A Tale of Pain Science with Dr. Bronnie L. Thompson, PhD

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I have for some years now, been reading articles by Dr. Thompson PhD. Some of these quotes are from articles and others are from interviews. Dr. Thompson is one of the lesser known pain experts, but in my opinion she deserves a lot more attention, for the great work that she does.

Dr. Bronnie L. Thompson, PhD is a occupational therapist, she graduated in 1984 with Diploma in Occupational Therapy from CIT. Since then Dr. Thompson continued to study at postgraduate level and published papers on ergonomics, mental health therapies, and psychology.  Dr. Bronnie has recently completed a PhD developing a theory of living well with chronic pain.  She also holds a MSc (1st class hons) in Psychology from Canterbury University.

Dr. Bronnie L. Thompson is also a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences. Dr. Thompson has worked in this field (pain management) most of her clinical career. She also has a very popular blog called health skills, I would recommend that you join Dr. Bronnie’s health skills facebook-page.

Without further ado, here are 32 quotes from Dr. Bronnie L. Thompson, PhD:

“Poor sleep lead directly to lower mood, and to higher pain, but when low mood was used as a mediator, it was found to mediate the relationship between sleep and pain. What this means for us as clinicians is that it may be helpful to address both sleep hygiene – and low mood – and that either or both may influence pain. 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.” Dr. Bronnie L. Thompson, PhD

“I think that if clinicians fail to explore the relevance of thoughts and emotions and values etc, and instead support patients misunderstanding of their pain as fixed, permanent and unable to be modified, then they do their patients great harm.” Dr. Bronnie L. Thompson, PhD

“The first set of skills that are crucial to effective pain management are those to do with communicating. The ability to listen carefully, reflect what’s being said, and to ask questions to genuinely understand what a person believes and feels, and how they got there.  To be able to help the person identify what’s important to them, their main concerns, their values and the direction they want to move towards. To know what to say and how to say it” Dr. Bronnie L. Thompson, PhD

“The second aspect of a pain assessment is to review the person’s thoughts about their pain, and the impact of their pain on their life. I call this the ‘psychosocial’ part of the assessment, and in our Center at least, it’s carried out by occupational therapists, nurses, social worker and clinical psychologists.  I am personally wary of the current tendency in New Zealand to call this assessment ‘psychological’ and confine it to psychologists only, because while people with chronic pain are often demoralised, may have low mood and can be worried about their pain, after working in the area for nearly 20 years, I don’t see all that many with frank psychopathology.” Dr. Bronnie L. Thompson, PhD

“The second set of skills involve being able to change behaviour. To be aware of operant conditioning, classical conditioning, and to use these principles along with those involving cognitions (eg “education” or providing information).  Interestingly, while these principles are derived from psychology, and perhaps educational research, ALL health professionals use these skills when they’re involved in asking the person to make a change outside of the treatment room.” Dr. Bronnie L. Thompson, PhD

“The third involve being able to progressively grade activities from simple to complex – modifying them so that the demands just slightly exceed the person’s capabilities or confidence.” Dr. Bronnie L. Thompson, PhD

“Most people with chronic pain are referred to an interdisciplinary, specialist center after many years.  I’ve previously estimated that people are referred to the place I work on average about two to five years after the onset of their pain.  This means that, in most cases, people have seen at least two or more medical specialists, many other health professionals such as physiotherapists – and may have had about two or three different diagnoses.  They’re often confused, and I find it incredible that many haven’t yet had an explanation that they can recall, or perhaps that they can understand.” Dr. Bronnie L. Thompson, PhD

“The medical assessment often focuses on identifying whether there is pathology that can be addressed through medical means, ensures that any investigations that may have been omitted are completed, and arrives at a diagnosis.  The diagnosis may be unsatisfactory because it may simply be ‘non-specific chronic low back pain’” Dr. Bronnie L. Thompson, PhD

“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.” Dr. Bronnie L. Thompson, PhD

“Well, for a while I’ve been saying that people working in this area of health (musculoskeletal pain) seem to be developed a set of common skills. That is, there is more in common between me and Jason Silvernail, Mike Stewart, Paul Lagerman, Alison Sim, Lars Avemarie, Rajam Roose and many others around the world from many different health professions, than there is between me and a good chunk of people from my own profession of occupational therapy. And I don’t think I’m alone in noticing this.” Dr. Bronnie L. Thompson, PhD

“That ongoing cycle of assess -> hypothesise -> test -> review -> reassess -> hypothesise -> test -> reassess ->  review. This is important because when people come to see us with a complex problem (and increasingly this seems to happen), the simple models break down. The tissue-based, the germ-based, the simple single-factor approaches do not fully explain what’s going on, and don’t provide adequate solutions.” Dr. Bronnie L. Thompson, PhD

