CSP Annual Conference 2000 - Reviews and Comments
Shimla Pinks, Birmingham 21/10/00
(Claire Mooney, Liz Macleod, Heather Muncey, Nick Kendall, Sue Mickleburgh and Maureen Simmons)
CONFERENCE COMMENTS
Liz Macleod:
I decided to put pen to paper after returning home to say how much I enjoyed this years CSP Conference. I've been to many Annual Conferences before and indeed was in Birmingham last year but this was the best yet!
We were privileged within the PPA programme to be listening to speakers whose names we read on research papers. Nick 
Kendall, the "Yellow Flags" author, Johan Vlaeyen whose work includes the relevant issue of Fear Avoidance Behaviours and Maureen Simmonds whose presentation on Pain and the Placebo was fascinating, were our international speakers. Through their presentations, the knowledge and experience both within the research and clinical fields of our own Penny Mortimer, Paul Watson, Louis Gifford, and George Peat provided for the audience relevant and challenging information. Contributions to the free paper sessions introduced physiotherapists who, through their own research were providing evidence upon which we can base our practice. The programme was varied, interesting and highlighted the complex nature of pain and it's effect on our patients.
As well as the stimulation of the presentations we discussed issues we face day by day. As kindred spirits, physiotherapists working with the pain patient had the opportunity to share ideas and reflect on practice. We examined the evidence and challenged our own beliefs. We were encouraged to consider different and hopefully better ways of managing our patients. More than anything I have come away inspired to look more closely at my own practice.
A big "thank you" to my colleagues in the PPA who took the time and effort to arrange the programme. Thanks to Philippa for manning the busy PPA stand, which does a great job in promoting the work we do. Thanks too to Philippa for organising a great curry experience at Shimla Pinks!
Well done PPA! Roll on next year's Conference!
Liz Macleod,
PPA-North Chair,
Edinburgh
Do health professionals, through their information giving, contribute towards chronicity and disability in patients with low back pain? Caroline Hafner, INPUT Pain Management Centre Bronllys hospital Powys.
Lesley Marshall:
The purpose of this study was to examine Low Back Pain patient's understanding of the information provided by Health Professionals.
The development of modern medicine has resulted in a significant increase in the numbers of patients reporting Low Back Pain (LBP). Previous studies have shown that 85% of LBP is benign and self - limiting but it appears this type of positive information is not often shared with the patients. This paper aimed to highlight the importance of Health Professionals giving accurate and meaningful information to the patient.
The study was an explorative and qualitative study from a patient's perspective. Two questions were asked and the answers written verbatim. They were;
- What have you been told about the cause of your pain?
- What is your understanding of this explanation?
The patients were mainly in their 40's and had suffered from LBP for over 10 years. Many had received physiotherapy that had either not helped or made them feel worse. The consistent theme that emerged was of patients being told that their spines were "degenerating" or "crumbling". Inaccurate information was also given an example of which was a 49year old patient being told they had "the body of a 70yr old". Lack of information was also unhelpful as ignorance often created fear and conflicting information created confusion. The study suggests the answer to the research question is yes.
The limitations of this research were that it was small and there was no way of checking the accuracy of the patient responses.
The conclusions reached were as follows;
- Accurate information should be available in the Primary Care setting,
- The consultation process can be harmful,
- LBP needs to be demedicalised,
- Health Professionals need to be aware of the effect their information can have.
This excellent study identified the need for Health Professionals to examine the delivery and content of patient information. Inaccurate or conflicting information can create catastrophising that may reinforce rather than challenge their beliefs. This may result in patients feeling fearful, vulnerable and pessimistic regarding their future physical wellbeing.
Lesley Marshall
Pain Management Programme
Astley Ainslie Hospital
Edinburgh
Do Health Professionals, Through Their Information Giving, Contribute Towards Chronicity & Disability In Patients With Low Back Pain? Caroline Hafner.
Alan Leigh:
Caroline reminded us of the rather frightening facts that despite all the advances in Health Care, disability in still increasing and that much Health care is still driven around the Cartesian / disease orientated models. Back pain is largely self-limiting and benign and yet paradoxically is a massive financial burden and poorly understood.
This was a pleasantly straightforward and incredibly useful presentation. Judging by the amounts of questions, and the comments that followed Carolines' presentation it obviously struck a "chord" with many of us. The presentation was a delight.
The aim of this qualitative research was to record verbatim what patients recall being told during consultations and what they understood the comments meant. The comments were very familiar and whilst amusing are also worrying. It can be no surprise that some patients do not get better.
"...My spine is crumbling...", "...I will end up in a wheel chair..." many of these patient comments came from 30 - 40 year olds.
38 subjects were included in the study age ranged from 22 - 61. With a range of pain duration from 1 - 34 years (mean 10 years).
