Doses and processes in pain management

In considering whether we can answer the question of whether there is a dose-response relationship in psychologically-based pain management for chronic pain problems, we need to step back a bit and think about what dose-response means. It’s based on a very simple notion of medication, perhaps of analgesia: that a small dose produces a small effect, a medium dose a medium effect, and a large dose … well, maybe a large effect or it could be toxic.

I’ll come back to this issue of the drug analogy at the end. So: what is the dose? The number of hours or the number of weeks? As a clinician, I have often wanted to pack more and more into the limited hours of treatment, or to extend treatment hours or weeks to allow for added content, or more discussion and exploration. I had the opportunity, when involved in a rolling inpatient programme, of comparing four week programmes where we took a week’s break in the middle for Christmas or Easter with those which ran continuously. So the hours were the same, but treatment was spread over more weeks. Our impression, and patients’ comments, suggested that the break in the middle allowed consolidation, experimentation, and then a return to a familiar setting and group to think about how that had gone and to revise plans.

Can the dose, whether in hours or weeks, be disentangled from content? Pain management programmes consist of a mixture of education; goal setting; exercise/stretch/relaxation; problem-solving of the difficulties posed by pain and the effects on mood, with cognitive methods to try to counteract unhelpful thinking patterns; various other components such as involvement of partner or family members, or preparation for return to work, may also be included. The proportion of these varies enormously: some programmes involve several hours’ exercise per day, while others just advise and encourage participants to exercise at home between sessions and devote their time to other aspects. And each of these components can affect any or all of the outcomes: reduced disability, improved mood, improved pain experience, return to work or to other valued activities, or reduced medication intake. Gains in one area boost confidence to tackle others, and the solidarity of other group members and availability of staff expertise provide excellent opportunities to try things differently.

Given all that, I was sceptical about whether a recent study by Waterschoot and colleagues, which combined various studies to produce an overall answer regarding dose response to psychological therapies, would be able to identify any benefits just attributable to dose. But they did – and to weeks of treatment (over 6 weeks), not hours, which varied from just over 6 to nearly 200 hours. But it was impossible to disentangle the effects from content, so we can’t say that regardless of content, the longer the programme in terms of weeks, the bigger the gains.

But the third important factor, beyond dose and content, is the level of difficulty of participants entering the programme. If there were consistent selection, either by clinical staff or by self-selection by patients, of only mildly disabled and distressed people for the briefest programmes, of moderately disabled and distressed people for the medium-length programmes, and the most severely disabled and distressed people for the longest programmes, and all made steady progress at the same rate, they could all end up at roughly the same level of disability and distress at the end. If you didn’t know that patients had been matched to length of programme, it would seem that there was no relationship between length of programme and extent of benefit.

So we need to think more about what changes we think happen during and after pain management, and what implications that has for time. Some physical changes can only be achieved cumulatively, while some cognitive changes might be sudden and substantial – the ‘aha’ moment when understanding shifts. Other cognitive changes – habits of thinking, and ways of seeing the world and oneself, are unlikely to happen rapidly even with an ‘aha’ moment or two. Here it is patients and clinicians, not researchers and statisticians, who will lead the way in establishing trajectories of change in different aspects, and how they relate to one another.

So back for a moment to the drug analogy. Drugs have plenty of effects other than dose-related benefit: adverse effects, and at higher doses, toxicity. It is rare to evaluate adverse effects of treatment, and I know of no investigation of whether too much psychology could be toxic. Nor do we know about delayed effects, or ‘slow-release’. Or about responders and nonresponders, unlikely to be distinguished by genotypes as with some drugs, but what about relative efficiency or inefficiency at processing information presented in particular ways? Again, we don’t know. The whole area is in dire need of some clear thinking about what actually happens in psychologically-based pain management interventions.

About Amanda

Amanda WilliamsAmanda Williams is an academic and clinical psychologist at University College London and at the Pain Management Centre, National Hospital for Neurology & Neurosurgery, active in research and clinical work in pain for over 25 years. Her particular interests are evaluation of psychologically-based treatments, including systematic review, meta-analysis, and guidelines; in expression of pain and its interpretation by clinicians; in assistive technology for people with pain; and in pain from torture. She has written over 120 papers and chapters on aspects of pain and psychology, presents at national and international meetings, and is on editorial boards of several major pain journals.

