Pain management programmes

[JimA]

I am in the process of setting up a physio led pain management programme but I am not sure of the best way to include the exercise component. Anyone know what format works best?

[Kriskul]

Tough question. Do all your patients need the same exercise format? What variables do they need to improve? Are you thinking of generic reconditioning?

[Luke Rickards]

Have you reviewed the current literature? If not, that would be the best place to start.

[JimA]

To be more specific about this group programme. Is it better to have a set circuit of functional exercises that patients work on at their own pace or individualise the exercise programme?
Should the exercise be in short bouts interspersed by the education or after the educational element.
What about some of Butlers active neural movts. rather than general fitness work?
Does it really matter as long as the patient gets moving?
I realise there may be no definate answer to this but what have people found from their experience?

[Diane]

How about ask the patient to breathe, move slowly, and sense their bodies as they move. Then they can move however they would like. (This is for a pain clinic, right?)

[nari]

Jim,

I think Butler's movement suggestions would be a good start.
What I found personally that people like the sinuous, smoothly executed movements a la Butler. So do their nervous systems.

Once they have the idea, encourage them to make up their own. Music is always useful, and probably fairly rhythmic.
I don't think aiming for fitness is appropriate; just let them go with the flow; fitness can come later once their nervous systems are coming off red alert.

Keep it simple and let each person develop his/her own thing if they wish. The crucial thing is movement, but it is far better if it is their movement.

Nari

[Randy Dixon]

Like Diane, I would suggest some sort of sensory awareness class. I'm not sure if it is important what form or name of this you use. Although an already existing program may make it easier for you.

[Luke Rickards]

Jim,

This editorial may be useful to you. I was particularly drawn to -

Finally, it should be kept in mind that there is sufficient evidence that physical treatment is effective (Hayden et al., 2005). However, there is increasing evidence that reconditioning itself is not the mediating process, but the reduction of pain related fear and pain catastrophizing.

[JimA]

Thanks for all the suggestions. Unfortunately Luke I am not able to access the editorial.
I asked the question because all pain group programmes I have read about seem to use general exercise, stretching and aerobic exercise and reading this site many suggest stretching and fitness exercise may not be the way to go.
This group is not linked to a pain clinic it is based in physiotherapy dept. and will progress to community based clinics/ health centres, mainly for moderate to severe chronic pain patients with no major psychological distress.

[Adiemusfree]

Originally Posted by JimA

Thanks for all the suggestions. Unfortunately Luke I am not able to access the editorial.
I asked the question because all pain group programmes I have read about seem to use general exercise, stretching and aerobic exercise and reading this site many suggest stretching and fitness exercise may not be the way to go.
This group is not linked to a pain clinic it is based in physiotherapy dept. and will progress to community based clinics/ health centres, mainly for moderate to severe chronic pain patients with no major psychological distress.

The programme developed by Mick Sullivan out of Canada (the PGAP and PDP) essentially uses exercise as a means to reduce avoidance based on fear of movement and pain; as an operant approach to rewarding well behaviour and as a general re-engagement in life activity. I haven't found many people with moderate to severe chronic pain who don't have psychological distress in my years of practice, but if you have some then the PGAP approach may be quite useful although it's been developed for subacute pain.
Another option is to forego exercise per se and run with activity which can include general activity such as walking, swimming, dancing, cycling, playing golf, kicking a ball around, playing on the Wii, even line dancing! I think one reason pain management programmes have been keen on including exercise is that it has great face validity, supervised exercise means the person believes they are being 'prescribed' the 'right kind' of exercise, and this reduces anxiety and increases adherence to actually doing it.

[JimA]

Thanks for this information,very useful. I have been working on establishing these group sessions for a year now and must admit to being rather frustrated at the lack of interest from patients in coming to group sessions, even small groups. So not run many as yet.Is this what others experience?
Also, as I have developed more skills,thanks to this site and neurodynamic courses, I have a battle inside my own mind about group versus individual sessions.

[Mary C]

JimA

I did not run "groups" for the exercise component, just made sure the schedule ended up "grouping" appropriate patients.

I work in a general hospital. Where do you work?