Content and interpretative analysis was carried out and common themes were identified.
Caroline suggested that the information that patients received was inaccurate, pessimistic and was insufficient. The information disempowered patients, enhanced vulnerability and was full of unhelpful metaphors.
She suggested that all health professionals can have a potent influence over patient's perceptions and could potentially disable them.
Unfortunately she had not recorded which health professional from her study had been most guilty of the long list of statements. She felt that Consultant Orthopaedic Surgeons may be at the top of the list but unfortunately there were physios on the list too.
Clearly patient's perceptions are valid but should not be looked at in isolation from the context in which information is given.
More importantly we may be guilty of not answering the precise fears that are felt by the patient. We may also be guilty of selecting and dealing with those fears that we feel should be important.
A report on the above free paper presented at CSP congress 2000:
Alan Leigh.
The effect of Upper Limb Tension Test 1 (ULTT1) on the conduction characteristics of the median nerve. Cathy Daborn.
Alan Leigh:
Cathy very successfully guided a well-attended Pain free-paper session through what was a technically complex study on asymptomatic subjects. Thankfully the summary in the congress proceedings book helped me get to grips with the basic methodology - and all delivered in 15 minutes - impressive!
An important question being posed was, What affects are there on the median nerve's ability to conduct during the ULTT1?
40 females were tested using an adapted ULTT1. The order of movement additions were: - (I hope this is correct as I was desperately trying to listen attentively and scribble) Cervical spine contra-lateral side flexion; Shoulder girdle depression; slight shoulder extension and abduction to 110°; shoulder lateral rotation; elbow extension. The wrist and fingers were allowed to be relaxed in flexion. The position was maintained in a specially designed splint, plus a pressure biofeedback cuff to maintain a set shoulder depression.
Conductance measures were taken before the test, during the sustained holding of the test at 2,7&12 minutes, and after the test at 7 & 12 minutes. Conductance measures used were: - sensory evoked potentials (SEP), amplitude and latency, taken at Erbs point, 7th cervical vertebra and the sensory cortex. Vibration threshold (VT) at a constant 100 Hz on the index and little finger tips.
The research indicates that the application of the ULTT1 can alter the conduction characteristics of the median nerve. Cathy suggested that the findings were due to: -
- Lengthening of the nerve.
- An increase in resistance to nerve conduction from a decrease in cross-sectional area of nerve fibres.
- A decrease in the nerve diameter that may lead to decrease in neural circulation.
1 & 2 she felt were likely to be initial responses where as neural circulatory changes would take time to change.
There are various limitations to this study for general application - all of which Cathy suggested would be future directions for her research.
Future studies include comparing this data to symptomatic subjects and looking at the effects with different order of movement additions. It would also be worth looking at asymptomatic and at risk subjects such as keyboard workers, those with a history of trauma to the wrist such as falls onto the out stretched hands, and women in & around the menopause. Cathy indicated that further studies would look at subjects with carpal tunnel syndrome.
Clearly there is still a need to research the role of movement on the nervous system in physiotherapeutic management.
A report on the above free paper presented at CSP congress 2000:
Alan Leigh.
CSP CONGRESS 2000 - POSTER REVIEWS
Clare Mooney:
I thought I'd do something a little different this year and review a couple of the posters from the CSP Congress.
THE PAIN BELIEFS OF PHYSIOTHERAPISTS - A NATIONAL SURVEY
Rhys A , Stephenson RC . School of Occupational Therapy and Physiotherapy, University of East Anglia, Norwich, Norfolk.
The aim of this study was to determine the nature of pain beliefs held by physiotherapists.
A modified version of the SOPA (survey of pain attitudes-Jensen et al 1994) questionnaire was distributed to physiotherapists working in NHS Trust Physiotherapy Departments in England. It looked at 7 different pain related beliefs :
- CONTROL (One's personal control over pain)
- SOLICITUDE (Appropriateness of solicitous responses from one's family when in pain)
- MEDICATION (Belief that medications in general are appropriate for chronic pain problems)
- DISABILITY (Belief in one's self as unable to function because of pain)
- EMOTION (Relationship between emotions and pain)
- MEDICAL CURE(A medical cure exists for the pain problem)
- HARM (Pain = damage and exercise and activity should therefore be restricted)
The results show a disparity in pain beliefs expressed by physiotherapists. Attendance on a pain course was the most frequent predictor of physiotherapy responses to the items of the SOPA. The majority believed emotion (anxiety,depression,etc) had an influence on the patient's perception of pain, but this was not linked to demographic variables.
Physiotherapists in more senior positions believed that the patients considered themselves to be disabled, but they themselves didn't believe that chronic pain should lead to disablility.