 References

Waterschoot FP, Dijkstra PU, Hollak N, de Vries HJ, Geertzen JH, & Reneman MF (2014). Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Pain, 155 (1), 179-89 PMID: 24135435

Williams AC (2014). How do we understand dose of rehabilitative treatment? Pain, 155 (1), 8-9 PMID: 24513409

Comments

  1. stuart miller says

    Hi, thanks for the interesting discussion. I was reviewing the 2012 Canadian guidelines for fibromyalgia and the framework for medication management was start low and go slow but with exercise prescription, it was simply exercise regularly. I think if you would ask the person in persistent widespread pain if this is helpful, they might disagree – if people find exercise threatening it may be best to follow the framework for medication prescription and start low and go slow. The framework from the Explain Book of a little more each day is helpful (to a point – the mountain figures and pictures on establishing comfortable baselines are very helpful to me). The intensity studies post stroke are helpful with 900 grasp and reach movements (with monkey studies) to result in activation of the cortex for neuroplasticity or 10000 steps / day or the heart and stroke guidelines for aerobic exercise of 150 minutes / week are helpful but is there such a thing as ‘ideal’ treatment or doses with the heterogeneity of diagnostic groups, people, environments ? I really like the discussion on education (achieving the aha moment) and I would think that changes in patterns of movement, thought or behavior would take time (so > 6 weeks with the Waterschoot study makes sense intuitively) and I would argue that psychological interventions that make the person think that there is something ‘wrong’ with them may be detrimental (in whatever dose provided). Thanks for the discussion !

  2. Patients health and wellbeing is off topic?

    “Doses and processes in pain management” let me understand that you are not interested in helping patient who suffer in pain, TODAY, with the tool we have available but allowing them to suffer while we debate neuroanatomy, biochemical and pharmacodynamic as it relates to a “your theory” counter to the last 100 yrs?

    May I ask why, what is the intent of this discussion and how will it help my patients today?

    BiM Reply:

    In answer to your question Stephen, this site discusses research, not treatments. If you wish to discuss particularly treatments you will need to find somewhere else to do so. Again, you will see this in our comments policy in the footer. You may also find our BiM “About” page helpful.

  3. Hi all. Thank you for your comments and what is certainly a passionate debate. Please do keep your responses on topic – “Doses and processes in pain management” as opposed to focussing on particular types of treatments.
    If in doubt please see our Comments policy in the footer of the blog.

  4. John Quintner says

    @ Dr Rodrigues. As I said above, your comments are out of place in this discussion. But the answer to your question is YES, the advocates of needling got it wrong. As you disagree, please assemble the scientific evidence that proves otherwise and get it published in a peer-reviewed journal for all to see.

    Why I labour this point is not only because you have exposed yourself and your theories to ridicule but also that a large number of mainstream physical therapists have swallowed the “needling” line with the hook as well as the sinker.

  5. @ Quintner
    “What you are missing is a realization that these past icons of the world of needling were wrong.”
    So you are saying that all of those clinical physicians were 100% wrong when they used needles of various types to treat complex chronic pain?
    That what these providers witnessed and what these patients experienced (less pain) were deluded?
    That the patients who had NOT responded to invasive intra-articular surgery, but did feel less pain and better range of motion were tricked?
    That time after time after time in over thousands of cases those patients were just being nice to the providers, making statements that “I feel better and have less pain” were made just to please the providers?

    “There is not a shred of scientific evidence to justify inserting stainless steel needles into innocent muscles.”
    You consider Gunn’s therapy of re-injury, igniting the healing cascade plus Cannon’s Laws of depolarizations really are 100% farce?

    @John you are convinced that all of the people/patients who failed open or replacement joint surgery were NOT-harmed by these procedures, but were ACTUALLY-harmed by myofascial release therapy with needles which improved their pain?

    @John you are saying is that the brain is where pain is located and that treating the brain will cure all with chronic pain?