Mary

[JimA]

I work in a General Hospital as well so there is a pressure to group people due to resource issues. However, I often wonder if some groups are just an easy way out of dealing with difficult to manage patients and at the end of the course they are out of the door! Looks good on numbers and I am sure there are ways to make the stats look good.
I have seen a few patients from well resourced pain management programmes elsewhere in the UK and not one of them seems any better off at managing their problem.
I take into account what the patient prefers and almost all want an individual approach.

[nari]

I agree with

I take into account what the patient prefers and almost all want an individual approach

But in a general hospital this may be nigh impossible to achieve. Some do well in a group because they 'see' those who are intent on getting better. The ones who don't fit into a social/cultural group usually flunk.
The ideal is to start with a group and rescue those who are unhappy after a couple of group sessions for individual programs.
Resources and other factors don't permit this to occur smoothly. The best compromise is to take on several high-risk-of-failure clients individually, and then suggest they return to the group later. Not easy, but possible.

Nari

[Adiemusfree]

Groups have some advantages beyond the ratio of therapist to patient!
They provide an opportunity for social cognitive learning - think Bandura
http://www.tcw.utwente.nl/theorieeno...ve_theory.doc/ This is a great and brief description of it.
Groups also provide really good operant conditioning opportunities.
People attending learn better from each other than from a supposed expert - even if what you provide has better evidence! So there is something about having an old hand (like a graduate of the group) attend to show the newbies how to do the exercises, and that it has benefits.
Given that in chronic pain management it doesn't seem to matter what specific exercises are done, an exercise programme in a group sounds like it should have some good effects.

Pain management per se probably also needs some individualisation - to make sure people don't just slide on by without actively adopting and practicing/integrating new behaviours in the 'real world' context.

[ian s]

Hello JIm,

Its a difficult thing ....in some ways its countercultural as patients are surrounded by choices which promise solutions --without them taking stock and doing something different in many cases.
http://www.arc-research.org.uk/commo...ue%20Disorders
There is a big study going on at the moment called the musician study organised via ARC which may be of interest .
Prof Lamb in Warwick also has positively reported big improvements in c back pain patients when education via cbt principles are followed --i have the programme she used here but I am not sure if i am able to put it on the net but you could pm me ?
I think running groups and public speaking/engagement is a real skill which not many of us have developed but I think your confidence /belief in the subject matter and getting to grips with teaching simple exercise principles are the key . I learnt a lot from this great guy who runs pain association scotland group pain management classes. Even with his personality and approach the attrition rate from groups with this challenging population is high --national centres also have high drop out rates and as you say the approach does not work well for all.
I got some money for community pain ed and movement and guess what despite a list full of chronic pain patients none of the GP's referred anyone into it ....This is a common issue very few Drs have much if any interest so the best source of referrals are from fellow Physiotherapists who understand practically the type of issues you are likely to encounter.
I now run a weekly class for my own patients who are referred via GP's and they pay a small sum for the room .Its an hour a week and i cover a topic of interest related to pain and neuroscience and then we do exercises . I use tai chi warm ups, stress the principle of 'soft limit' and we do enjoyable(to me at least) exercises based on body awareness/balance /breathing. I do these things myself see www.mydailyyoga.com (warm up's for example).
Cells that fire together wire together .....see Norman Doigs chapter on cpain via maladaptive neuroplasticity to see why for many people undoing the knot of cpain is a challenge. Creativity is the key .
I do think classes can be very worthwhile and the commitment of coming to a group which if run well can be a real catalyst for growth and change . Two patients that i have seen both 'one to one' and who now attend my class for example have make great gains in observable behaviour and function as they have broken out of their social isolation and introspective fear avoidance.
We run back fit classes in our trust --the missing part is good education but its the most difficult thing to get right .
http://heroesnotzombies.wordpress.co...-in-your-life/
This is from a friends blog .....although not addressing pain --i think the analogy is useful and i used this the other day ...we need to make more dents and encourage people to do the same in their own lives ...However much of medicine seems to focus on making the one dent bigger and deeper in many cases....
Good luck!
ian

[ian s]

http://www.nifplay.org/what_opp_education_md.html

maybe taking some of this on board is important !

