognitive behavioural programmes for chronic pain. It’s even in my description of this blog! At the same time, it’s difficult to arrive at a definition of self management that “everyone” agrees upon. Self management can mean helping people to be “actively involved in their health care and to provide a variety of creative and individualized strategies to deal with their health problem in their daily life and ultimately to live as normally as possible despite their symptoms” (Zuffery & Schulz, 2009) – but the Devil is in the details! What exactly does being “actively involved” mean?  Can it mean accessing treatments like massage, injections, acupuncture &#8220... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=5159895 Mon, 22 Aug 2011 19:21:38 +0100 5159895 http://www.medworm.com/index.php?rid=5140334&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F08%2F18%2Feducation-or-a-cognitive-behavioural-approach%2F In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8.  Both groups received a group-based programme of 10 sessions of 90 minutes.  They both received a workbook and additional reading material.  The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not. Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced.  Instead it presents thematic analysis from in-depth interviews of the participa... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=5140334 Wed, 17 Aug 2011 19:35:42 +0100 5140334 http://www.medworm.com/index.php?rid=5130661&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2011%2F08%2F15%2Fevaluation-of-learning-resources-for-end-of-life-care-in-extra-care-settings-executive-summary%2F Title: Evaluation of learning resources for end of life care in Extra Care Settings: Executive Summary Scan or click to download 'Evaluation of learning resources for end of life care in Extra Care Settings: Executive Summary' The Skinny: Summarises experiences from the use of learning resources developed to support end of life care in an “extra care” setting. Publisher: The University of York, Centre for Housing Policy Published: 13/07/11 Size: 6p. Filed under: Ooops Missed Category! Tagged: Behavioural sciences, Education, End of Life Care, Grey Literature, Medical Treatment, Palliative Care, Terminal illness, Training (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=5130661 Mon, 15 Aug 2011 13:43:26 +0100 5130661 http://www.medworm.com/index.php?rid=5125694&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2011%2F08%2F12%2Fnursing-times-2011-vol-107-no-26-3%2F Fade fave: How to manage harmful drinking Fade skinny: A summary of the latest NICE guideline advising on diagnosing, assessing and managing harmful drinking and alcohol dependence in adults and young people. Contact the Library for a copy of this article Filed under: Journals Tagged: Alcohol Misuse, Cognitive Behavioural Therapy, Guidelines, NICE (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=5125694 Fri, 12 Aug 2011 14:51:04 +0100 5125694 http://www.medworm.com/index.php?rid=4945248&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F06%2F17%2Fwhat-to-do-about-catastrophising-even-when-youre-not-a-psychologist%2F In this study, 25.9% of those reporting acute pain, and 51.3% of those reporting chronic pain endorsed catastrophising beliefs.  And this group of people were not seeking treatment (as an aside, this is one of few studies to look at non-treatment-seeking people)!  The study also found that in those with high levels of catastrophising, mental health problems were more prevalent, and that catastrophising explained a good proportion of work disability.  In other words, even in this very healthy group of people, catastrophising was associated with greater vulnerability to having difficult managing pain and keeping mentally healthy.  If this finding is identified in other non-treatment-seeking people, I think we can confidently draw the conclusion that catastrophising may be one of the more... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4945248 Thu, 16 Jun 2011 23:24:01 +0100 4945248 http://www.medworm.com/index.php?rid=4911844&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F06%2F08%2Fa-brief-review-of-cognitive-behavioural-approaches-for-pain-management%2F Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems.  While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health.  In fact it has only been in the last few years that research into the process of change in pain management have been conducted. What defines a cognitive behavioural approach? The assumption that people can learn to accept their chronic pain That people can broaden their self-concept beyond being “a patient” into being “a person with pain” That people can learn or re-explore skills to deal ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4911844 Wed, 08 Jun 2011 00:39:00 +0100 4911844 http://www.medworm.com/index.php?rid=4893949&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F06%2F01%2Fpain-behaviours-persist%2F In this study by Martel, Thibault and Sullivan (2010), people with back pain were recorded on two separate occasions (on averge 22 days apart) while carrying out two lifting tasks designed to elicit pain behaviours.  These recordings were reviewed by trained observers who recorded the number of pain behaviours in each segment of film using a standardised coding scheme (developed by Keefe and Block, 1982).  Participants in the lifting tasks also completed a range of questionnaires – the Tampa Scale for Kinesiophobia, the McGill Pain Questionnaire, and the Pain Catastrophising Scale. Before I describe the findings, in this study two different forms of pain behaviour were identified – communicative behaviours are things like grimacing, speaking, sighing, moaning and so on; while... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4893949 Wed, 01 Jun 2011 05:26:00 +0100 4893949 http://www.medworm.com/index.php?rid=4780495&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F05%2F04%2Fmore-psychological-stuff-isnt-in-my-scope-of-practice-so-what-can-i-do%2F I promised there would be more on this topic – it’s a popular one and full of vexing questions.  I left off yesterday, after making four points that IMHO might help incorporate some of the psychosocial management to a nonpsychological practice.  They were: Give precise advice about what to do. Give reasons for your advice. Ask the person about their understanding of their pain. Make sure you give clear timeframes for any activity restrictions. The underlying rationale for each of these is to counter two main problems that appear to underpin the development of longterm disability associated with pain: catastrophising, or ‘thinking the worst’, and avoidance. This point is really important, so listen up! It’s not the presence of pain alone that is the problem.�... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4780495 Tue, 03 May 2011 19:32:40 +0100 4780495 http://www.medworm.com/index.php?rid=4753984&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F04%2F27%2Fworking-inside-the-envelope-or-pushing-the-boundaries%2F This study examines four different treatments carried out in parallel, it’s an unblinded/masked randomised trial designed to establish the effectiveness of these treatments as well as the adverse events associated with each treatment, and reviews the outcomes up to one year after treatment ended. Participants were carefully selected to meet the criteria for a diagnosis of chronic fatigue syndrome, and it’s interesting to see that only 28% of the people initially recruited actually met these criteria, and of this group, only 71% or 641 people actually progressed through to treatment.  Thankfully the CONSORT trial profile included in the paper shows very clearly who was ‘in’ and who was ‘out’ – and why! Clinicians were carefully trained, supervised ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4753984 Tue, 26 Apr 2011 19:35:40 +0100 4753984 http://www.medworm.com/index.php?rid=4664499&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F03%2F31%2Fmoodjuice%2F I had a nice email from James Hardie from Moodjuice website, an NHS Scotland site developed for both health professionals and individuals to access self help resources. For patients, the site starts by saying “Emotional problems are often the mind and body’s way of saying that something needs to be changed in our life” - I like that!  I like the way the patient area is based on practical problems like housing, childcare, hobbies and interests, meeting people, relationships and so on. For professionals, the feature that really appeals to me is the “build your own resource” area.  This enables you to put together the most relevant handouts for the person you’re seeing – a lovely feature! Then you can print the whole lot off, and it’s a pulled-tog... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4664499 Wed, 30 Mar 2011 20:12:26 +0100 4664499 http://www.medworm.com/index.php?rid=4429241&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F02%2F03%2Fcbt-approach-in-the-real-world%2F While there are many papers published about the outcomes from using a cognitive behavioural approach, there are very few describing the process ‘in the real world’. This leaves a gap for many clinicians who may read about it, maybe have training in delivering this type of intervention, or work in a team where it’s an integral part of practice – but who may not know how it ‘works’ except as it’s delivered in a pen-and-paper, sitting-in-a-clinic-room kind of way. Today I’m describing one way I go about integrating a CBT approach into my work.    This case study is a compilation of several people I’ve worked with, in order to protect patient privacy. Simone has neuropathic pain in her dominant hand. She’s a tough cookie who worked... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4429241 Wed, 02 Feb 2011 19:33:39 +0100 4429241 http://www.medworm.com/index.php?rid=4419467&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F02%2F01%2Foccupational-therapy-the-cognitive-behavioural-approach-for-pain-management-ii%2F In the first post on my commentary of Robinson, Kennedy and Harmon’s review of occupational therapy for chronic pain, I argued that they have misinterpreted the cognitive behavioural approach to pain management, and in particular, that they appear to hold an outmoded view of pain as either biological/organic or psychological, and refute the place of psychosocial models in occupational therapy practice. Yesterday I distinguished between cognitive behavioural therapy and a cognitive behavioural approach - while the therapy is often primarily concerned with ‘talk’ therapy followed by behavioural changes to improve mood for example, a cognitive behavioural approach is a broader concept that is based upon the assumption that people are able to make changes in the way they unde... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4419467 Mon, 31 Jan 2011 17:46:19 +0100 4419467 http://www.medworm.com/index.php?rid=4419468&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F30%2Foccupational-therapy-the-cognitive-behavioural-approach-for-pain-management%2F I have always resisted being labelled. I am much more than my gender, my marital status, my diagnosis, my professional background.  I also feel quite uncomfortable about being told what I may or may not do (maybe that’s where my kids get it from?!). I don’t like being told what is and isn’t ‘my role’ or someone else’s role.  I’m interested in what works and doing it well and at the right time for the right reason.  Today’s post is the first of a two-part commentary on a paper by Robinson, Kennedy and Harmon published in the American Journal of Occupational Therapy this month in which it is argued that occupational therapists who offer cognitive behavioural therapy ‘without sufficient attention to occupational therapy’s professi... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4419468 Sat, 29 Jan 2011 19:00:53 +0100 4419468 http://www.medworm.com/index.php?rid=4399841&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F26%2Fpulling-it-all-together-biopsychosocial-assessment%2F Over the past little while I’ve been writing about how a comprehensive pain assessment can be carried out.  Today it’s time to pull that information together to develop a formulation, or set of possible explanations for why this person presents in this way at this time – at least for one or two aspects of his presentation. For example, if the person’s pain is low back pain, where surgery has failed to improve the person’s pain, but he has maintained working in a teaching job where physical demands are reasonably light, but is having trouble with sleep, feels irritable, can’t manage things like mowing lawns, and is very careful not to bend because he was advised after surgery to avoid bending because it may affect healing.   Limited forward flexion, si... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4399841 Wed, 26 Jan 2011 01:00:45 +0100 4399841 http://www.medworm.com/index.php?rid=4361321&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F19%2Fa-comprehensive-pain-assessment%2F What makes up a comprehensive pain assessment?  I could begin and never end this particular topic, I know, so I’ll try to confine myself to some of the major themes as I see it.  While this is my opinion, and readers should always remember this, there are some very good researchers and clinicians who hold this view as well – and I’ll cite one or two at least! The first aspect to determine in any assessment is its purpose.  I’ll explore this much further in future posts – the process I’ll describe is to guide initial case formulation and broad direction for pain management.  That is, it’s to identify any medical strategies required, to ascertain the basic coping ability (and thus the need for self management), and finally, to gauge the general f... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4361321 Tue, 18 Jan 2011 18:15:38 +0100 4361321 http://www.medworm.com/index.php?rid=4338291&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F12%2Fworking-out-who-does-what-teamwork-at-its-best%2F I work in a large team of clinicians.  We have clinicians from occupational therapy, physiotherapy, nursing, social work, clinical psychology and specialist medics with anaesthetic, musculoskeletal and occupational backgrounds.  Teamwork is absolutely vital to our work. When we start to work with an individual, we work in much smaller teams of two or three: someone with a psychosocial flavour, another with a functional flavour, and (often) someone with an applied focus. While scouting around in my office I found an old book chapter from a book called “Pain Management. A Handbook of Psychological Treatment Approaches” edited by A. D. Holzman and D. C. Turk. It’s an old book, published by Pergamon Press in 1986, but don’t let that fool you – a couple of the ch... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4338291 Tue, 11 Jan 2011 23:17:08 +0100 4338291 http://www.medworm.com/index.php?rid=4331265&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F11%2Fbrain-training-it-happens-all-the-time%2F At the risk of seeming untrendy, the trend to rave on about neuroplasticity can be a bit overdone.  Not, I add quickly, because it doesn’t happen, or it’s not important – in fact, quite the opposite – but because it happens all the time.  And at the back of our minds, I think we’ve known this for quite a while.  How else do you think we manage to learn new things even in our elder years? The reason I’m raising this today is, after yesterday’s post on phantom limb pain and the parts of the brain that are active when we have pain and when hypnosis is used for pain relief, I started to mull over the range of treatments that are used in managing chronic pain.  Now, we don’t have fMRI studies for all the treatments available.  I don’t t... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4331265 Mon, 10 Jan 2011 21:40:09 +0100 4331265 http://www.medworm.com/index.php?rid=4327074&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F10%2Fits-really-all-about-the-brain%2F Neuroscience is such a geeky area to study. And I have to say I didn’t really study the brain all that well in my undergraduate training all those years ago – but oh, how the worm has turned! It’s so exciting to see how basic science directly influences treatments that we can use for people who don’t have many pharmacologic options for their pain. While I don’t have really up-to-date papers today, I think the 2008 paper by Herta Flor presages some of the approaches we’re starting to use in clinical settings now, a scant three years later. Flor’s work has always been impressive – she has often looked at what happens when brains are deprived of their normal feedback because of trauma or amputation, and (really exciting!) she is coming to Austra... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4327074 Mon, 10 Jan 2011 03:02:46 +0100 4327074 http://www.medworm.com/index.php?rid=4314228&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2011%2F01%2F06%2Fsleep-posts-from-2010%2F Sleep is so important for wellbeing (ask any young parent!), and yet many people with chronic pain have really poor and unrefreshing sleep, and very poor sleep habits.  Some pain conditions show changes to the quality of the sleep stages (such as fibromyalgia for example), to the point where these changes can almost be diagnostic, while many people with chronic pain also have low mood in which sleep disruption is a common feature. I’ve written about sleep several times over the past year, and today I provide links to some of these posts for your education and enjoyment. Sleep problems in chronic pain and what helps – Pain can be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4314228 Wed, 05 Jan 2011 18:13:48 +0100 4314228 http://www.medworm.com/index.php?rid=4298821&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F12%2F30%2Fskills-strategies-resources-in-2010%2F Part of the reason for this blog is to introduce clinicians to some of the research and application of coping strategies for people with chronic pain.  While I can summarise the year’s developments in (almost) a single sentence (see below!), it’s also true that I’ve posted a lot of really interesting findings about coping over the year.  