Physiotherapists that had attended a pain course :-
-didn't believe pain = damage, but thought that the patients did
-believed that exercise/movement were not good at reducing pain
-believed that patients wanted more solicitude, although they didn't believe that the patients needed more.
Due to the diversity in physiotherapists pain beliefs, there is potential for the patient's pain to be interpreted differently across all physiotherapists. This may therefore influence the the way that the patient's pain is managed.
A question raised at the end of the poster was - "Do these differences need to be standardised during training?" In my opinion I think this would be very beneficial to physiotherapists and their patients. At the moment there are huge inequalities in the way that chronic pain patients are managed. It would be no less than a vast task to educate all currently employed physiotherapists in chronic pain management, but, if it were possible to improve awareness at university/college level, then at least this would be a starting point to standardising pain beliefs of physiotherapists and therefore the patient's management.
References:
Jensen MP, Turner JA, Romano JM, Lawler BK (1994). Relationship of pain-specific beliefs to chronic pain adjustment. Pain 57: 301-309.
Marteau TM (1989). Health beliefs and attributions. In: Broome AK (ed). Health Psychology : Processes and applications. London, Chapman and Hall. 1-23.
A REVIEW OF THE VALUE OF PAIN RATING SCALES AND THEIR APPLICATION TO PHYSIOTHERAPY.
Rodger J (O'Driscoll L). University of East Anglia, Norwich, Norfolk
This study consisted of a literature review of pain rating scales which included:
- VAS (visual analogue scale)
- NRS (numerical rating scale)
- VRS (verbal rating scale)
It was found that all 3 scales were clinically valuable, valid, and reliable in terms of consistency and repeatability. It was felt that the scales were giving a limited view to pain only (ie-not including function/distress, etc). The scales were adequate for use in acute pain, but other assessment tools would be more useful in chronic pain.
The question brought up was :- "Were clinicians to adopt a more biopsychosocial assessment of pain, would they then have to consider adopting a more holistic treatment approach?"
I feel that the answer to this question is a resounding YES! Further studies on the measurement of chronic pain are required, as is the teaching of a broader minded, holistic, interdisciplinary approach.
References:
Klabber-Moffett JA, Richardson PH (1997). The influence of the physiotherapy-patient relationship on pain and disability. Physiotherapy Theory and Practice. Vol 13, pp89-96.
Raj PP (1996). Pain mechanisms. In Pain Medicine - a comprehensive review. Edit Raj PP, Mosby, London.
Simmonds (1999). Pain management : How are we doing? How do we know? Physical Therapy Review, Vol 4, pp1-4.
I thoroughly enjoyed reading both of these posters, and would like to thank the people involved in the studies for giving us all plenty of "Food for Thought".
Clare Mooney,
PPA-North Secretary,
Edinburgh
Research shows link between fear and pain
Taken from Frontline 'Congress focus' 1st Nov 2000:
Patients who avoid certain activities because they are scared of injuring or re-injuring themselves can be treated using the same principles applied to treating phobias, delegates heard.
Giving the Patrick Wall lecture at a meeting held by the PPA, clinical psychologist Dr Johan Vlaeyen, said studies had shown a link between fear and pain.
Specifically, research had identified that in chronic musculoskeletal pain, fear of pain or injury was more disabling than the pain itself, said Johan, who is based at the University of Maastricht in the Netherlands.
He compared the characteristics of pain-related fear to arachnophobia. People with the spider phobia kept away from spiders, worried about what a spider would do next if they saw one and were hyper-vigilant, spotting even the tiniest spider in a room which someone else might not even see.
In much the same way, those suffering from kinesiophobia - a term introduced in 1990 for describing pain related fear - avoid certain activities, worried about the effect the activity might have on them and were vigilant about bodily sensations. Fear of pain or injury limited the daily activities of 'kinesiophobics', Johan said.
In a follow-up session he examined a practical approach for reducing pain-related fear, drawing on the preliminary findings of a study he was involved in.
The study looked at the effectiveness of an approach, based on the treatment of phobias, for treating patients with back pain. The patients were afraid of exercising and lifting activities for fear of injuring or re-injuring themselves.
The treatment approach is based on screening to identify what stimulates the fear, education about the harmlessness of physical activity and graded exposure to the feared activities.
Telling an arachnophobic there was nothing to fear from spiders was unlikely to be effective, Johan suggested. But letting a spider crawl over them could be a powerful way of demonstrating their harmlessness.
However, the study indicated that education could be useful with the back pain patients. But exposure to situations or activities identified as dangerous or threatening by patients significantly reduced pain-related fear.
An additional, unexpected finding was that some patients pain intensity also reduced during exposure, Johan reported.
(Taken from Frontline 'Congress focus' 1st Nov 2000)