[Adiemusfree]

Along the same lines, I use experiential learning a lot throughout the pain management programme I work on - it's like playing, but it's got a really deep purpose. There are some great sites on the net about this approach - and yes I do think a lot of it about personal growth, and the participants being ready to engage in a playful way to experience what a situation brings.
Wilderdom is a site that has heaps on this approach to learning - I think it's more powerful than simply 'teaching', especially for adults, so may be a good thing to consider including. The other thing to think of is whether you could include a skilled OT to help with groups, because this is something most OT's are trained in...

[Karen L]

From Institute of Play

Body Play & Movement
If you don’t understand human movement, you won’t really understand yourself or play. If you do, you will reap the benefits of play in your body, personal life and work situations. Learning about self movement structures an individual’s knowledge of the world - it is a way of knowing, and we actually, through movement and play, think in motion. For example the play-driven movement of leaping upward is a lesson about gravity as well as one’s body. And it lights up the brain and fosters learning. Innovation, flexibility, adaptability, resilience, have their roots in movement. The play driven pleasures associated with exploratory body movements, rhythmic early speech (moving vocal cords), locomotor and rotational activity - are done for their own sake; pleasurable, and intrinsically playful. They sculpt the brain, and ready the player for the unexpected and unusual.

Karen

[Adiemusfree]

Thats exactly it!

[JimA]

A big thank you again to everyone who replied. It was nice to know that other people have had similar difficulties with patients and particularly GP's lack of interest in referral despite many chronic pain patients on their lists.
I do actually agree with everyone about the effectiveness of groups and with the reasons for using them and I have plenty of experience with group work. I was just getting increasingly frustrated that I couldn't get patients to start the sessions. Must be poor sales technique!

[Adiemusfree]

Not poor sales technique at all - I think one problem is that many medics continue to think they will 'cure' the person, and they lack the 'sales pitch' to put it to patients that perhaps living a full life with chronic pain is possible!

Another problem is that many patients have been so enamoured of the idea that everything can be fixed with one little pill or one little operation, that they forget that actively doing is integral to health! So when we suggest exercise or activity might help, they think 'but that sounds like hard work!'

[EricM]

I was just getting increasingly frustrated that I couldn't get patients to start the sessions.

You aren't alone here Jim. We have exactly the same trouble. This seems to be a characteristic of persistent pain patients. And the ones who do come probably don't really need to. When you can get people to commit to a series of sessions, attendance can be spotty and drop-outs common. A solution, at least in part, seems to be in managing expectations right from the start. We now offer an orientation to our interdisciplinary pain clinic. If what we have to offer doesn't suit someone - fine. We simply don't have the resources to help everyone, so at least this way we work with those who want to learn to help themselves.

[nari]

Eric, your post expresses much of what the Pain Clinic staff here decided: that only those who really want to be responsible for their own welfare instead of passive dependance, did well.
Despite introductory talks, including expectations, there were probably 50% who wanted to be told exactly what to do in order to be well again, with minimal effort on their part.
Rather like trying to convince PTs of the importance of neuroscience....

Nari

[EricM]

The question that keeps nagging me though is this; how do we serve that other 50%? It could be argued that they are more in need of help than the 50% who never seem to be able to let go of the clinic and its services. Is the problem with them, or with us?

[Diane]

Eric, it might be that they prefer one-on-one, is all.

[EricM]

it might be that they prefer one-on-one, is all.

I understand what you're saying and that may be true of some, however there is a significant number of people referred to pain clinics who fail to show up for appointments at all - of any kind. We send questionnaire to our new referrals and wait lists. I'm estimating but the number returned is only around 60%. I won't deny that these people don't have pain or that they don't want help, but something somewhere is missing for them.

[nari]

Our return for the questionnaires was around 80% - don't know what the difference means.

Even though the team recommended to the specialist who was appropriate for the program and who wasn't, it didn't seem to help significantly. Often, in meetings when the psych thought Mr X was not appropriate, and everyone else thought he was, we generally deferred to the psych's opinions. I knew of several clients who were pulled out of the program by the physio for individual attention by the PT or the psych or both, and who did much better.