    Is that an accurate summary of what you believe?

  6. John Quintner says

    @ Dr Rodrigues. The simple answer to your final question is YES! What you are missing is a realization that these past icons of the world of needling were wrong. There is not a shred of scientific evidence to justify inserting stainless steel needles into innocent muscles. As I have said to you many times before, your strident advocacy for these harmful procedures causes untold damage to the cause of advancement of knowledge in this difficult area of musculoskeletal medicine.

  7. John Quintner says

    Eric, in the words of Martin Buber, might I suggest that in this context we must strive to replace the “I-it” relationship with one that is “I-thou”?

  8. @ John Quintner, Why the singular academic exercise on a minute part of the overall perplexing and dreadful situation of people in life destroying chronic pain??

    @Marcel says: Dry needling is misunderstood and as as such has not been used to it’s full potential. Dry needling comes in many varieties and is not just “dry needling.” The perfect analogy is stating that this “car” is just a car. A “car” is a vehicle that comes in many varieties; a 2 or 4 wheel drive, 2 or 4 seater, a pickup or flatbed all of which have a different utility. Same with “dry needling!” You can dry needle with a thin filament needle into the surface tissues as in Mark Seems Techniques, or deep and aggressive as in C. Chan Gunn IMS dry needling. Then you can dry needle with a hypodermic needle — ouch!

    If you need a different vehicle than move over to “Wet Needling.” “Wet Needling” comes in the same varieties as dry but the provider injects a mixture of chemicals or concoctions.

    My personal opinion is that the success or failure of both types is not WHAT you inject but the technique, experience, the time and effort applied in the the procedure and the intent of the provider. These nuances would be ideal research opportunities to determine the “whos whats and hows” so these modalities can be updated by modern research and development models so we can utilized them in the office setting just like back in the last century.

    @NOI is confusing for me, my trials and errors in pain therapy have culminated in a thought pattern that works for me, my patient and matches up with a lot of these clinicians. These are some a few of the authors: Travell/Simons, Hackett, Rachlin, Gunn, Seems, Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason, and Lennard.

    Here are a few key threads of data in all of these textbooks are:
    1. Pain can not be seen with imaging.
    2. Pain is not where you or the patient’s think it is.
    3. Chronic pain rarely emanates from the joint proper.
    4. These author are not one size fits all and personalize therapy based on each unique person.
    5. These authors knew that if you treat a problems and did not address the original causes, all of your benefits, time and efforts many trickle away. Attack the perpetuating factors.
    6. These authors also knew that once the therapy was started that the patient had to do their part with proactive home care with stretching, exercises like yoga, assisted care from a therapist.
    Warning To All:
    7. Chronic myofascial pain should be effectively treated because of the possibility that it will spread into surrounding muscles and even in the small rotators of the vertebra and ignite Spinal Segment Sensitization. SSS is “Hell Fire and Brimstone” Pain Syndrome.

    Am I missing something as it relates to NOI?

  9. John, can you think of anyone in medicine, rehab or psych who takes an ethological approach to understanding the interaction between provider and patient. I agree, much of the work in science and medicine is about creating classification systems that describe underlying mechanisms of pain within the individual. However, most of these descriptions chop up the person into subsystems or are sub-personal. Further they all together ignore larger population based analysis of pain. If you take this seminal work: The Social Determinants of Health by Wilkinson and Marmot

    http://www.amazon.com/Social-Determinants-Health-Richard-Wilkinson-ebook/dp/B000SEVU7U/ref=sr_1_1?s=books&ie=UTF8&qid=1394983530&sr=1-1&keywords=9780191578489

    Flip to the index and look up pain–nothing. I worry that our subpersonal classification schemas are all but despersonalizing and removing the provider by a series of degrees from actually being able to provide empathetic care for those expressing pain.

  10. John Quintner says

    Eric, your question(s) go to the heart of the problem we as clinicians all face – how best to meaningfully engage with the person in pain who sits before us? Before I would even attempt to formulate some answers (and I accept that these would necessarily be biased) may I suggest from my own observations that the key ingredient absent from current inter-professional education is the “person-in-pain”? This may sound surprising but, in my opinion, this elementary omission stems from the way in which we are all taught and from the lack of understanding of the role of empathy, in all its connotations, by the opinion leaders in academia.