Today’s summary links to the goodies I’ve found in 2010. Oh, my summary? There is nothing especially new under the sun in self managing pain – it’s about goals, acceptance, exercise, engaging in important activities and roles, gratitude, connecting with people…oh and mirrorbox for some lucky people for whom it works well! Cognitive behavioural approaches to pain management Before I post the links, a quick w... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4298821 Wed, 29 Dec 2010 22:04:49 +0100 4298821 http://www.medworm.com/index.php?rid=4272660&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F12%2F20%2Fa-year-in-review%2F This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too. What has been the same this year is the endless need to repeat to all and sundry the following: All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand. All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model. Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological res... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4272660 Mon, 20 Dec 2010 07:22:22 +0100 4272660 http://www.medworm.com/index.php?rid=4253468&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F12%2F14%2Fknowing-how-is-not-equal-to-doing%2F There have been several attempts to develop a standardised approach to self management – one of the most popular in New Zealand is the Flinders Program (TM). This is a programme developed in Australia from the 1990 Australian Coordinated Care Trials. It’s based on cognitive behavioural therapy, includes problem solving and motivational interviewing techniques, and provides a set of tools and processes that clinicians can use to help people assess and then develop self management plans. The aim, as for any self management programme, is to shift the ‘balance of power’ so to speak from clinician-centred to patient or client-centred partnership, so that shared decision-making about health occurs. It has been used in New Zealand for some years: the Arthritis New Zealand ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4253468 Mon, 13 Dec 2010 18:31:21 +0100 4253468 http://www.medworm.com/index.php?rid=4207517&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F29%2Fcan-psychological-management-of-fibromyalgia-affect-pain%2F When I’m working with someone who has chronic pain, from the outset I’m pretty straight-up that the treatments I offer don’t directly affect pain intensity.  It’s not my focus, and very often after the first session, I don’t even discuss pain – I’m more interested in what the person is doing! And for this focus, I sometimes get some reasonably snippy comments, none more so than a doctor (who shall remain nameless) who said to some of my students that psychological and functional approaches to pain management are, in effect, useless because they ‘can’t directly address the pain’. Well, I beg to differ, kind sir. While pain intensity isn’t the focus of treatment, it very often is affected by the treatments offered using a cog... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4207517 Sun, 28 Nov 2010 21:06:30 +0100 4207517 http://www.medworm.com/index.php?rid=4197387&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F24%2Fdeveloping-a-set-back-plan-in-pain-management%2F In this study, access to this support was maintained for four months. What this research found was that across a wide range of outcome measures including pain intensity, mental health, physical activity and disability, participants maintained their changes.  Not only did they maintain these changes during the four months of telephone support, they also maintained changes over a subsequent four months – to a greater extent than those who didn’t have access to this kind of support. I think this approach is promising.  Ongoing support groups have some negative effects, particularly if they rely on volunteer or lay leaders (who may have their own issues to manage), and they can foster a degree of ongoing identification with the ‘patient’ role.  Similarly, providing i... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4197387 Tue, 23 Nov 2010 18:30:46 +0100 4197387 http://www.medworm.com/index.php?rid=4190545&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F23%2Fflare-ups-breakthrough-pain-or-set-backs-self-managing-exacerbations-of-pain%2F A couple of days ago I wrote about medication and managing flare-ups, and out of that post there was a bit of discussion about what exactly I meant by flare-up, and whether it might be better defined as break-through pain.  I’ve found that there is not a lot of agreement in the literature – nor with clinicians! – in terms of distinctions between flare-up or breakthrough, so I’ve decided to redefine the problem completely. Not that I’m the first to do so, as you’ll see from the paper I’ve referred to today.  I have to admit that I like Turk’s approach to chronic pain, as it’s the way I have been trained to approach pain management.  Turk is also the author of a self-help book for chronic pain management that I still think is one of th... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4190545 Mon, 22 Nov 2010 21:34:13 +0100 4190545 http://www.medworm.com/index.php?rid=4175986&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F18%2Fmedication-and-self-managing-chronic-pain-iii%2F When discussing medication and pain reduction for chronic pain, it’s not surprising there are some very strong opinions and emotions.  After all, having pain is universally known to be unpleasant, very few people really want to have pain (except those who like the rush of acute pain – vis a vis body suspension!), and the first person many people go to discuss their pain is a medical practitioner. The way the centre in which I work views medication is that it forms part of a toolkit for managing pain, alongside all the self management strategies that we also endorse.  So, by and large, most of the people we see are on a stable regime of medication targeting the underlying mechanisms thought to be influencing the nervous system’s sensitivity to stimuli. A reader suggested... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4175986 Wed, 17 Nov 2010 20:03:55 +0100 4175986 http://www.medworm.com/index.php?rid=4152303&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F10%2Frebuilding-work-identity%2F I love helping people return to work.  It’s got to be one of the most rewarding parts of pain management for me because not only is work important for health, it’s a major part of our day, and it’s a whole lot about individual identity.  So helping people reconstruct their sense of self to the point where they can go to an employer and say ‘I can do this for you’ with confidence is an enormous challenge. To feel confident enough to put yourself on the line to an employer despite chronic pain is a challenge.  It involves at least some of the following (and yes, this is mostly from my experience on this post!): Good self efficacy for managing pain - to the point where fluctuations in pain intensity can be taken with equanimity Strong knowledge of what you ca... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4152303 Wed, 10 Nov 2010 01:28:00 +0100 4152303 http://www.medworm.com/index.php?rid=4143033&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F08%2Fhappy-happy-joy-joy-increasing-positive-experiences-to-improve-mood%2F I am sure there will be people who read today’s post who will feel like giving me a bit of a slapping. “How”, they will say, “Are you supposed to get happy when you’re feeling bad?” And I would have been one of these people a few years ago too, given my history of low mood and love of whining. Seriously, it’s completely counter-intuitive to think that when you’re feeling flat and low, all you need to do is get out and enjoy yourself! It goes a bit like this, I think. When someone is feeling a bit flat, maybe having done too much and started to feel fatigued, it’s normal to stop doing quite so much and rest up. But if resting fails to increase energy – maybe because of a chronic condition like fibromyalgia, or really any of the chr... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4143033 Sun, 07 Nov 2010 18:37:39 +0100 4143033 http://www.medworm.com/index.php?rid=4134291&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F11%2F02%2Fresilience-catastrophising-and-positive-emotions%2F Catastrophising, or thinking the worst, is one of those psychological factors that we know influences distress and disability in people with chronic pain. It’s quite a common phenomenon, and sometimes can stand us in good stead – after all, if we can think of the worst things that can happen, then plan to avert those possible disasters, then life will be sweet, yes? ermmmm – no, as a matter of fact.  Catastrophising can actually function to narrow our thinking down, reducing the range of options we can come up with to manage situations, and it can also function to focus us on things that haven’t worked out while at the same time minimising our appreciation of things that are working well. In chronic pain, catastrophising is often an outcome to measure – the t... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4134291 Tue, 02 Nov 2010 08:49:36 +0100 4134291 http://www.medworm.com/index.php?rid=4119761&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F27%2Fpsychological-therapy-works-for-fibromyalgia%2F An ‘enigmatic’ disorder – this is what Perry Nicassio calls fibromyalgia. I hadn’t thought of it that way, because so many chronic pain problems seem to be equally ‘enigmatic’! It’s a common disorder, affects many more women than men, has a multiplicity of effects on people ranging from fatigue, poor sleep, widespread aching, other pain sensations such as stabbing or needle-like pains that can appear anywhere in the body, often with low mood and loss of function.  There are few medications that seem to help, and many people never seek treatment for their pain.  If people do look for treatment, they can be faced with skepticism from some health providers, despair from others, and offered a multiplicity of treatments that don’t seem to do an ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4119761 Tue, 26 Oct 2010 18:37:56 +0100 4119761 http://www.medworm.com/index.php?rid=4082343&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F19%2Fhow-did-that-happen-stories-of-returning-to-work%2F Yesterday I started to talk about returning to work with chronic pain. I mentioned that it’s often not the degree of importance an individual places on returning to work that engenders resistance – it’s more likely the lack of confidence the person has towards the process, the fear that this won’t work out and they will fail… A story or two might help detail some of the issues that people I work with encounter when they’re returning to work. Now I recognize that the people I see are possibly at the more complex end of the spectrum than many, so these stories might well be more extreme than what many clinicians see, but at the same time they illustrate where things go wrong. A note: vignettes used in this blog are composites of people I’ve worked wi... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4082343 Tue, 19 Oct 2010 05:21:29 +0100 4082343 http://www.medworm.com/index.php?rid=4082344&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F19%2Fworking-and-chronic-pain%2F If there is one aspect of chronic pain management that has received more attention than returning to work, I don’t know it! In 1995 when I started working at my current workplace, work was almost a dirty word. I was accused at one time of being a ‘Siberian workcamp’ Commandante because some people thought it was cruel to ‘force’ people with chronic pain into the workplace. Thankfully this attitude has changed over the years, and most people recognise that working when you have chronic pain, while difficult, is achievable and good for health. At the same time, returning to work with pain has never been especially easy and there are numerous issues to work through. Today is the first day I will discuss the practical aspects of returning to work with the current ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4082344 Mon, 18 Oct 2010 18:37:07 +0100 4082344 http://www.medworm.com/index.php?rid=4077624&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F17%2Fworkability%2F There can sometimes be a delicate balance in therapy, between challenging people to try something new and step away from ways of coping that are easy because they’re habits, and at the same time respecting that people have different ways of doing things, different values and beliefs, and in the end have to choose what works for them. In a recent discussion, someone asked me why Psychology is so quick to judge treatments and why ‘evidence’ is restricted to therapy that has been subject to things like randomized controlled trials and so on. After all, lots of people come to see this person after ‘conventional’ treatment has failed, and they feel very happy with the treatment he gives them. To answer that question, and at the same time give due regard to individ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4077624 Sun, 17 Oct 2010 05:37:29 +0100 4077624 http://www.medworm.com/index.php?rid=4061090&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F13%2Fflexibility-of-the-psychological-kind%2F More holiday reading to ponder… One of the fascinating developments in psychology over the past 50 years is the ongoing study into what constitutes psychological health. It’s been known by many names – ego-resilience, executive control and self-regulation – but the work on these areas hasn’t been pulled together into a coherent whole until recently. The authors of this paper suggest that this is partly because of the nature of defining this particular beast – what is health after all? Their argument, and one that I find rather appealing, is that a main feature of health is to be able to apply the right kind of response to the many different situations in which we find ourselves. In other words, flexibility. Occupational therapists in particular will rejo... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4061090 Tue, 12 Oct 2010 18:38:39 +0100 4061090 http://www.medworm.com/index.php?rid=4055968&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F10%2F12%2Fcounting-your-blessings-or-looking-on-the-bright-side-of-life-whistles%2F My family were big on the Andrews Sisters. One of my strong memories as a child is listening to the song ‘count your blessings, name them one by one…’ [no, I will not sing it ok?!]. And I remember the book Pollyanna (you can read it for free here!) and the ‘Glad game’ where she looked for the positive in her rather dire situation when she went to live with her strict Aunt Polly. And guess what?  There is something in this approach to coping that makes a difference! While on holiday, sad person that I am, I did spend one or two days reading journal articles.  Several of them were related to the theme of positive psychology in a special issue of Clinical Psychology Review. While research into optimism, positive affect and even psychological flexibility has bee... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4055968 Mon, 11 Oct 2010 18:36:40 +0100 4055968 http://www.medworm.com/index.php?rid=4013604&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F29%2Fgo-on-expose-yourself%2F …er, maybe not that way OK?! Graded exposure in vivo (with response prevention) is a specific treatment for pain-related anxiety/fear and avoidance.  More specifically, it’s for people who are avoiding activities that are not going to harm them, but may increase their pain.  Their beliefs as to why they ‘shouldn’t do’ these activities or movements differ widely – some people recognise that while they’re not going to harm themselves, they don’t want to or feel overwhelmed when they experience increases in pain, while others are definitely concerned that their pain means some damage is likely to occur, or more often, ‘might’ occur. Simple reassurance doesn’t help people in this situation.  Just telling someone that ’... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4013604 Wed, 29 Sep 2010 03:56:33 +0100 4013604 http://www.medworm.com/index.php?rid=4003454&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F28%2Ffearanxietyavoidance-%25e2%2580%2593-treatments-review%2F For years, clinicians working in pain management have mixed together a rich assortment of strategies to help people function better.  But to identify the ‘active ingredients’ of multidisciplinary pain management using a cognitive behavioural approach, it’s been important to tease each element apart.  One size does not fit all – and just as a physician chooses the most effective medication for a disorder, in time I hope we will be able to choose the most effective strategy for the problems each individual experiences rather than applying our current ‘scatter-gun’ approach. Yesterday I gave a brief overview of the three main treatments to helping people who are fearful/anxious of their pain (or harm) and avoid activities as a result. They are: Graded ex... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4003454 Mon, 27 Sep 2010 18:25:26 +0100 4003454 http://www.medworm.com/index.php?rid=4003101&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F27%2Ffearanxietyavoidance-and-some-treatments%2F I’ve been pondering the post by Neil O’Connell on Body in Mind in which he comments on a paper by Foster, Thomas, Bishop, Dunne and Main (2010) in which he makes the point that “There is a huge emphasis on psychological variables in research and current care for low back pain. My experience (the usual biased, unreliable, non-replicable shambles) tells me that this is justifiably so. But in this rigorous study the four psychological variables found to have a unique influence individually explained just 2.5% of the variance or less. The big players were the level of disability when the patient arrived at the GP and demographic factors which together explained 50%.” Now this flies in the face of the general trend towards emphasising psychosocial variables associated wi... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=4003101 Mon, 27 Sep 2010 05:35:16 +0100 4003101 http://www.medworm.com/index.php?rid=3994369&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F23%2Fworking-with-thoughts-habits-take-time-to-change%2F If only there was a magic wand. I could make millions out of a ‘quick fix’ to changing habits! Unfortunately my magic wand is red and glittery – and plastic. I call it my ‘self management’ wand because it reminds me that self management is no quick fix, and a good deal of the work we need to do is about helping people recognize unhelpful thoughts and behaviors that might work in the short term, but not so in the long term. Changing patterns for sleeping well despite chronic pain is no different – what might have been going on for years isn’t likely to change overnight. Some of the thoughts that people have when embarking on cognitive behavioral therapy for insomnia can be quite unhelpful. One woman I worked with became despondent and eventually gav... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3994369 Wed, 22 Sep 2010 18:35:51 +0100 3994369 http://www.medworm.com/index.php?rid=3987247&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F21%2Fthinking-about-sleep-or-not%2F It’s 3.00 in the morning.  You haven’t slept since you got into bed at 11.00, and the last time you had a full night’s sleep was some months ago.  Every morning you wake up feeling as though you haven’t really slept yet – and every day is just the same. I can understand why people who have sleeping problems (and yes, I’m one of them!) often have quite strong reactions when they’re introduced to some of the concepts that are most successful for restoring a normal sleep pattern.  While the basic principles of sleep hygiene are well-known and reasonably simple, putting them – and other more challenging strategies in place – can be quite a difficult process. It’s what goes through a person’s mind that makes it difficult &#821... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3987247 Tue, 21 Sep 2010 09:06:04 +0100 3987247 http://www.medworm.com/index.php?rid=3983559&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F20%2Fsleep-problems-in-chronic-pain-what-helps%2F I have written about sleep problems in people with chronic pain several times. It is one of those aspects of dealing with pain that inevitably arise as I talk with people about energy, their activity through the day, and their mood. Many people blame the pain for their sleep problems, which is unsurprising really – once you’re awake in the middle of the night, there’s not a lot else to think about! But it seems like while pain might be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep. What are those factors? Well, one of the first ones is ‘general affective disturbance’ - in other words, feeling low or flat, whether frankly depre... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3983559 Mon, 20 Sep 2010 08:02:29 +0100 3983559 http://www.medworm.com/index.php?rid=3969196&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F15%2Fthe-tigger-effect-resilience-emotion-regulation%2F Tigger. That orange-furred, black-striped, tiger character originally introduced in A. A. Milne’s book The House at Pooh Corner. Tigger is a very bouncy fella. Tigger is amongst the most exuberant creatures in the 100 Acre Wood, and his most stand out and well-known feature is his very springy tail. Tigger has resilience. The wonderful thing about Tiggers…..Is Tiggers are wonderful things…..Their tops are made out of rubber…..The bottoms are made out of springs…..They’re bouncy, trouncy, flouncy, pouncy…..Fun, fun, fun, fun, fun…..But the most wonderful thing about Tiggers is…..I’m the only one…..The wonderful thing about Tiggers…..Is Tiggers are wonderful chaps…..They’re loaded with vim and vigor…..T... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3969196 Wed, 15 Sep 2010 09:22:49 +0100 3969196 http://www.medworm.com/index.php?rid=3969197&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F15%2Fwhat-to-do-when-feeling-low-grumpy-or-fatigued%2F Yesterday I wrote about emotion regulation and how this is seen as an essential part of achieving good mental health.  Emotion regulation is about being able to monitor, judge, and work with emotional responses in order to achieve goals. People with chronic pain often experience a range of negative emotions – pain itself is characterised as being a negative emotional and sensory experience. At the same time we know there is an interaction between feeling low and experiencing pain that makes both experiences feel worse. Three of the more troublesome emotions that people experience when they have chronic pain is low mood (not always depression, often ‘demoralisation’ or simply feeling sad and down); frustration and anger; and fatigue. Fatigue you say? Is that an emotion? W... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3969197 Tue, 14 Sep 2010 19:40:31 +0100 3969197 http://www.medworm.com/index.php?rid=3965719&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F09%2F14%2Fessential-skills-for-living-with-pain%2F I could actually head this post with the title ‘Essential Skills for Living’ and leave out the pain part, because as I reflect on the events over the past week, and the aftermath as residents of Christchurch start to demolish then rebuild their homes and businesses, these same skills apply. How do people live well despite adversity? Our lives are not straightforward and both major events and daily hassles are encountered and influence thoughts, emotions and behaviour. It’s normal to have a range of emotions, abnormal to be ‘happy, happy, joy, joy’ all the time (despite the adverts!). It has been postulated that the ability to regulate emotions is a sign of adulthood, and that being unable to regulate emotions is a contributor to much emotional ill-health. Emot... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3965719 Mon, 13 Sep 2010 19:36:20 +0100 3965719 http://www.medworm.com/index.php?rid=3993816&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2010%2F08%2F31%2Fjournal-of-the-american-medical-association-2010%2F This article aims to test cognitive behavioural therapy for ADHD in adults treated with medication but who still have clinically significant symptoms. The article concludes that among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months. An NHS Athens password is required to access this article online, alternatively contact the Library for a copy of the article. Filed under: Athens Password, Current Awareness, E-Journals, Journals, Ooops Missed Category! Tagged: ADHD, CBT, Cognitive Behavioural Therapy, Relaxation Therapy (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=3993816 Tue, 31 Aug 2010 11:55:24 +0100 3993816 http://www.medworm.com/index.php?rid=3920781&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2010%2F08%2F31%2Fjournal-of-the-american-medical-association-2010%2F This article aims to test cognitive behavioural therapy for ADHD in adults treated with medication but who still have clinically significant symptoms. The article concludes that among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months. An NHS Athens password is required to access this article online, alternatively contact the Library for a copy of the article. Filed under: Athens Password, Current Awareness, E-Journals, Journals, Ooops Missed Category! Tagged: ADHD, CBT, Cognitive Behavioural Therapy, Relaxation Therapy (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=3920781 Tue, 31 Aug 2010 11:55:24 +0100 3920781 http://www.medworm.com/index.php?rid=3915308&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F08%2F31%2Fgraded-exposure-in-the-real-world%2F Well, not exactly the real world – yet – just the clinic. A man I’m working with is very worried about his back.  Some years ago he had a discectomy and his surgeon told him he needed to be ‘very careful’ with his back – and so he has.  No bending, twisting, lifting for this man!  He’s given up some of his favourite things like fishing and whitebaiting and even golf because of this worry, although when I talk things through with him he’s not exactly sure what might happen if he ‘disobeyed’. Let’s call him Matt for wont of a better name (and yes, as usual, details have been changed to ensure confidentiality), and he’s a fairly ‘blokey’ man who loved his fishing, diving, and taking off for days in his conv... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3915308 Mon, 30 Aug 2010 21:02:47 +0100 3915308 http://www.medworm.com/index.php?rid=3915309&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F08%2F30%2Fexposure-in-vivo-for-kinesiophobia%2F In this study, the authors firstly looked at outcomes of graded exposure and whether anxiety, depression and catastrophising moderated these.  While anxiety was found to influence outcome generally (leading to poorer outcomes for those who were more anxious), catastrophising was found to have a more complex relationship.  Graded exposure was effective for low and moderate catastrophising, but for those with high catastrophising the results were far less spectacular.  And depression? Made little difference to outcome at all. After finding that high levels of catastrophising influenced outcome, the next step in this study was to examine those people who made a good deal of changein disability  and compare them with those who made much less change in disability.   For this part of the s... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3915309 Sun, 29 Aug 2010 19:33:53 +0100 3915309 http://www.medworm.com/index.php?rid=3891826&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F08%2F23%2Fwho-drops-out-of-cbt-for-chronic-pain%2F Wouldn’t it be wonderful if everyone we saw was ready for self management and committed to putting everything in place? Wouldn’t it be even better if we could tell who was and who wasn’t going to drop out? Then we could focus treatment on people who were ready for treatment, and help those who are not ready prepare to get ready (or manage their situation differently). Unfortunately, it’s one of those areas that is not well-researched, even though it’s a very important part of our clinical planning and can affect up to 60% of people initially enrolled in a cognitive behavioural approach to pain management. Over the years I’ve worked in pain management, I’ve seen several different approaches for establishing whether people should be included or not. ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3891826 Mon, 23 Aug 2010 09:14:55 +0100 3891826 http://www.medworm.com/index.php?rid=3858433&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F08%2F12%2Fwhat-do-people-with-chronic-pain-health-anxiety-worry-about%2F This study by Tang and colleagues took a group of 60 patients with chronic pain attending a pain management centre, half of whom had high health anxiety and half with low health anxiety.  They conducted in-depth semi-structured interviews with these patients, and looked at how much the cognitive, affective, physiological and behavioural responses described by the participants were consistent with the predictions of the health anxiety model. The groups were distinguished in terms of health anxiety by their responses on the Short Health Anxiety Inventory, a popular tool for assessing clinically significant health anxiety.  The high health anxiety group all scored well above 18, the cut-off score for Health Anxiety, while the low health anxious group didn’t reach this cut-off at all. ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3858433 Wed, 11 Aug 2010 19:31:20 +0100 3858433 http://www.medworm.com/index.php?rid=3845298&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F08%2F09%2Ftop-down-bottom-up-or-both-attention-to-pain%2F I guess we all pretty much know that our brains don’t seem to capture everything that goes on around us – thankfully we can filter out a lot of unnecessary information (no, I don’t want to know what that funny noise outside is right now!) so that we can focus on what is important. When it comes to pain, the limited capacity of our brains to process information has been used to explain why there are times that, despite a large amount of nociceptive input, we can remain pretty much oblivious to it. Clearly it would be wonderful if we could harness this and use it as a form of analgesia. The place to start, I guess, is with recognition that one function of our brain is to keep us focused on important goal-directed activity. Because of this function, some information that is ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3845298 Sun, 08 Aug 2010 19:41:48 +0100 3845298 http://www.medworm.com/index.php?rid=3754108&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F07%2F15%2Fonline-self-management-works-for-some%2F Given that you’re reading this, I suspect that the thought of an on-line approach to managing pain wouldn’t take a terrible stretch of the imagination. The idea is certainly appealing – after all, there are many, many people with chronic low back pain in the community, and not nearly so many clinicians specialised (or even interested!) in helping people to learn to live well despite their pain. Along with the practicalities of getting the message across to as many people as possible, there is some evidence that people are prepared to reveal more about themselves and their health problems via computer than face-to-face (Williams, Freeman, Bowen, et al. 2000). In this well-described study, participants were recruited to either receive written material about back pain (the N... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3754108 Wed, 14 Jul 2010 19:43:20 +0100 3754108 http://www.medworm.com/index.php?rid=3747009&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F07%2F13%2Fold-beliefs-die-hard-case-conceptualising-coping-with-a-flare-up%2F We know about neuroplasticity – how the brain so wonderfully remodels connections continuously.  We also know how hard changing habits can be.  The underlying premise of the cognitive behavioural approach to coping with chronic pain is that people can learn new ways of viewing their situation and develop new responses, and in doing so, start to live well again.  The process is not easy! Before I go further, I want to reassure readers that the case presentation I’m going to discuss is a fiction – based on several real patients, but with details altered to protect identity. One of the most difficult aspects of coping with chronic pain is that the pain doesn’t remain at a constant level.  It fluctuates in intensity, it can remain high for varying periods, it can dr... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3747009 Mon, 12 Jul 2010 19:35:48 +0100 3747009 http://www.medworm.com/index.php?rid=3703114&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F28%2Fhi-ho-hi-ho-its-off-to-work-we-go%2F I know, it’s Monday and such cheer about work should be reserved for people with no life – but helping people return to work has been and still is one of my favourite parts of pain management. A pity that work rehabilitation has become somewhat far removed from pain management as it is practiced in New Zealand. This paper by a group of Canadian researchers takes the basic steps to returning to work, and maps them onto relevant theory associated with both managing low back pain and changing behaviour. It is one of a very few papers I’ve read that demonstrate the reasoning behind how an effective work rehabilitation programme is established. The focus of this paper is on describing how a work rehabilitation programme can work by “having trained personnel coordinate th... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3703114 Sun, 27 Jun 2010 19:37:17 +0100 3703114 http://www.medworm.com/index.php?rid=3683912&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F22%2Fwhat-obstacles-get-in-the-way-of-self-managing-chronic-pain%2F Learning to manage pain using self management strategies ain’t easy – as we know, changing habits and doing things differently is not something any of us do without a bit of effort. It’s especially difficult when life in general is full of challenges, but so much more so when pain is the problem,you have a mood disorder that saps your energy and when other people (even health professionals!) challenge your decision to manage pain independently. There are even some researchers who would say that using self management strategies is not all that important – after all, after about a year, many people don’t use any of the new skills, but still feel differently about pain anyway (Curran, Williams and Potts, 2009). The Stepped Care for Affective Disorders and Musculo... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3683912 Mon, 21 Jun 2010 19:38:18 +0100 3683912 http://www.medworm.com/index.php?rid=3666248&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F16%2Fsemi-structured-screening-interview-for-participants-in-group-pain-management%2F It’s not always easy to work out who will make the most of a pain management programme.  While some clinicians have a ‘take it or leave it’ approach, others spend a long time ‘preparing’ people for inclusion in a programme – or is there another way?  We do know that not everyone who attends a programme will ‘fit in’ – some people have difficult communication skills (or lack of), some are not able to focus for the time needed for a 9 – 4 daily programme, some have ‘other issues’ that interfere with participation (like chaotic lifestyles or alcohol/drug problems), and some are simply not looking for what a programme is intended to address. While there is no guaranteed way to accurately select who is ‘in’ an... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3666248 Tue, 15 Jun 2010 22:08:32 +0100 3666248 http://www.medworm.com/index.php?rid=3645072&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F09%2Fgroup-based-cbt-for-pain-in-primary-care%2F I briefly discussed yesterday the content of this six-session group-based cognitive behavioural approach for chronic pain, delivered in the community. Today I want to look a little more closely at the way the programme was delivered and how the findings might differ from what happens in New Zealand. To refresh your memory, this is a study of around 700 people with sub-acute or chronic ‘troublesome’ low back pain, recruited via their GP, who were randomised into two groups – while both groups received ‘advice’ in the form of ‘The Back Book’, the CBT group also received the CBT programme, while the other group were able to seek their ‘usual care’. The programme was delivered to groups of roughly 8 participants by a single therapist, and t... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3645072 Wed, 09 Jun 2010 00:03:57 +0100 3645072 http://www.medworm.com/index.php?rid=3641350&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F08%2Fgroup-based-cbt-for-troublesome-low-back-pain%2F These two papers have created a bit of a storm in the health news recently – a six-session CBT group programme for chronic low back pain that not only provides good outcomes, but is also cost-effective?  Unbelievable!  And it’s not delivered exclusively by any specific health professionals.  AND it’s delivered in primary care! My take on this study is, much like others, very positive.  I think it’s wonderful that an intervention that has been used for years in secondary and tertiary health care has been successfully translated into primary care.  It seems to have used a pragmatic study methodology, and pretty fairly represents the kind of person that, at least in New Zealand anyway, misses out on pain management of this kind unless they’re funded by ACC (... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3641350 Mon, 07 Jun 2010 19:35:11 +0100 3641350 http://www.medworm.com/index.php?rid=3618108&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F06%2F01%2Foh-to-sleep-cbt-for-insomnia-in-chronic-pain%2F This study protocol used an eight-week programme covering the strategies I’ve described above, and I’m immediately jealous because it’s common for me to see people for 12 weeks (once a week) to cover not only poor sleep, but also activity management, understanding chronic pain, developing relaxation responses, communication etc etc!  8 sessions are not a lot of sessions, and by comparison with the short-term effects of taking medication, these skills will last a lifetime. While this study clearly demonstrates that CBT-I is an effective approach for people with chronic pain who also have the common symptom of poor sleep, I wonder whether this will influence the GP or pain physician tendency to prescribe sleep medication.  Taking a medication is a mixed blessing – s... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3618108 Mon, 31 May 2010 19:35:43 +0100 3618108 http://www.medworm.com/index.php?rid=3530051&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F05%2F04%2Frelaxation-how-why-the-evidence%2F Over the weekend a discussion about relaxation and the how’s and why’s came up in a discussion group I belong to. Several members of the group, including me, contributed our ‘list of do’s and don’ts’, much of it based on years of clinical experience – until I thought (as I do!) what about the literature? What does research tell us about precautions and effectiveness of relaxation? I have to say that my searches in the literature so far have failed to consider many of the practical tips that the group came up with, but I have found some really helpful reviews of relaxation that support its use in pain management.  One of those more recent references is the one I’m focusing on today. At the same time as wanting to briefly look at the evidence ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3530051 Mon, 03 May 2010 19:28:35 +0100 3530051 http://www.medworm.com/index.php?rid=3508478&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F28%2Fif-youre-not-asleep-get-out-of-bed%2F If you’ve read the sleep hygiene information I posted yesterday, you’ll read that it’s not a good idea to stay in bed if you’re not asleep.  Here’s another version. Beds are for sleep and sex, not for being awake – because our brains are very good at learning to put two and two together to come up with PING! Bed = Awake.  Much of the sleep hygiene approach involves reducing the association between stimulus and response, and by reducing any influence of stimulants, or factors that interrupt the sleep architecture. For a great review of CBT approaches to sleep problems in people with chronic pain, Nicole Tang has written a nice review looking at various aspects of sleep and pain – and the CBT approaches that have been recommended and studied.   B... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3508478 Tue, 27 Apr 2010 19:37:48 +0100 3508478 http://www.medworm.com/index.php?rid=3508479&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F27%2Fto-sleep-perchance-to-dream%2F This study found that negative mood may influence pain intensity via poor sleep – meaning that if negative affect is addressed, it may have an influence on pain indirectly. It also suggests that as therapists we may need to move beyond simple sleep hygiene practices. ‘ Sleep restriction temporarily reduces an individual’s time in bed to be consistent with the amount of time that they report actually sleeping (typically via sleep diaries). This reduces the amount of time spent awake in bed and may also result in individuals’ developing a temporary sleep debt, which primes homeostatic mechanisms to promote sleep.’ More on this strategy later this week! O’Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, & Robinson ME (2010). Negative m... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3508479 Mon, 26 Apr 2010 19:34:11 +0100 3508479 http://www.medworm.com/index.php?rid=3487396&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F20%2Fhow-does-it-work-pick-your-theory%2F I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up. We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; hel... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3487396 Mon, 19 Apr 2010 19:28:27 +0100 3487396 http://www.medworm.com/index.php?rid=3483154&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F19%2Fwho-will-do-well-who-will-not%2F If I had a crystal ball, and could decide who would do well in self managing their pain, and who would not, what would I do? A holy grail for insurance companies and health economists and yes, clinicians, is to find some precise way to decide who needs the most help with their pain, and who will manage well without as much assistance – with the ultimate aim to reduce disabilty and therefore costs (both human and fiscal). The problem is that so far, the experience of pain can’t be objectively measured, and ultimately, it’s the person experiencing the pain who will do or not do, and we have no way of deciding whether the person ’should’ or ’should not’ be expected to function well. This poses an enormous problem in health and insurance. How on earth ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3483154 Sun, 18 Apr 2010 20:45:48 +0100 3483154 http://www.medworm.com/index.php?rid=3463878&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F13%2Fjust-doing-it-behavioural-activation%2F This post is sparked by a pre-print paper I read yesterday, but follows a long time cogitating about the use and value of “just doing it”. Behavioural reactivation is a set of techniques often used for mood management.  It usually incorporates activity monitoring, assessment of life goals and values, activity scheduling, skills training and problem solving, effective communication training, relaxation training, contingency management, and managing things like avoidance. Fellow occupational therapists will probably feel a tad superior here because these are core aspects of the ways in which occupational therapists work with people, but beware troops! The research from psychology is vast, and it’s rapidly gaining recognition as a psychological approach to reactivation. Beh... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3463878 Mon, 12 Apr 2010 19:31:38 +0100 3463878 http://www.medworm.com/index.php?rid=3449198&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F08%2Fgoals-how-relevant-are-they%2F A few posts ago I discussed a motivational strategy that had been shown to help people be specific about the benefits of exercise and plan to overcome obstacles that may prevent them from engaging in it (Christiansen, Oettingen, Dahme and Klinger,2010). Today’s post relates to this as I read an editorial written by Schrooten & Vlaeyen about that same study in which it is pointed out that goals are a very complex concept, and that to simply identify the pro’s and con’s of a single activity that has been ‘imposed’ on the person might fail to address one of the most important aspects of goal setting – the relevance or context of the goal itself. I’ve written quite often about goals and goal-setting, mainly reflecting that setting goals is a pretty... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3449198 Wed, 07 Apr 2010 19:38:26 +0100 3449198 http://www.medworm.com/index.php?rid=3444004&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F07%2Fpain-and-health-anxiety-working-with-beliefs%2F Over the past few posts I’ve been looking at pain and health anxiety, and how anxiety about body symptoms can be misinterpreted to represent something sinister when it may be a reflection of the level of physiological arousal in the individual. In fact, one definition of anxiety is ‘over-estimating the threat’ while ‘under-estimating the resources to cope with the threat’. I really like Salkovskis statement ‘People suffer from anxiety because they think situations as more dangerous than they really are’, and ‘Treatment helps the person to consider alternative, less threatening explanations of their problem’. These explanations have to fit with past experiences of the person – and work when they’re tested out. The process of ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3444004 Tue, 06 Apr 2010 21:13:41 +0100 3444004 http://www.medworm.com/index.php?rid=3429471&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F04%2F01%2Fhealth-anxiety-chronic-pain-ways-to-work-with-worried-people%2F There are many strategies to use when working with someone who is really anxious and worried that their pain is something nasty, and becomes hypervigilant to symptoms that are actually physiological arousal, or symptoms of anxiety. The first practical thing to do is take the time to listen and understand what the person thinks his or her symptoms indicate. Sounds easy, right?  But as people with persistent pain say time and again, very few clinicians go beyond asking for a description of symptoms, and few ask about the conclusions the person has drawn from both symptoms and bits of information they’ve heard (or misheard) from the various health providers they’ve seen (or even the internet sites they’ve been on, or books they’ve read). How could you do this? One way... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3429471 Thu, 01 Apr 2010 06:36:17 +0100 3429471 http://www.medworm.com/index.php?rid=3425148&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F31%2Fhealth-anxiety-chronic-pain%2F Yesterday’s post about ‘hypochondria’ and chronic pain created a bit of a storm.  Emotions run high when you have chronic pain and someone somewhere suggests (a) that it’s ‘all in your head’   or (b) you’re just being a ‘hypochondriac’.  There are loads of reasons why both of those comments are inaccurate and unhelpful, but as I said yesterday, there is also a lot of research suggesting that health anxiety might play quite a big part in increasing the distress and disability associated with having persistent pain, and maintaining both. How would you know if you, or a patient you were seeing, was anxious about his or her health? You know I’m going to say there is no black and white answer to this one, don’t you?! Anxiety ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3425148 Tue, 30 Mar 2010 20:12:49 +0100 3425148 http://www.medworm.com/index.php?rid=3420776&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F30%2Fyoure-just-being-a-hypochondriac-health-anxiety-chronic-pain%2F I think that label has to be one of the most feared amongst the people I see with chronic pain.  To be judged as being obsessed about nonexistant illnesses when actually having pain every day must be incredibly difficult to cope with.  At the same time, being anxious about health and having mistaken beliefs about the meaning of symptoms can be part of both having chronic pain and having health anxiety (the condition previously known as hypochondriasis).  And the temptation some health providers have to say “Oh just go and pull yourself together and stop worrying”  is both unhelpful and part of the problem! I’ve been reading about health anxiety as I look at ways to identify and work with people who are fearful of experiencing pain while at the same time have been told... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3420776 Mon, 29 Mar 2010 18:35:56 +0100 3420776 http://www.medworm.com/index.php?rid=3408676&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F26%2Ffear-of-pain-not-always-fear-of-harm%2F I know it’s actually Friday Funnies day, but before I go there I want to explore something I’ve been observing for a while.  Over the past four or five years, the TSK (Tampa Scale for Kinesiophobia) has been a really popular instrument for identifying and monitoring pain-related anxiety and avoidance.  It has been found to have a two-factor structure, ‘harm’ and ‘activity avoidance’, and has been used as both a predictive measure and an outcome measure that is strongly associated with disability. What I’ve seen though, is that many patients have a fairly low score overall on the TSK, particularly characterised by a low score on the ‘harm’ scale.  At the same time, these patients have been among the most fearful of the patients I see ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3408676 Thu, 25 Mar 2010 19:40:32 +0100 3408676 http://www.medworm.com/index.php?rid=3404168&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F25%2Fwondering-does-targeting-specific-outcomes-have-an-effect%2F I’ve recently read a couple of studies of group-based CBT for chronic pain showing that outcomes are both durable and cost effective – and I started to ponder a little, as I do. So far, it seems that no-one can identify the vital ingredients in a CBT approach that ‘do the work’ or create the greatest change.  Despite the various studies that have been done, most of them treat the contents of a programme as some sort of ‘black box’ into which people are  taken, emerging some weeks later having made changes that then last.  But some studies have found that 12 months later the specific ’skills’ that individuals were shown during a programme (and carried on using 1 – 6 months later) have been dropped, but the positive changes in terms of... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3404168 Wed, 24 Mar 2010 18:30:49 +0100 3404168 http://www.medworm.com/index.php?rid=3399048&cid=t_189388_122_f&fid=36582&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FSharpBrains%2F%7E3%2F-V4ktNxBuUI%2F Excellent article in the UK’s newspaper The Independent on the growing adoption of cognitive-behavioural therapy (CBT) by the National Health Service (NHS). Very relevant to the US too, given that a growing number of insurers are offering computerized CBT. Quotes: “Why are we asking this now? There is growing frustration among GPs at the difficulty they face in providing psychological therapy for patients with mental problems including depression. A survey by the Royal College of General Practitioners (RCGP) published at the weekend found almost two-thirds of respondents said they were “rarely” able to obtain treatment for patients within two months. Getting help for children who had suffered abuse or trauma was even more difficult. Professor Steve Field, the presi... SharpBrains blogs http://www.medworm.com/rss/comments.php?id=3399048 Wed, 24 Mar 2010 15:38:14 +0100 3399048 http://www.medworm.com/index.php?rid=3399200&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F24%2Fefficiency-pain-management%2F I can’t remember a time when people working in health were told ‘Go and spend as much as you like to help people get well’ – in fact, in over 20 years I can only recall being told ‘there is less money in the kitty, we need to look for efficiencies, tighten your belts’! So it’s no surprise to me that once again, no matter where you look in the world, health professionals are being told to look at ways to be more efficient.   I don’t have a problem with this – if I’m a patient I want to know I can be treated quickly and effectively so I can get back to being a person and not a patient.  What I do have a problem with is when, in the urgency to save money, problems in health care are given a quick fix solution without taking a look... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3399200 Tue, 23 Mar 2010 18:32:54 +0100 3399200 http://www.medworm.com/index.php?rid=3391016&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F22%2Faccepting-chronic-pain%2F How willing are you to have persistent pain? Can you accept pain without fighting against it? If you were told your pain was going to be there forever, would you avoid important activities or would you start to get back into life again? Recently I reviewed about 200 questionnaires completed by people attending the Pain Management Centre where I work. I was looking especially at what they’d written down as goals for coming to the Centre, and unsurprisingly, most of them were to ‘reduce my pain’ – to tolerable levels, to manageable levels, or so the person could begin ‘living a normal life’. I hate to break it to you – even the most effective medication seems to only reduce pain by about 30%, and most people wanting pain reduction are after at least ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3391016 Sun, 21 Mar 2010 18:21:45 +0100 3391016 http://www.medworm.com/index.php?rid=3370706&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F17%2Fsetbacks%2F A couple of days ago I mentioned the satisfaction I feel when a person I’ve been working with faces a setback and manages it successfully on their own for the first time.   