“We know there are a lot of people in our communities who have relatively simple pain problems – a temporarily painful knee after walking up hills for the first time in ages, a painful back that “just happened” overnight, a rotator cuff problem that makes it difficult to get dressed or hang out washing. We know that there are some pretty simple things that will help in these situations: some reassurance that the awful thing the person is worried about isn’t likely to happen (no, you won’t end up in a wheelchair because of your back pain, and no it’s not cancer); some pain relief to help with sleeping more soundly and so we can keep doing things; and gradually returning to normal occupations including work even if the pain hasn’t completely gone.” Dr. Bronnie L. Thompson, PhD

“What I think this means is the time has come to stop describing various treatments as “belonging” to any single discipline. They don’t “belong” to anyone – they’re generic skills that we ALL use. So I, as an occupational therapist warped by psychologists, will have greater technique in communicating, noticing psychosocial obstacles, and helping a person generalise skills into a range of contexts by virtue of my training. Paul, as a physiotherapist, will have greater technique in prescribing specific exercises for certain muscles, and have more confidence in exercise progression. Scott will have greater expertise in enhancing expectations and helping a person reconceptualise their pain in a way that dethreatens it. We ALL have effective skills across all of these areas, but at the same time we have particular expertise in what we originally trained in.” Dr. Bronnie L. Thompson, PhD

“I think MI (red. Motivational interviewing) is by far and away the best approach for people to start with. The underlying principles of CBT are useful but in the end it’s MI that gets people on board.” Dr. Bronnie L. Thompson, PhD

“I’m not quite as convinced that neuroscience education actually does a lot for people who have more complex needs. It’s fine for those who are not catastrophising, don’t have strong avoidance, have little other psychopathology, don’t have negative reinforcement in their social environment, and who “believe” the person telling them (the personality of the educator) – but for those who do have these complications a more comprehensive and integrated approach is needed. TNE is a good thing, far better than giving a biomechanical explanation, but it’s not a panacea.” Dr. Bronnie L. Thompson, PhD

“It’s common to find that there are no medication solutions to phantom limb pain.” Dr. Bronnie L. Thompson, PhD

“It’s not an all or nothing situation certainly. And I’m not knocking TNE – but to me it runs the risk of being over applied like so many, to the exclusion of other excellent approaches that have a long history and good evidence base. TNE used to be called psycho education when I began in pain mgmt in the late 1980’s,so I find it really interesting that it’s being so widely promoted as a new thing! I think the main difference is that PT’s are getting into it with a move away from anatomical and biomechanistic explanations. Perhaps PT’s are gaining confidence in their communication skills, perhaps its the Moseley effect(!) whatever it’s simply another tool.” Dr. Bronnie L. Thompson, PhD

“The thing is that to counter the popular culture of “it’s a slipped disc” or “don’t use your back like a crane” the TNE approach can be a bit abrasive. The other thing is that we don’t know the relevance of nociceptive factors vs psychosocial and neurobiological ones. The bit that gets missed so much is the social – why do we, as a culture, get so much mileage from complaining about pain? why do we think we should always be painfree, never have to moderate our activities even though we’re aging/unfit, want to be “perfect” specimens and never have to DO anything to become well? These are the issues that remain unaddressed even with explain pain in the toolkit!” Dr. Bronnie L. Thompson, PhD

“There’s nothing wrong about giving accurate & nonthreatening information. Just remember though that on its own it’s unlikely to create spectacular change. Combined with addressing other aspects it forms a really useful tool in the kit that every clinician needs.”  Dr. Bronnie L. Thompson, PhD

“Information is, from what I read, intended to change beliefs. Belief and behaviour change go hand in hand – so if someone has resistant beliefs (ie they hold firmly to the idea that hurt = harm) it may be because they have yet to reconceptualise their pain in terms of the new information they’ve received. This has been hashed to death in early research in psychology, so I guess I’m just a little perturbed to find another whole new thread of research arguing that information is critical. It is, but not alone.

As I said, my worry is that education will be dumped on people without them being supported within their schema (neurotags, to use NOI language). Psychologists call these schema – and the idea has been around for a very long time (since the 1970s at least). What would worry me is if medics justify info dumping when they do procedures and think they have “done” what needs doing for reconceptualising. Then they go and blame the patient!” Dr. Bronnie L. Thompson, PhD

“Many studies have shown psychological factors such as catastrophising (thinking the worst) and low mood are associated with poorer outcomes (Riddle, Wade. Jiranek, & Kong, 2010; Roth, Tripp, Harrison, Sullivan & Carson, 2007; Shelby, Somers, Keefe, Pells, Dixon & Blumenthal, 2008).  The outcomes looked at so far include length of stay in hospital at the time of surgery, analgesia use during surgery, increased disability after surgery and revision rates.