  11. One interesting consideration of this dose conversation is regarding the role of the institution of medicine to tackle pain. It seems that best intensive chronic pain efforts are aimed at tackling cognition, habits, social relationships and behaviors. This multidisciplinary approach could in essence be thought of us as transporting the patient from an environment that reinforces a certain interpretation of “pain” to a novel one that attempts to redirect the interpretation of “not-pain”. My question, which is purely exploratory, to what degree can (or should) the institution of medicine be responsible for this? Can medicine/psychology based interventions reconstruct healthy relationships? Can it re-balance the issues of social inequality that may underlie part of the chronic attribution of threat to one’s environment? Is there enough dose in psychology or medicine to palliate all of these pains?

  12. Stephen you mention a list of suggestions some like dry needling have very poor evidence? Beside that you forgot the most important intervention.
    I like to quote someone:

    “Well delivered Explain Pain education currently has the best outcomes of any intervention for chronic pain”. “David Butler”
    From: Noi website

    About dose relationships: it seems 1 on 1 education works better than group education. Might the dose be less in group education? Due to maybe distraction or the perception of attention being given by the therapist?

    Indeed nocebo could be seen as a toxic effect but does that relate to dosis?

  13. John Quintner says

    Dr Rodrigues, with respect, your comment has nothing to do with the topic under discussion, “Doses and processes in pain management.” If you want to receive some critical comments on your rediscovered protocol, I suggest that you enter the lists of those who strive to publish their views in the peer-reviewed scientific literature. But I recall that over the past year or so we have had this conversation many times! All to no avail, it would seem.

  14. Stephen S. Rodrigues, MD says

    If I made chime in on this conversation. Your question is valid and I understand your logic and reasoning. I’ve read many books and articles on the subject of the pharmacodynamics of opiates, dosing and I discovered a lot of clinical variation in patient to patient, that managing these patients was very frustrating.

    Then I discovered a new protocol to treat pain of various types that alter one’s sense of wellbeing requires much more than a medication. This “new” or actually recycled protocol was what some in the medical community experimented with in the last century. They actually had very good success. The premise was to address pain with a team, recipe or protocol, not just a singular option. ie a pill or a surgical blade.

    Mostly sub-acute and chronic pain, either from cancer, trauma or unknown causes all have a different set of circumstances causing the pain, but they all need the same intensity of care. Sub-acute chronic pain requires therapy and therapy should be an all inclusive recipe personalized to the individual person.

    Here it is:
    1. Make sure the patient is well nourished and not depleted, so tank- them-up with Vitamins minerals and trace elements, eps Magnesium in the form of glycinated. Addressing the perpetuating factors that come from self or doctors; diet and medications.

    2. Make sure the patient has a recreation, work, family life, stress balance. Especially for chronic pain sufferers you have to address their mind-body, stress management, 3. Especially for chronic pain sufferers they have to do some type of movement of the total body as with dancing, aerobics, walking, yoga, jogging and or swimming. Make sure that one of these will increase the core body temperature.

    4. It’s also vital that their muscles and connective tissues are manipulated by manual hands-on therapy as with acupressure, trigger point knobs or doohickies, massage, chiropractic adjustments, rolfing and kneading.

    5. The muscles and connective tissues may need to be needled as with Travell/Simons dry/wet needling or Gunn-IMS and less advantageous are Prolo, Bio, Sugar or a few other injections esp into deeply painful areas. Acupuncture would be a very good and safe option also.

    6. Establishing quality sleep; pattern, quality, depth.

  15. John Quintner says

    Amanda, pursuing the analogy with drugs, would you care to comment on placebo and nocebo effects relevant to those delivering programmes that might have a bearing on outcome? Individual drugs that are being scrutinized in controlled trials have been manufactured to be identical in content, whereas those who deliver educational programmes to people in pain must vary considerably in their personality, delivery style, presentation skills, knowledge, and experience.