Someone replied saying that we all face pain setbacks alone, so what did I mean really – and I thought today I’d quickly expand on what I did mean! Chronic pain persists (goes without saying) but its pattern is to fluctuate from time to time and often without clear provocation – so it’s not very helpful to try and look at what ’caused’ the pain to change.  Yet this is so often what we as clinicians ask about, and more often what the person experiencing the pain tries to do.  Flare-ups happen irrespective of how hard we try to avoid them, so it’s useful IMHO to group fla... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3370706 Tue, 16 Mar 2010 18:23:08 +0100 3370706 http://www.medworm.com/index.php?rid=3366452&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F03%2F15%2Fmaintaining-change%2F This study by Christiansen, Oettingen, Dahme and Klinger, shows an extension of the motivational approaches based on Motivational Interviewing, integrates it with traditional problem solving, drags in a bit of goal achievement theory and ties it all together in two half hour sessions – and produces a significant change in functional outcome.  How so? Importance and confidence The two important drivers of action seem to be how important an activity is and how confident a person is to achieve it.  In this study, a group of patients was asked to rate the importance and confidence to ‘improve physical capacity’.  They were then asked to list four positive aspects associated with making this change – eg getting in shape, having fun, distraction from pain.  They were ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3366452 Sun, 14 Mar 2010 18:20:24 +0100 3366452 http://www.medworm.com/index.php?rid=3280076&cid=t_189388_122_f&fid=34736&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FChannelN-PodcastsPoweredByOdiogo%2F%7E3%2FZNj3z0zhmpY%2Fpredictors-of-recovery-from-ptsd.html A Longitudinal Investigation of the Neural Correlates of Recovery from PTSD Post-traumatic Stress Disorder (PTSD), described as both a psychiatric and memory issue, was investigated using fMRI neuroimaging. Why do some people recover after a trauma while others have persistent symptoms and seek treatment? Study participants were examined soon after a trauma and then 6 to 9 months later, looking at early neural predictors of recovery and later neural correlates of recovery after cognitive behavioural therapy (CBT). Grey matter volume in areas of the ventral medial prefrontal cortex and anterior cingulate cortex appeared to be predictors of recovery. Slightly confusing talk, not for beginners, but interesting findings. (Source: Channel N) Channel N blogs http://www.medworm.com/rss/comments.php?id=3280076 Wed, 17 Feb 2010 13:30:34 +0100 3280076 http://www.medworm.com/index.php?rid=3280210&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F17%2Fgoals-and-satisfaction-with-pain-management%2F This study does all of this, and the language used and methods described mean it’s easy to see how they arrived at their conclusions. The findings from this study of 86 people who completed all measures showed that goal attainment scaling was a more sensitive measure of satisfaction than outcomes from any other questionnaires (using multiple regression analysis).   Satisfaction with progress was more stronly related to personal functional goal achievement than to more traditional outcome measures including pain, disability, fear-avoidance, lifting, trunk flexibility and treadmill endurance. Why would we worry about patient satisfaction? Good question if you are only worried about getting someone to go through a process and not as interested in what matters to the person you’r... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3280210 Tue, 16 Feb 2010 18:34:18 +0100 3280210 http://www.medworm.com/index.php?rid=3259299&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F10%2Fan-interview-with-f-sommer-anderson-central-sensitisation-syndromes%2F How many of you have headed off to ‘Therapy Worksheets’ blog? Yes, that’s the one I’ve linked to in my roundup of the best CBT resources on the internet.  Will Baum, the editor of that blog is also the author of where the client is, a blog about professional private practice in mental health care.  Will contacted me the other day and sent me a link to a really interesting interview with Frances Sommer Anderson, a clinical psychologist who works with people experiencing chronic pain.  Her take on chronic pain management is influenced by John Sarno, who has a hypothesis that much chronic pain is influenced by psychological factors (often emotional issues) from childhood.  One of the premises of his approach is that people need to heal their ‘repressed’... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3259299 Wed, 10 Feb 2010 07:45:32 +0100 3259299 http://www.medworm.com/index.php?rid=3259300&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F10%2Fbalance-control-passion%2F Yesterday a couple of colleagues were talking about balance in life, and making it plain that they think people who spend a lot of time and energy on their work are sad.  Their opinion? Work is the means to pay for your ‘real’ life, to spend more on working means less on what is really important to them. And musing on this, as I do, I thought about values and what we bring in to pain management and how this influences our practice.  It also started me thinking about the goals and values of the people we see with chronic pain and disability. One way of looking at the distress and disability associated with chronic pain might be to think of it as a result of conflict between what can be done (resources) and both values (what is important) and goals (how I want to express my val... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3259300 Tue, 09 Feb 2010 18:46:08 +0100 3259300 http://www.medworm.com/index.php?rid=3251428&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F08%2Fhow-long-does-it-take-to-get-there%2F With so many people experiencing long term pain and disability, you’d think health care providers (and funders) would be doing all they could to make sure referrals to specialist centres were made as early as possible – and yet it’s still just not happening.  I took a brief look through the referrals to our tertiary pain management centre recently, and apart from finding that over half of the referrals were for people who had already been seen by us, the majority of the rest were for people with ongoing pain for more than 12 months.  In fact, although I didn’t calculate it, the ‘average’ pain duration varied between 8-9 months and over 10 years, roughly 3 or 4 years being the modal time. That’s a long, long time for someone to be seeing doctors f... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3251428 Sun, 07 Feb 2010 18:41:43 +0100 3251428 http://www.medworm.com/index.php?rid=3246850&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2010%2F02%2F06%2Finfluencing-public-behaviour-to-improve-health-and-wellbeing%2F Title: Influencing public behaviour to improve health and wellbeing Skinny: Builds on current approaches, using the latest evidence from areas such as behavioural economics and psychology, to suggest ways in which the Government could become more effective in this area, to help people to make healthier choices where they wish to do so. Publisher: DH Size of Publication: 40p. Published: 01/02/2010 Filed under: Grey Literature, NHS Tagged: Behavioural Economics, Choice, Economics, Grey Literature, Health Literacy, Psychology (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=3246850 Sat, 06 Feb 2010 16:19:02 +0100 3246850 http://www.medworm.com/index.php?rid=3236125&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F03%2Fa-wish-list-for-a-pain-management-programme%2F As I review the last few people I’ve had the privilege to assess, I can see numerous factors that have lead them down the road to chronic disability from their persistent pain.  One of the most common would have to be multiple medical assessments with medical management that has failed to address the person’s disability, while in some cases actually increasing the person’s beliefs that they are not in control of their lives.  An example? A man I saw who, four years after the initial event firmly believes the annular tears must ‘heal’ before he can return to work.  Two orthopaedic surgeons indicated to him that surgery wasn’t an option (and he didn’t want it anyway) but also advised him ‘these things take time to heal’ – or at l... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3236125 Tue, 02 Feb 2010 18:33:21 +0100 3236125 http://www.medworm.com/index.php?rid=3228035&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F02%2F01%2Fif-you-were-designing-a-pain-management-programme-from-scratch%2F … what would you include? I’m a fan of using a group approach for pain management. Lots of reasons, but several that really spring to mind right now. Groups offer participants a chance to learn from each other – this can be both good and not so good!  Provided the group is managed well, and both CBT techniques and the group process are attended to, participants become their own (and other’s) therapists. Participants often challenge each other far more strongly than clinicians, because they already have ‘face validity’ – in other words, they’re all on an equal ‘I’m in it with you’ level. Groups enable each participant to be exposed to a broader range of issues and situations than individual therapy – as each participa... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3228035 Sun, 31 Jan 2010 21:00:59 +0100 3228035 http://www.medworm.com/index.php?rid=3185659&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F01%2F19%2Fwhen-in-danger-when-in-doubt-just-remember-deep-breath-in-deep-breath-out%2F It was a physio who first chanted that wee slogan at me some ten years ago… for a physio, he wasn’t bad at all! Come to think of it, I have worked with some great physiotherapists (please don’t let them know!).  Anyway, it’s been one of those sayings that I’ve carried with me ever since he taught me, and it actually works. One of the simplest, easiest and least intrusive coping strategies for pain has to be diaphragmatic breathing. I’ve always thought it work partially because it buys a little time – a bit like ‘counting to ten’ to stop you losing your temper! And I’ve often used breathing techniques because it works so quickly on physiological arousal…it’s one of the few aspects of arousal level that we can conscious... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3185659 Mon, 18 Jan 2010 19:41:37 +0100 3185659 http://www.medworm.com/index.php?rid=3182401&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F01%2F18%2Fdepression-demoralisation-and-cbt-for-everyone%2F I was roving through my Twitter feed this morning,when I got word (via Gail Eva) of a paper debating the introduction of an enormous amount of money to provide CBT to people in England with anxiety and depression. The paper is in the British Journal of Psychiatry here and it’s available in its entirety. While there is no doubt that in New Zealand there are plenty of people with mental health problems who simply do not get seen within the mental health system, it’s difficult to know whether an initiative like this one in the UK will ‘fix’ the problem. We’ve seen similar increases in the number of especially men start to openly acknowledge depression which has made the job of getting help to them much easier (especially in the chronic pain population), but I do ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3182401 Sun, 17 Jan 2010 21:34:14 +0100 3182401 http://www.medworm.com/index.php?rid=3167479&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F01%2F13%2Fattention-please-attention-management-for-chronic-pain%2F A debate that’s been going on for some time is the role of ‘distraction’ in pain management. So many of the people I see have told me they ‘just ignore’ the pain, or ‘I try to distract myself’, or similar, that there isn’t much doubt to me that people habitually use attention management as a coping strategy – yet the research findings have been quite mixed, especially with respect to ‘distraction’ and ‘ignoring’ pain. Pain is naturally an attention-grabber. That’s one of the main purposes of acute pain, IMHO, to attract attention and direct the person to DO something in response. Of course in chronic pain, there is little to DO, so the person needs to redirect attention away from pain and back into the task... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3167479 Tue, 12 Jan 2010 19:51:04 +0100 3167479 http://www.medworm.com/index.php?rid=3164084&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F01%2F12%2Ftwo-tools-for-screening-risk-start-back-tool-and-orebro-musculoskeletal-pain-screening-questionnaire%2F This study asked 244 patients seen in eight GP practices in the UK to complete the two questionnaires, plus a number of other questionnaires – unfortunately these are not listed in this paper, although they are included in a previous paper (Hill, Dunn, Lewis et al, 2008). Correlations and discriminant analyses were carried out, and the results detailed in this paper. Only 53% of the patients actually completed the questionnaires. That’s probably quite good in terms of usual response rate, but a little low for the purposes of being able to make effective generalisations. The correlations between the SBT and OMPSQ are reported as being ‘excellent’ or rs=0.80. The subgroups, however, differed a little. Although qualitatively they ‘looked’ the same – i... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3164084 Mon, 11 Jan 2010 20:30:27 +0100 3164084 http://www.medworm.com/index.php?rid=3159996&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2010%2F01%2F11%2Fpeople-with-pain-are-not-all-alike-mpi-classifications-outcome%2F As an individual with chronic pain, I know that each person with chronic pain is different from the next, and as a clinician I know that there are few ways to predict who will benefit from what treatment – but it’s like a Holy Grail to find a way to group together people who will benefit from one type of intervention compared with another. Please bear in mind as you read the rest of this post, that I’m not suggesting questionnaires ’sort’ people into defined groups – yet – but as part of developing a picture of what works for whom and when, this study by Verra, Angst, Briochi, Lehmann, Keefe et al., caught my eye. The MPI (Westhaven Yale Multidimensional Pain Inventory) is a robust and comprehensive questionnaire that has been used both for researc... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3159996 Sun, 10 Jan 2010 22:41:28 +0100 3159996 http://www.medworm.com/index.php?rid=3096788&cid=t_189388_86_f&fid=36669&url=http%3A%2F%2Ffadelibrary.wordpress.com%2F2009%2F12%2F17%2Farchives-of-general-psychiatry-2009-vol-66-no-12%2F content page Fade Fave: Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care Fade Skinny: Major depression often becomes a chronic disorder in older people, with up to 74% of people in the community remaining depressed 1 year after detection.1 Physical ill health may make conventional pharmacotherapy less desirable, and factors such as bereavement and social isolation make psychological interventions more relevant. NHS Athens is required to access this article online Posted in Athens Password, Current Awareness, E-Journals, Journals Tagged: Athens Password, Clinical Effectiveness, Cognitive Behavioural Therapy, Current Awareness, Depression, E-Journals, Older People, Primary Care (Source: Fade Library) Fade Library blogs http://www.medworm.com/rss/comments.php?id=3096788 Thu, 17 Dec 2009 13:46:45 +0100 3096788 http://www.medworm.com/index.php?rid=3089600&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F12%2F15%2Fbut-im-not-ready-to-stop-looking-for-a-cure%2F People come to pain management with a wide range of attitudes and expectations.  Over the past few months I’ve been reviewing the ‘goals’ that people write in their pre-appointment psychometric questionnaires, and almost without exception people write ‘Reduce my pain’ or ‘Fix my pain’.  While they’ll also write down ‘do more’, ‘return to work’, ‘get a life back’ – these things are all ‘provided that…my pain is gone’. I spent a half hour talking to a man yesterday who has spent seven years searching for firstly ‘the reason’ for his pain, and now ‘the cure’ for his pain.  He told me he’s not yet ready to accept that his pain might be permanent.  His li... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3089600 Mon, 14 Dec 2009 18:33:10 +0100 3089600 http://www.medworm.com/index.php?rid=3075782&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F12%2F10%2Frecovering-from-a-wrist-or-ankle-fracture-pain-related-fear-catastrophising-and-pain-influences-outcome%2F I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated! This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3075782 Thu, 10 Dec 2009 05:50:57 +0100 3075782 http://www.medworm.com/index.php?rid=3052417&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F12%2F03%2Fback-to-the-basics-cognitive-behavioral-therapy-and-psychosocial-factors-in-low-back-pain%2F In New Zealand, the national accident insurer, Accident Compensation Corporation, has been reviewing its pain management service contracts. The latest message from both the Government and ACC is the need to reduce costs (not that I’ve ever heard anyone say ‘let’s go for broke, let’s spend all we can!’) and one way to do this is to look at how to reduce the risk of long-term disability associated with chronic pain. So, in their pursuit of ways to do this, ACC has consulted with providers and reviewed opinions about services provided to claimants under the various pain services contracts and come up with some pretty sensible options. Some of the findings from examining current services simply do not surprise me – amongst two of the most common services, pa... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3052417 Wed, 02 Dec 2009 18:34:49 +0100 3052417 http://www.medworm.com/index.php?rid=3026926&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F25%2Fpain-management-in-groups-using-a-cbt-approach-important-therapist-factors%2F I’m going to jump ahead of myself in this discussion of pain management in groups, using a CBT approach, and cut to a description of therapist factors that can influence how well a group programme works. I should add at this stage, that I’m basing much of what I write on my own experience over …ermmm… a few years… but also from an extremely helpful book ‘Cognitive behavioral therapy in groups’ by Bieling, McCabe and Antony.  It’s published byThe  Guilford Press, New York, 2006, and is a hefty 452 pages long.  It’s a great book —- but it doesn’t have anything about chronic pain management, so I’m working on describing how the factors that are discussed in this book can apply in chronic pain management. OK, so while I... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3026926 Wed, 25 Nov 2009 08:27:25 +0100 3026926 http://www.medworm.com/index.php?rid=3023441&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F24%2Fpain-management-in-groups-using-a-cbt-approach-%25e2%2580%2593-why-do-it-2%2F I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion. I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people m... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3023441 Tue, 24 Nov 2009 08:29:49 +0100 3023441 http://www.medworm.com/index.php?rid=3023442&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F24%2Fpain-management-in-groups-using-a-cbt-approach-%25e2%2580%2593-why-do-it%2F `Yesterday I started to look at why pain management using a CBT approach can work well in groups.  As I mentioned, it’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  Yesterday I looked at how a group approach can offer participants a sense of optimism.  Today I’m looking at inclusion (sense of commonality), and group-based learning. One of the most striking features of having an invisible health problem is that many people can be walking around in our communities with their pain without anyone being any the wiser.  The sense of isolation experienced by some of the participants in the pain management programme I work on is astonishing.  It’s as if they are living in a bubble that makes inter... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3023442 Mon, 23 Nov 2009 18:30:21 +0100 3023442 http://www.medworm.com/index.php?rid=3019250&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F23%2Fpain-management-in-groups-using-a-cbt-approach-why-do-it%2F This week I’m looking a working effectively with groups for pain management using a CBT approach.  Someone said recently ‘why should six clinicians be tied up for three weeks with only six patients? there are other people who need pain management too’ - and over the past ten years I’ve seen numerous attempts to move from the group approach to individualised therapy, so some time reviewing why groups are a useful way to help people develop pain management skills might not be amiss! Using a group approach was typical for pain management in the earlier days, say around the mid-1980’s and earlier.   It’s a convenient way to bring the specialised skills of an interdisciplinary team to people with pain, and especially within the setting often used in the be... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3019250 Sun, 22 Nov 2009 19:55:54 +0100 3019250 http://www.medworm.com/index.php?rid=3008418&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F19%2Fa-model-of-executive-functioning-and-stress-regulation%2F I’m a visual kind of girl, I need to see a diagram to help me conceptualise how the things I’ve been writing about recently all fit together. I’ve been looking at the various aspects of self regulation, emotions and executive functions and how this affects and is affected by stressors, of which chronic pain is certainly one. Drawing again from Williams, Suchy and Rau, i’m going to try to describe how I think their model of executive functioning might influence the way I look at stress regulation in people with chronic pain. This diagram is sort of upside down to me, but anyway, this is how I interpret it. Initially we all have a genetic inheritance, or the genotype we were born with. This influences the way our neurotransmitter systems, brain circuitry, physiology ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3008418 Thu, 19 Nov 2009 08:58:09 +0100 3008418 http://www.medworm.com/index.php?rid=3008419&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F19%2Fstress-the-final-frontier-executive-functions%2F It’s visceral. Stress – hits you in the guts. Some of us cope well, some of us don’t – some of our stress lingers, sometimes it’s just the little things, those ‘daily hassles’ that end up tripping the switch. And I don’t think anyone would disagree that chronic pain is an enormous stressor. Regulating that stress level, or managing it effectively, has to be the main challenge in learning to live alongside chronic pain. Today’s post discusses executive functions (the parts of the brain that carry out self regulation) and stress. Executive function is ‘… a multifaceted construct comprising a number of basic neurocognitive processes, including working memory, cognitive flexibility, response selection, inhibition, initiation, se... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=3008419 Wed, 18 Nov 2009 18:02:18 +0100 3008419 http://www.medworm.com/index.php?rid=2999879&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F17%2Fgoing-with-the-flow-emotion-regulation-and-coping%2F I’m in two minds about attempting to regulate emotions. From ACT, and in particular, mindfulness, I’m learning that trying to control emotions and thoughts is darned near impossible – and unhelpful. From the research on the effect of pain on emotions and subsequently on self regulation, goals and coping, it seems that pain strongly influences emotion and that negative emotions in particular, influence the range of coping strategies and goals we choose – and success or failure in turn generates further emotion, and so on. As Hamilton, Karoly and Kitzman say ‘the primary function of pain is to disrupt other ongoing activities and to direct attention toward the cause of injury or the extent of tissue damage’ – of course, in chronic pain, there may no ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2999879 Mon, 16 Nov 2009 18:29:34 +0100 2999879 http://www.medworm.com/index.php?rid=2996047&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F16%2Ftheories-of-emotion-self-regulation-and-pain%2F Can chronic pain be a force that shapes how we go about responding to challenges within our environments? Does chronic pain influence how we feel emotionally about daily activities that contribute to overall goals, and perhaps negatively bias the way we think about the process of setting and achieving goals? I’ve already concluded that having pain doesn’t mean people can’t do what they want to do, but it certainly makes it harder and less enjoyable.  Today’s post will briefly look at two theories that link emotion, cognition and pain.  Once again, I’m drawing from a paper written by Hamilton, Karoly & Kitzman (2004). These authors refer to two theories – the first being a two-factor model developed by Carver and colleagues in which it is proposed... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2996047 Mon, 16 Nov 2009 07:35:42 +0100 2996047 http://www.medworm.com/index.php?rid=2989429&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F13%2Femotions-and-self-regulation-in-chronic-pain%2F I posted about the reciprocal effect of emotions on goal content and today I want to look a little further into this. A profound statement in the paper by Hamilton, Karoly & Kitzman is this: ‘If emotional well-being influences the selection and the valuation of a particular goal, then it is likely that the relationship between goal content and affective outcomes is mediated in the social context within which a person pursues his or her goals.…Health goals that depend on cooperation from other people … may set the stage for the experience of personal distress.‘ Emphasis is mine. And don’t we see this so often. Not only in people with chronic pain – those who set goals while seeking social validation (warm fuzzies!) and then don’t get that suppor... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2989429 Thu, 12 Nov 2009 19:36:27 +0100 2989429 http://www.medworm.com/index.php?rid=2984910&cid=t_189388_122_f&fid=34736&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FChannelN-PodcastsPoweredByOdiogo%2F%7E3%2FB0GoKt7PEMk%2Fpolitical-behaviour.html Left Brain, Right Brain: Human nature and political values Trends in economics and politics including consumerism and changes in democracy, and how research into psychology, social networks and behavioural economics is relevant. (Source: Channel N) Channel N blogs http://www.medworm.com/rss/comments.php?id=2984910 Thu, 12 Nov 2009 16:30:32 +0100 2984910 http://www.medworm.com/index.php?rid=2985057&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F12%2Fchronic-pain-management-is-not-just-like-any-other-chronic-disease%2F The other day someone said to me that managing chronic pain was just the same as managing something like diabetes, hypertension, asthma or any other chronic disease.  It irked me at the time and I couldn’t put my finger on just what it was that bothered me, but after a couple of days thinking about it I’ve got a few thoughts to share. Chronic pain comes with a whole lot of misinformation that most other illnesses don’t have. Unlike diabetes or emphysema, people with chronic pain have usually spent a long time searching for a diagnosis, and have usually seen multiple health providers all with various names for what the person has, and promising some sort of cure.  Even for something as clear-cut as ankylosing spondylitis, it takes around 4 years from initial symptoms to... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2985057 Wed, 11 Nov 2009 18:33:02 +0100 2985057 http://www.medworm.com/index.php?rid=2981393&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F11%2Fwhat-do-i-do-when-ive-had-enough-the-effect-of-emotions-on-self-regulation-chronic-pain%2F As soon as read the first paragraph of the paper I’ve used as the basis for this post, I knew I was onto something that resonated with my original occupational therapy values. It says this: ‘Living with chronic pain is a balancing act. People with chronic pain are required to make daily decisions about how best to cope with illness-related demands while managing other role-related obligations. Although some people become overwhelmed by the demands of illness and daily life, many, if not most, remain focused and well-adjusted, and do not require the services of a mental health professional. … Why do some redouble their coping efforts following a health set back, whereas others become demoralised?’ I concur with the idea that ‘most remain focused and well-adjust... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2981393 Wed, 11 Nov 2009 06:15:44 +0100 2981393 http://www.medworm.com/index.php?rid=2977601&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F10%2Fself-regulation-what-it-is-and-what-to-do%2F So, if self regulation is about exerting control over thoughts, feelings, actions and physiology, how does it work? When I skipped through some Google references last night (o font of all knowledge!) I found a good number of sites referring to self regulation and children – but not nearly as many relating to adults, or the long-term results of limited self regulation. Curious in our world where kids get to ‘express themselves’ and are protected from disappointment, have few challenges set (especially those where they have to persist with difficult tasks), and don’t need to think about consequences for themselves because parents and teachers do it for them… Hmmmm When I got to reading though, self regulation really is what much of pain management is all about. ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2977601 Mon, 09 Nov 2009 18:34:33 +0100 2977601 http://www.medworm.com/index.php?rid=2974233&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F11%2F09%2Fim-so-tired-of-coping-self-regulation-executive-functions-and-chronic-pain%2F Changes take energy – that’s nothing new, I know, but perhaps something as clinicians we might forget when we work with people who have chronic pain. I was thinking about this as I’ve had a week away from regular blogging so I could focus on writing and some self care.  Things are busy and as we enter the run up to Christmas, not likely to slow down any time soon – and yes, this takes energy! Adjusting to living with a chronic health problem is demanding, it’s complex and requires people to reflect on what is important to them, how to achieve important activities all the while maintaining a sense of self.  Self regulation is a term used to refer to the ability to alter thoughts, feelings, and behaviors.  In chronic pain ‘[the] demands cross biopsychos... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2974233 Sun, 08 Nov 2009 18:28:43 +0100 2974233 http://www.medworm.com/index.php?rid=2939583&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F29%2Fa-recording-or-the-real-thing%2F I’m musing about an article I read while browsing the internet looking for information on hypnosis. It’s from the BBC – you can read it here – where it is announced that a recording of guided imagery is useful for kids with abdominal pain, saying ‘they can imagine themselves in scenarios like floating on a cloud’ and experience improvements in their pain. I think this is a great piece of news with a sting in the tail. Like most news articles it fails to deliver the detail, and as you know, the devil is in the details! Let me say firstly that I haven’t read the original article which is found in the journal Pediatrics, and apparently follows on from similar studies showing that hypnosis for kids has some good effect – apparently because kids h... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2939583 Wed, 28 Oct 2009 18:39:44 +0100 2939583 http://www.medworm.com/index.php?rid=2934969&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F28%2Fhypnosis-response-expectancies%2F Let’s explore the proposed mechanisms in hypnosis as I wander through the subject this week. According to some researchers, response expectancies, or ‘the expectation of one’s own non-volitional reactions to situational cues’ are thought to play a major part in both hypnosis and placebo responding. Let’s translate that: a person’s belief that they will respond to something may lead to them actually responding. Possibly the original ‘mind over matter’! Both hypnosis and placebo (or meaning response – see Dan Moerman for more details on this!) are complex effects that are not yet really understood, except to confound most RCT’s and to provide food for thought for philosophers and psychologists and lay people alike. In this paper, respon... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2934969 Tue, 27 Oct 2009 21:18:05 +0100 2934969 http://www.medworm.com/index.php?rid=2931310&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F27%2Fit-was-a-piece-of-cake-hypnosis-for-sleep-and-tummy-pain%2F After briefly looking at hypnosis yesterday, I found this lovely case study written by Leora Kuttner of an 11 year old girl with problems going off to sleep, including tummy pain and anxiety. The girl had been through CBT, and introduced to the idea that she had a ‘worry bug’, and that the way to rid herself of the ‘worry bug’ was to ‘climb the fear ladder’. The ‘fear ladder’ being a graded hierarchy where her mother would gradually ease away from her side when going off to sleep. The problem being that this little girl kept waking as her mother left the room – and would start to panic. At 11 years old, this wasn’t exactly the best thing for her, given that girls like to go to sleep-overs! Apparently this young girl had always bee... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2931310 Mon, 26 Oct 2009 18:33:51 +0100 2931310 http://www.medworm.com/index.php?rid=2912552&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F21%2Ftalking-past-each-other-models-and-interdisciplinary-teams%2F As time passes, therapists can form their own way of working with people – sometimes we get away with this by calling our treatment models ‘eclectic’.  This can be a euphemism for ‘I’ll use whatever I think fits’, or even ‘I like doing this, so this is what I’ll do’! While this may not be too troublesome if we’re working alone, when we work as a team, and particularly if we work in an interdisciplinary team with shared goals and common treatment approaches, it can mean we talk right past each other – especially if we use the same words, but mean totally different things! For example, if we have team members assessing a person, unless they clearly define what they mean when they talk about assessing interpersonal/social aspe... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2912552 Tue, 20 Oct 2009 20:21:16 +0100 2912552 http://www.medworm.com/index.php?rid=2908915&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F20%2Fthat-old-mind-body-thing-again%2F I am not a philosopher.  Neither am I very conversant in the arguments around consciousness.  But working in pain management means the mind-body debate is something I run into now and again.  Is pain all about the body? Is pain all about the mind? Or is it both?  Which influences the other? This debate can often be pushed to one side in the day-to-day practicalities of helping people live well with their chronic pain, but it is often raised when we’re talking about whether it’s important to focus on reducing the underlying disease process (and hopefully reduce the pain) or whether it’s more important to help people live well despite their pain. IMHO it’s not about which is more important: it’s about when to focus on each aspect. Anyway, suffice to say that... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2908915 Mon, 19 Oct 2009 18:31:00 +0100 2908915 http://www.medworm.com/index.php?rid=2905140&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F19%2Ffeeling-the-pain-distractionrelaxation-or-exposure%2F It’s not the pain, it’s the judgement of the pain that makes it so distressing – or at least, that’s how the cognitive behavioural model of pain views our experience of pain. As a result, most pain management therapies working to help people manage when their pain can’t be removed involves reviewing how people judge their pain. Of course, we’ve all had experience of pain since we were babies (at least, those of us with normal nervous systems), so we’ve all learned that pain is not something to enjoy and that it’s really something we should avoid. This works well when it’s short-term or acute pain, we learn not to do whatever caused the pain, and we carry on in life a little wiser. When pain persists, we usually bring this same judgement... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2905140 Sun, 18 Oct 2009 18:36:29 +0100 2905140 http://www.medworm.com/index.php?rid=2894786&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F15%2Faccepting-low-back-pain-is-it-related-to-a-good-quality-of-life-2%2F This study is another from the Bath University stable, this time from a PhD study carried out by Dr Victoria Mason and supported by Beth Mathias and Dr Suzanne Skevington. Mason’s PhD was around developing a chronic pain component/module to the World Health Organisation’s Quality of Life measure, the WHOQOL, and this study was a part of the larger programme. Quality of life is one of those terms that I’ve never really taken to – it’s always felt quite nebulous. The WHO definition of quality of life is ‘‘‘an individual’s perception of their position in life, in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.’’ Hmmm, suitably broad, so reasonably difficult to me... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2894786 Wed, 14 Oct 2009 18:34:35 +0100 2894786 http://www.medworm.com/index.php?rid=2883228&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F12%2Facceptance-in-chronic-pain%2F It’s a truism that no-one really wants to have pain (and if they do, we probably need to ‘talk’!).  Accepting pain may be equated with ‘giving up hope’ or ‘giving in’ – perhaps acceptance is thought to be about resignation rather than acknowledgement.  In any event, very few of the people I work with seem to be ready to acknowledge the reality of having pain and at the same time being aware of the ability to also experience joy, peace, fun and all the other good things in life. I’m not entirely surprised by this when I consider the way we’re raised to believe that: (1) pain is bad and must be avoided (2) doctors are all-powerful and can fix anything if only they try hard enough (except the common cold – but we can take ant... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2883228 Sun, 11 Oct 2009 19:26:01 +0100 2883228 http://www.medworm.com/index.php?rid=2865944&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F07%2Fwhat-is-an-acceptable-outcome%2F This study didn’t appear to directly look at the relationship between distress and treatment expectation – it would be an interesting area to study. What I’ll take from this study is this: part of my role is to help people move toward accepting that even if pain is present, and it’s more intense than hoped-for, life is still good and there are things we can do to make life better. Thorne, F., & Morley, S. (2009). Prospective judgments of acceptable outcomes for pain, interference and activity: Patient-determined outcome criteria Pain, 144 (3), 262-269 DOI: 10.1016/j.pain.2009.04.004 Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985;5:219–47. (Source: HealthSkills Weblog) HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2865944 Tue, 06 Oct 2009 18:37:59 +0100 2865944 http://www.medworm.com/index.php?rid=2862759&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F06%2Fself-care-or-medical-care-for-low-back-pain-what-patients-want%2F This study is an old one, dating from 1999, but there’s no reason to believe the findings differ too much from what we’d find today. It was conducted by Saunders, VonKorff, Pruitt and Moore, based mainly in Seattle, and looks at the extent to which specific patient attitudes and beliefs about medical care and self-care for back pain predict future healthcare use. The study design involved a five year follow-up of patients who had attended Group Health Cooperative of Puget Sound.  All patients were primary care patients, so unlike many studies, these people were not necessarily seen in a tertiary hospital setting. There were three groups of patients: the first group of around 1200 were recruited in 1989 and 1990, and were adult primary care patients with back pain, interviewed ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2862759 Mon, 05 Oct 2009 18:29:27 +0100 2862759 http://www.medworm.com/index.php?rid=2862760&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F10%2F05%2Fcoping-what-is-it%2F Some of you will know I’ve been striving to write my PhD proposal lately, ending up with loads more words than actually necessary! However, as part of it I’ve been reviewing some of the material I’ve collected over time on coping. Coping is one of those difficult words - one we all know, but don’t always define especially well. One definition of coping is ‘purposeful efforts to manage the negative impact of stress’ – this one’s by Lazarus & Folkman. This definition suggests that coping involves active choices about what to do in the face of stress. Wikipedia (o font of all knowledge) defines coping as ‘managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce o... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2862760 Mon, 05 Oct 2009 07:15:49 +0100 2862760 http://www.medworm.com/index.php?rid=2842828&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F29%2Ffibromyalgia-an-overview%2F I didn’t intend to get into a theme this week, but this paper arrived in my inbox this morning, and given both the prevalence of fibromyalgia, and the often ‘fuzzy’ management that can be provided, I thought it might be worthwhile taking a look at it.  The paper itself is a pre-print, but has been revised earlier this year and is probably the final version. The outline of the paper covers diagnostic criteria, and briefly discusses the place of neuroimaging (if only we could get that done readily here!), but notes that many other conditions overlap or mimic FM such as hypothyroidism, tendonitis, ankylosing spondylitis, as well as chronic fatigue, suggesting some sort of common pathway in either the peripheral or central nervous system, raising the possibility of some comm... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2842828 Mon, 28 Sep 2009 20:26:02 +0100 2842828 http://www.medworm.com/index.php?rid=2836350&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F28%2Ffibromyalgia-time-for-the-rheumatologists-to-hand-over%2F The American College of Rheumatologists developed diagnostic criteria for fibromyalgia in 1990, the culmination of many years of debate and disparagement of the existence of this pain problem.  At the time, it was thought that it was a rheumatic complaint due to the presence of body pain and soft tissue tenderness, so the diagnosis and management of it was firmly in the rheumatologists camp.  Research over the last few years shows that it is in fact a pain syndrome centered in the nervous system. Two rheumatologists now suggest that fibromyalgia should no longer be managed by rheumatologists and it should be handed over to…primary care physicians. The information above is drawn from an editorial by Shir and Fitzcharles, in The Journal of Rheumatology 2009; 36:4.  What does this st... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2836350 Sun, 27 Sep 2009 18:33:09 +0100 2836350 http://www.medworm.com/index.php?rid=2814753&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F21%2Fhealth-anxiety%2F We used to call it hypochondriasis – and that’s a term loaded with unhelpful meanings if ever there was one!  What hypochondriasis meant was ‘it’s in your head, there’s nothing wrong with you, go away and pull yourself together’.  Ask someone who has had an episode of noncardiac chest pain to ‘go away and pull yourself together’! The definition of heath anxiety is: - preoccupation with, and fear of developing or having a serious illness - it persists despite medical reassurance - this worry interferes with everyday life - it’s been going on for 6 months or so Health anxiety is about misinterpreting body sensations and changes and thinking that they are evidence of underlying serious illness – despite reassurance and lack of conf... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2814753 Sun, 20 Sep 2009 19:21:10 +0100 2814753 http://www.medworm.com/index.php?rid=2804255&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F17%2Fgoal-setting-again%2F This post is most definitely an opinion piece, because once again I’m struggling with the practicalities of goal setting with people experiencing chronic pain. There is no doubt at all that goal setting is an integral part of pain management – it’s designed to focus the input, make sure the underlying reasons for using pain management are relevant to the person, and it helps the person monitor their own progress (not to mention help the therapists measure outcomes!). The problems are that goal setting is a really complex activity, and to make goals patient-centred rather than therapist-driven involves time, and great communication skills. Here are some of my observations about what makes goal setting difficult, at least in my experience in pain management: many patients ... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2804255 Wed, 16 Sep 2009 19:27:21 +0100 2804255 http://www.medworm.com/index.php?rid=2793441&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F14%2Fits-a-long-road-to-pain-management%2F In New Zealand there are three comprehensive pain management centres where interdisciplinary three week programmes for managing chronic pain are run. That’s not a lot for a country of 4 million or so. No wonder it takes many people a long, long time to get a referral to a pain management centre for their chronic pain. Now I wish I could tell you how long it takes, on average, to get to pain management, and I wish I could say how much it costs New Zealand in lost productivity, health care costs, sickness and invalid’s benefits – but sadly, we simply don’t have that information. And yes, there is a difference between people receiving ACC and those who are not – there is a very clear disparity of access between people who have had ‘an accident’ and th... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2793441 Sun, 13 Sep 2009 18:53:36 +0100 2793441 http://www.medworm.com/index.php?rid=2782336&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F10%2Fhow-depressing-pain-and-depression%2F This study shows that there is some hope that common treatments available already can help – maybe it’s time to target some community-based programmes to carry this sort of thing out. Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2099-2110. (Source: HealthSkills Weblog) HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2782336 Wed, 09 Sep 2009 19:24:15 +0100 2782336 http://www.medworm.com/index.php?rid=2774933&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F08%2Fpatient-determined-outcomes-if-you-cant-take-my-pain-away-then-at-least-let-me-do-more%2F If I had a dollar for every time that I’ve asked someone what they would like from pain management and they’ve answered ‘take my pain away’ – well I wouldn’t be writing this blog early in the morning before work! The findings from this piece of research by Thorne and Morley (2009) suggests that people think an acceptable reduction of pain should be about 45 – 75% – but most pain treatments achieve about 30 – 50%.  Part of the process of receiving treatment seems to be helping people become more accepting of a higher level of pain but an improved level of function. A couple of points from this paper really interested me – one was the acknowledgement that most outcome measures in research are determined by the researchers themselve... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2774933 Mon, 07 Sep 2009 22:17:56 +0100 2774933 http://www.medworm.com/index.php?rid=2772731&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F07%2Fpacing-and-avoidance-in-fibromyalgia%2F The recent emergence of study into ‘pacing’ or activity regulation in pain management is a welcome addition to our knowledge of this coping strategy. Although pacing has been described and included in many self-help books as well as clinical texts as an effective strategy for people with chronic pain to use, the research base for its use is pretty skinny (see Gill and Brown, 2009). McCracken and Samuels (2007) found that increased use of pacing was associated with higher disability and less acceptance, while Nielson and Jensen (2004) found that it was associated with lower disability in people with fibromyalgia. The study I’m looking at today, by Karsdorp and Vlaeyen, looked in whether pacing specifically was different from ‘other behavioural strategies assessed wit... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2772731 Sun, 06 Sep 2009 19:32:30 +0100 2772731 http://www.medworm.com/index.php?rid=2762172&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F03%2Fblog-roundup%2F I’m taking a break from tradition today, and linking to several blog posts that caught my eye for a number of reasons. The first is from the excellent Science-based Medicine, written by David Gorsky (don’t you like how he uses his own name – no pseudonyms here! BTW you can get my details on the About page). The whole blog is about examining the evidence for pseudoscientific claims about treatments for various health ailments, and the post I want to highlight is There must be a reason – or how we support our own false beliefs. I echo his frustration at how ‘…being a skeptic and championing science-based medicine is just how unyielding belief in pseudscience is. Whatever realm of science in which there is pseudoscience I wander into, I find beliefs that s... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2762172 Wed, 02 Sep 2009 19:19:19 +0100 2762172 http://www.medworm.com/index.php?rid=2758157&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F02%2Fpain-management-programmes-guidelines%2F I was wandering through the internet as I do, and came across several resources that might be useful if you’re thinking about what goes into a pain management programme. They’re not very detailed in terms of the disciplines involved, or even the contents of a programme (such as relaxation, fitness, diet, information on chronic pain) because at the moment the literature is not clear on the necessary and sufficient components for a cognitive behavioural approach to pain management.  So it’s a bit like a ‘black box’ – all the goodies go in, and provided that the general principles are there, programmes can be said to be ‘working’. That’s not especially helpful if you’re just starting out, or want to review what you have in your prog... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2758157 Tue, 01 Sep 2009 19:16:12 +0100 2758157 http://www.medworm.com/index.php?rid=2752229&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F09%2F01%2Ftake-the-pain-away-and-the-other-problems-go-too%2F There are some days I despair that the biopsychosocial model will EVER take hold in the died-in-the-wool medical interventionist strongholds. This quote from a discussion with a colleague might help you join in my pity party…The conversation is about a case of a young woman with 18 month history of neck pain post-MVA, she has been to pain management and ‘while this has helped her understand and manage her pain better, the pain persists to the point that she is becoming increasingly frustrated, with deterioration in her work, personal and social environment.’ In my discussion with my colleague, he stated that ‘…the reasons that the patient is frustrated is that she still has pain.  Take that away (if it is possible) and the other problems go too.’ He wen... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2752229 Mon, 31 Aug 2009 21:24:14 +0100 2752229 http://www.medworm.com/index.php?rid=2748158&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F31%2Fquestioning-a-skill-for-health%2F I must have driven my parents mad as a child: I’m the eternal 4 year old asking ‘Why’! It’s got me into a lot of trouble over the years when I can’t seem to sit with the status quo, just need to ask the question, understand the reasons things are the way they are – or at least ask why they are the way they are! In my work, I use Socratic questioning as I work with participants in both group and individual pain management. Socratic questioning is a method of enquiry ‘to challenge accuracy and completeness of thinking in a way that acts to move people towards their ultimate goal.’ It can be used poorly to almost ‘bully’ someone to come around to a specific point of view (ever watched one of those law shows where the lawyer neatly tr... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2748158 Sun, 30 Aug 2009 19:33:43 +0100 2748158 http://www.medworm.com/index.php?rid=2741624&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F28%2Fwhat-is-self-management-in-chronic-pain%2F Self management. It’s term we use very often in pain management, but do we really agree about what we’re talking about? Maybe self management is different things to different people, maybe even different things to different people at different times! But if we don’t talk about what we’re aiming for, especially if we’re in a team that don’t talk – we’re bound to run into trouble. Self management has been defined by academics in several ways, which doesn’t help, but all the definitions seem to include concepts of wellbeing, activities that the person with the health condition does, and encounters with the health system. The Institute for Healthcare Improvement states that self management includes three things: care of the body and manag... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2741624 Thu, 27 Aug 2009 19:44:09 +0100 2741624 http://www.medworm.com/index.php?rid=2738036&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F27%2Fdont-go-to-the-internet-to-get-good-information-about-chronic-pain%2F …it’s true, you know, the quality of the information about chronic pain found on the internet is poor – at least it was when this study was conducted (of course, that was before this blog got started!). ‘In December 2007, there were an estimated 1.3 billion Internet users worldwide with the usage growth increasing by 265% from 2000 to 2007′ – I don’t think that numbers will have decreased since then! Anyway, in this study, Corcoran and colleagues developed a scoring tool to measure the quality of the material they found when searching the internet using the terms ‘chronic pain’, and using the popular search engines like Google and Yahoo. Their scoring was developed from terms from the Health on the Net code, with some modification to im... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2738036 Wed, 26 Aug 2009 19:30:33 +0100 2738036 http://www.medworm.com/index.php?rid=2730383&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F25%2Freal-world-outcomes-still-matter-why-medical-and-psychological-is-not-enough-in-pain-management%2F NB: The following rant does not reflect the opinions of my employers, colleagues, family or pets! It is MY opinion! I feel rather weary today, having come to a realisation that although pain management as a field of work has become much more recognised, there are some serious differences of opinion around approach and priorities between various members of the health care team.  I could list my current gripes and take up more than one screen on this blog, but I’ll try and confine myself to whining about just one: the lack of recognition of  ‘real world’ functional outcomes. What I mean is this – we can have the widest range of self report questionnaires covering all the variables in the world from pain intensity, pain quality, pain location to self efficacy, depres... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2730383 Tue, 25 Aug 2009 06:03:48 +0100 2730383 http://www.medworm.com/index.php?rid=2695661&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F13%2Fgoals-goals-goals%2F Today I had the challenge of working with a new group of participants in the Pain Management Programme. They’re with us for three weeks, and at the beginning of this time I say to them that if their lives are no different six months from then, it’s not worthwhile attending. Usually they’ll all nod happily in agreement, and I think to myself ‘good, now let’s get on and work out what they want to be different’. After we’ve worked our way through ‘get rid of my pain’ (and I make the quip about the magic wand in my office that’s a self management wand made of plastic), we start to work on goals. My first step is to ask people to go through a list of possible areas that people with pain often want to focus on – things like learni... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2695661 Wed, 12 Aug 2009 19:33:47 +0100 2695661 http://www.medworm.com/index.php?rid=2674528&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F06%2Flearning-cognitive-behavioural-therapy-an-illustrated-guide%2F Despite this book being unrelated to pain management, I can’t go past this one for learning how to develop the basic skills in cognitive behavioural therapy. It’s (you guessed it!) ‘Learning cognitive behavior therapy: An illustrated guide’ written by JW Wright, MR Basco & ME Thase, published by American Psychiatric Publishing, Inc, Washington, 2006.  It is one of the titles included in the ‘Core Competencies in Psychotherapy’ series, and was written to provide ‘an immersion in the fundamentals of each form of psychotherapy and explicitly addresses the seix core areas of competency needed in medical practice as outlined by ACGME and the American Board of Medical Specialties’. More importantly for me, it’s a really clear guide, base... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2674528 Thu, 06 Aug 2009 08:32:23 +0100 2674528 http://www.medworm.com/index.php?rid=2671122&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F05%2Fdevelop-your-skills-in-cbt-for-chronic-pain%2F I’ve never found one single book that covers all the areas I think are important for chronic pain management, but today I want to review one that I have found helpful – and I’ll review another tomorrow! I got this one about two years ago, and I’ve referred to it quite often, especially for worksheets. The book is Cognitive behavioural therapy for chronic illness and disability by Renee Taylor (2006), published by Springer, New York. I got mine from University Bookshop (another wicked place…) for NZ$125 , but as you can see it’s available from Amazon as well. Renee Taylor is a clinical psychologist, but one with a unique twist – she’s based in the Department of Occupational Therapy, University of Illinois, Chicago, and her book reflects the or... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2671122 Wed, 05 Aug 2009 08:43:40 +0100 2671122 http://www.medworm.com/index.php?rid=2667759&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F04%2Ffacilitating-a-group%2F Group-based approaches to pain management are common. They’re used not just for cost-effectiveness (because there are some ‘hidden’ costs to groupwork such as screening participants and team meetings), but also because some processes are better conducted in a group setting – such as observing others ‘well’ behaviours, learning vicariously from others’ experiences – and because experiential learning in a group setting replicates many of the work and family settings that people who experience pain will need to function in. I use experiential learning, that is, the idea that change and growth take place when people are actively (physically, socially, intellectually, emotionally) involved in their learning rather than just being receivers of info... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2667759 Tue, 04 Aug 2009 10:10:08 +0100 2667759 http://www.medworm.com/index.php?rid=2664133&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F08%2F03%2Fa-week-of-book-reviews%2F This week I’ve decided to review some of the books that I’ve recently bought for my bookshelf (not that they stay there!). Anyone who knows me will agree that I’m a bookworm, and the two most horrible websites (at least to my bank balance) are Amazonand Fishpond! Onto today’s book – just arrived, although not a new book, published in 2006, it’s called ‘Cognitive behavioural therapy in groups’, written by Peter J. Bieling, Randi E. McCabe and Martin M. Antony. It’s published by Guilford Press, and I got mine from Fishpond at a cost of $58.25. The reason I’m so pleased with this book is that for ages I’ve been looking for something to help with group processes and carrying out cognitive behavioural therapy. While groupwork wa... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2664133 Mon, 03 Aug 2009 10:21:18 +0100 2664133 http://www.medworm.com/index.php?rid=2513405&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F06%2F18%2Fif-we-can-get-rid-of-the-pain-is-it-worth-knowing-about-psychosocial-factors-in-acute-back-pain%2F In this study, (and I won’t go into the details of the design) a group of around 900 people seeing their GP for a first visit for acute low back pain under ACC funding, provided their responses to the Orebro Musculoskeletal Pain Questionnaire.  This is a widely used questionnaire designed to identify those people at risk of developing ongoing problems with their back pain, and has been used in New Zealand (and many other places in the world) as a screening tool to determine the need for early intervention. In this study, the findings showed that the factors present at the time of the first visit for back pain, as identified in the scores on the OMPQ, were associated with the eventual overall cost of the claim.  Now the association wasn’t a linear one, there was some variabili... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2513405 Wed, 17 Jun 2009 19:28:47 +0100 2513405 http://www.medworm.com/index.php?rid=2470012&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F06%2F11%2Fwhen-to-start-self-management-for-chronic-pain%2F There’s no doubt that early self management for chronic pain is a good thing – but in our facility, we’ve always had a rather mixed feeling about introducing self management while people are still receiving medical treatment for their pain. Our experience has been that few patients are really committed to learning how to modify their lives when just around the corner there could be a procedure that will ‘fix’ the pain. So I was interested to read about this study, published last year, about a four-week programme self management programme for people who are still undergoing medical treatment. A couple of interesting points from this study:  participants were carefully selected; the programme was brief; and participants were involved in the programme from aroun... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2470012 Wed, 10 Jun 2009 19:10:45 +0100 2470012 http://www.medworm.com/index.php?rid=2470013&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F06%2F10%2Fchronic-disease-management-follow-up-and-support-needs-from-diabetes-is-this-a-model-for-pain%2F Self management for chronic pain is not the only area in which self management has been introduced. Heart disease, obesity and diabetes are all very commonly managed with a combination of biomedical and self management strategies. While reviewing different ways to provide support for people who have newly developed coping strategies, I have found a fairly limited number of studies directly examining varying options for providing follow-up. This paper by Fisher, Brownson, O’Toole and Anwuri (2007), while not an empirical study itself, does draw on the experiences of fourteen self management programmes for diabetes management that have been studied under the auspices of the Diabetes Initiative of the Robert Wood Johnson Foundation in St Louis, Missouri. I’m not suggesting that pa... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2470013 Wed, 10 Jun 2009 05:29:23 +0100 2470013 http://www.medworm.com/index.php?rid=2464478&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F06%2F09%2Fself-management-follow-up-a-focus-group-study%2F In this study, the focus group participants were only those who had received the stepped care approach. The groups were moderated by an external facilitator, and a simple open-ended semistructured discussion was conducted. Members of the research group were also present to code responses. Although the questions were not specifically about the relationships that people had formed with the care manager or GP, the groups are reported to have raised this relationship often during the course of the discussion. Typically the participants were less than happy with the pain management they had received from their GP, and much more satisfied with the pain management provided during the self management programme. Now, the key differences between the two approaches are summed up as these: time acces... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2464478 Mon, 08 Jun 2009 19:04:31 +0100 2464478 http://www.medworm.com/index.php?rid=2453264&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F06%2F03%2Fsupported-self-management-new-but-old%2F I attended a workshop today on supported self management for chronic health conditions.  It’s something the New Zealand Ministry of Health are keen to support, it’s popular in the US and UK – hopefully will save money, because it’s all about what the person with the health condition does, it’s a bit of a buzz-word. Some of the other buzz words for the day: biopsychosocial model; health literacy; cognitive behavioural therapy; and patient-centred. I was pleased to see so many people from a diverse range of practice settings all keen to hear about new ways of delivering health.  It was exciting to see people given hard evidence that self management in a condition such as refractory angina actually works.  It does cost less to help someone do some daily exerci... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2453264 Wed, 03 Jun 2009 09:11:31 +0100 2453264 http://www.medworm.com/index.php?rid=2415871&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F05%2F18%2Fwhy-i-didnt-make-it-goals-and-reasons-for-nonachievement%2F Part of most therapy, especially in chronic pain, involves setting goals. A major part of moving from ‘patient’ to ‘person’ means refocusing life from a round of appointments ‘to get better’ to actually doing things that matter in life – being ‘better’. Some of the people we work with achieve these goals and feel more in control, start to focus on interesting things in life rather than pain, and hopefully won’t need to come back and see us again! Others find it much more difficult to achieve the goals they’ve set and need more intervention. This paper explores the reasons people gave for not achieving goals in various domains. The goals were set in the last week of an interdisciplinary pain management programme, and follow-u... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2415871 Sun, 17 May 2009 19:34:27 +0100 2415871 http://www.medworm.com/index.php?rid=2406273&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F05%2F11%2Fhorses-for-courses-or-how-to-choose-the-best-person-to-get-spinal-injection-treatment%2F There are many different ways to report on the findings of a clinical study: this one intrigued me because it looks at who does well after radiofrequency and injection treatments for low back pain. In a post hoc study of 161 people receiving these treatments for back pain and sciatica, subsequently treated in an open prospective follow-up period, those with positive psychosocial features did well, while those who were psychologically ‘more vulnerable’ did not do as well. The study is interesting for a couple of reasons – it was part of a double-blind study of radiofrequency neurotomy (RNF), in which patients received sham RF lesioning (no current was applied to the nerve, although anaesthetic was still provided). The major finding of this study was that ‘the vast ma... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2406273 Sun, 10 May 2009 19:10:54 +0100 2406273 http://www.medworm.com/index.php?rid=2381178&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F04%2F30%2Fabsolutely-positively-healthy%2F New Zealand readers will recognise the origins of the heading for this post - a few years ago, Wellington used that phrase to promote visiting that wild and windy place (don’t worry Wellingtonians, I’ve lived there for a few years - and among the wild and windy days are those gloriously balmy sunny days that take your breath away!). The theme for this week has been resilience, or taking a look at how people who are living ‘well’ with their pain manage to do so.  So a couple of links today to resources for those who would like to learn more about positive psychology. The first is a 2008 paper by Martin Seligman (my hero!) who reviews the concept of healthiness, returning to the origins of the WHO definition of health ‘not merely the absence of disease’&#... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2381178 Thu, 30 Apr 2009 08:57:09 +0100 2381178 http://www.medworm.com/index.php?rid=2365487&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F04%2F23%2Fwhat-goes-into-a-pain-management-plan%2F Today’s post is a practical one.  The scientific evidence for interdisciplinary pain management using a cognitive behavioural approach is pretty strong now (e.g. Guzman, Esmail, Karjalainen et al. 2001; Guzman, Esmail, Karjalainen et al. 2002; van Geen, Edelaar, Janssen et al. 2007) although the components that make it effective are not yet known. One suggestion for why these programmes work is that they help people develop a new attitude towards their pain - it’s no longer a frightening, dominating experience that controls life, rather the person becomes more aware of their options, develops a sense of optimism and starts planning and taking steps towards the future. Part of this change of focus from ‘patient’ to ‘person’ involves developing a plan. Th... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2365487 Wed, 22 Apr 2009 19:32:17 +0100 2365487 http://www.medworm.com/index.php?rid=2302541&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F03%2F31%2Fattention-management-for-chronic-pain%2F In this study, it was great to see that a single element was the focus - but this could have reduced the overall effect size that could be achieved in a more common pain management setting where multiple modalities are used. I wonder what the results would have looked like had the participants also been undergoing exercise or activities of daily living reactivation at the same time - this would have combined both the cognitive and the behavioural components of most pain management programmes, and could have demonstrated a greater (and more realistic) effect.  However that would have reduced the purity of the study design, and now that we have a reasonable level of evidence for a cognitive behavioural approach to pain management, it is time to establish the specific elements that are helpf... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2302541 Mon, 30 Mar 2009 18:04:54 +0100 2302541 http://www.medworm.com/index.php?rid=2235676&cid=t_189388_165_f&fid=37959&url=http%3A%2F%2Fhealthskills.wordpress.com%2F2009%2F03%2F04%2Fmy-pain-is-no-different-but-i-feel-differently-about-it%2F Anyone who works in pain management knows that sense of profound satisfaction when someone says ‘My pain is no different, but I feel differently about it’.  It’s a sign that something has shifted for the person, that they’ve started to move towards accepting it, taking charge of life again instead of waiting for, hoping for something to take it all away. After working for about 12 weeks with one man, yesterday was the last session.  We reviewed his formulation together - looking not so much at how his pain arose (it’s neuropathic post-surgical pain), but the influences on his experience of his pain.  We looked at the problems he was having with his pain - poor sleep, feeling unwell and nauseous when it spiked, trouble concentrating and managing work, feelin... HealthSkills Weblog blogs http://www.medworm.com/rss/comments.php?id=2235676 Tue, 03 Mar 2009 18:17:42 +0100 2235676