What to do with the large number who don't benefit at all?? Good question. If the doc and/or the nurse figured out they were only interested in more drugs, they were discharged back to the poor GP.

Is the problem with them, or with us?

Possibly both. Though finding the dividing line is very difficult, and arduous. After a lot of education from the clinic, the drug-addicted folk were referred to Detox. Feedback was patchy, so many fell through the cracks. I think one can try to help only so far....

Nari

[ian s]

I don't think its a problem with 'us or them'......The complex problem of pain and suffering is a large and growing social problem . There is a disproportionate number of people with 'maladaptive' and chronic pain who have chronic multifactoral stress problems . Pain is much more than a medical issue --although it is deemed to be .....see David Morris for example-http://litmed.med.nyu.edu/Annotation?action=view&annid=818
I am realistic, there are many people who have been conditioned by culture and medicine to expect a curative intervention for things it is powerless to influence.
Many people i see have prolonged nocebo reactions and resurrecting self efficacy is difficult to say the least.
People /patients have to want to engage and move forwards, many are simply not able or willing at that particular time to do so . There are integrated biological and social reasons for this -see Elizabeth Gould http://seedmagazine.com/news/2006/02...p?page=all&p=y
I am not sure of the answers or if there are any but some of the problem as i experience them include; fragmented obsessive biomedical testing , failure of many Drs to engage and encourage optimistic participation in non pharmacological approaches, the reinforcement of illness behaviour due to structurally dominated thinking, the social factors of stress and the disencentives in the poorly paid with families when disability benefits are ok and finally the malaise and passivity in large areas of modern life!!
These are a few of my biased thoughts .......
ian

[Adiemusfree]

Ian those are not biased thoughts at all - numerous studies of factors involved in prolonged disability attributed to chronic pain have shown just exactly those factors...

Internationally chronic pain patients have a high don't show rate for any appointments - a combination of low self efficacy, low energy, low mood and general passivity, I think.
Also I do wonder whether we as therapists need to work harder on helping these guys move further along the readiness path - a la Prochaska and DiClemente's stages of change model.

[Diane]

As in precontemplative, comtemplative, etc?
Neil Pearson here in our Pain Science Division talks about this often.

[Adiemusfree]

Absolutely - precontemplation, contemplation, preparation, action and maintenance.
A good book is Health Behavior Change: A Guide for Practitioners Stephen Rollnick, Pip Mason, and Chris Butler - there's also a newer edition out, but I can't remember the reference for it. I've blogged about stages of change several times if you're interested.

[Diane]

It's a great set of concepts Bronnie - thanks for the links.

[EricM]

Adiemusfree, I have two questions.
Do you have a method for determining where someone is on the stages of change continuum?

I've read on you blog that you published a paper to the NZ Pain Society journal on 'Inter'disciplinary teams. Would you be willing to share that in the SoS forum? I work on a team that seems to be in perpetual crisis mode. Though from reading around, this seems to be the norm in most places - so perhaps I shouldn't feel so bad.

[Adiemusfree]

The stages of change continuum is somewhat contentious - some argue that it's not really a 'stage' theory because each stage isn't completely distinct from the next.
I'll put up a new thread on this, because I think it's a helpful framework for getting people engaged in their own therapy.

Re the interdisciplinary teams, yes I'll put the paper up in SoS - I'm pretty passionate about teams and teamwork! I'll have to dig the thing out from the archives, the NZ Pain Society journal doesn't do pdf...

[Diane]

The stages of change continuum is somewhat contentious - some argue that it's not really a 'stage' theory because each stage isn't completely distinct from the next.
I'll put up a new thread on this, because I think it's a helpful framework for getting people engaged in their own therapy.

Thanks in advance for this Bronnie.

I think considering stages of change is helpful for not just moving around, through, putting a new frame around pain - I think it's helpful for all sorts of change at any level.

For example, within PT itself, many here are at the preparation, action and maintenance levels with regard to pain science itself. Others are at the "contemplative" level... still others (most of the profession in fact) are still "precontemplative."

[Adiemusfree]

Hah! I totally agree - it's not just PT either, probably refers to most if not all professionals reconceptualising pain and pain management!