Now, one solution to this problem could be simply not performing joint replacement surgery in people who are depressed and tend to think the worst. The problem is that two of the strongest predictors for looking for treatment are – you guessed it: low mood and catastrophising (and disability). Dr. Bronnie L. Thompson, PhD

“What this means in healthcare, I think, is adopting a framework that works across diagnosis and into the idea that people actively process what happens to them, they make their minds up about what’s needed, and they can learn to do things differently. I’d call this self-management, but I could equally call it a cognitive behavioural approach, or behaviour change, or motivational approaches or even patient-centred or person-centred care. The idea that people understand more than we often give credit, that they make sense from what happens to and around them, and that this knowledge influences what they do comes from a cognitive behavioural model of people, and fits beautifully within a biopsychosocial framework.” Dr. Bronnie L. Thompson, PhD

“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 professional domain could lead to occupational therapists’ duplicating the interventions of other multidisciplinary team members.” Dr. Bronnie L. Thompson, PhD

“We know that people in lower socioeconomic areas present with poorer prognosis, higher rates of chronic pain, lower employment, poorer health behaviours and I think it is hard to change these things as a therapist and as an individual. Things like culture are larger units of analysis and I don’t think we really know how they influence the individual. I guess it’s one of the things I keep coming back to – neuroscience gives us a great deal of insight into certain aspects of pain, but there’s a risk that people will equal what’s going on in the brain with the totality of the experience. It’s part of it but these other factors exert influence that we’ve not yet understood well enough to know how they do so. Not sure I am making sense but I just have this worry that neuroscience might become the next biomechanics.” Dr. Bronnie L. Thompson, PhD

“Helping people develop good sleep patterns is a common part of pain management.  Simple sleep hygiene habits (like this) are often included in pain management programmes.  Relaxation strategies are also often part of pain management.  Including relaxation training in sleep management can help people counter their increased arousal levels if they wake during the night, but can also help people fall asleep in the first place, making the use of hypnotics, alcohol and other drugs less necessary.  A recent study of CBT treatment for insomnia found that it is highly effective, even when delivered in a group format.” Dr. Bronnie L. Thompson, PhD

“The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption.” Dr. Bronnie L. Thompson, PhD

“Reconceptualising is about helping the person think differently about their pain – often it’s about helping them think about their experiences and considering how they differ in different circumstances. It’s also about them developing an individualised model of their experience including what they think is happening, their responses emotionally and cognitively as well as other people’s responses. It means understanding that they can influence their own experience and responses (including functional limitations) so they know they can take an active part in managing it. Pain Education can be an info dump on a person who doesn’t feel heard and may not answer their unique concerns.” Dr. Bronnie L. Thompson, PhD

“A cognitive behavioural approach to pain management is not exactly the same as cognitive behavioural therapy for depression or anxiety.  In pain management, while cognitive behavioural therapy as used for mood management can be one of the therapeutic strategies used, the CBT approach is broader than this.  Basically, the CBT approach conceptualises the problem of disability and distress as due to inaccurate understandings about pain (such as hurt = harm, or that pain must dictate behaviour), and thus, inappropriate activity levels are maintained, and these in turn lead to negative mood states.” Dr. Bronnie L. Thompson, PhD

“But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.” Dr. Bronnie L. Thompson, PhD

“We also know that after a few days without good sleep, we can get cranky.  Life doesn’t seem quite so nice!  Sleep disruption is often a feature of mood disorders and anxiety – and many people with persistent pain have co-occurring mood problems.  Combine low mood with poor sleep – and we know the outcome is increased pain on the days following a poor night’s sleep, and after a day of increased pain, the following night’s sleep is often poor as well.” Dr. Bronnie L. Thompson, PhD

“There is also a very strong possibility that by conducting a ‘psychological’ assessment, the incredibly important social aspects of having pain can fail to be assessed – or this aspect can be given less emphasis than it deserves.

The purpose of the psychosocial assessment is to identify factors that influence the person’s experience of their pain, and to start to explore factors that may be influencing pain behaviour.  Possibly the simplest way to remember the basic psychosocial factors is to use the mnemonic ‘A B C D E F and W’.” Dr. Bronnie L. Thompson, PhD

Pain-science-de
Dr. Bronnie  is also head keynote speaker at
Canadian Physiotherapy Association’s Pain Science Division conference, together with Pain Expert Dr. Adriaan Louw, who I have also done a article about, called The Tao of Pain.