- More discussion on Functional Capacity Evaluations
- Journal impact factors
- Patients Are Often More Engaged In Their Health Than Providers Think
- Trust, teamwork and transparency
- Living well with persistent pain – a problem solving model
- Nerdy, Sciency Stuff
- The Graded Motor Imagery Handbook – a review
- Lorimer Moseley throws the gauntlet down!
- How occupational engagement might work in pain management
Bronwyn Thompson offers comprehensive information on topics such as post accident trauma and pain management, learn about pain management here. Also, learn about topics such as scar revision and massage for relaxation Now listed with Ceatus Media Group NB I don't endorse/recommend any specific product or approach, this is simply an advisory Filed under: Uncategorized
Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work "fitness". I've received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable. I haven't found anything recently, and I'm still concerned that FCE are used inappropriately for people with chronic pain. There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves - and have a flare-up for some days afterwards but get a "good" report suggesting they have put in "full effort" and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies - and avoid a flare-up but receive a "bad" report, suggesting they haven't put in "full effort" and despite this, they can manage a full time job of a certain MET demand. I can't understand why FCE providers don't work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. For the record, I'm not against establishing functional abilities. And I think having a systematic approach to doing this. I am against FCE's being touted as a way to reliably determine work capacity, or to being able to determine "effort" through "consistency". There simply isn't published evidence to support these claims. If someone can provide me with evidence, I'll gladly change my mind because if there is one thing scientific training teaches, it's that it's OK to change your mind - if there's evidence to do so. This doesn't mean that FCE's would then be fine and dandy - because, as I've seen far too many times - HOW they're used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same. Here's my original post, and some very good references are at the end of it. Filed under: Uncategorized Tagged: Chronic pain, fitness for work, functional capacity evaluations, reliability, Return to Work, science, validity
If you've ever wondered about how well-connected and respected a journal is, journal impact factors claim to give you the answer. Theoretically, a "good" journal will be cited widely by others, and have authors clamouring to contribute to it. Of course, unpopular topics like chronic pain are trounced by their flashier cousins exploring things like global warming and new theories of evolution, and there is the effect of advertising and prominent endorsements on circulation numbers, but there you have it. This is from a respected university, so read and enjoy.citation_analysis Filed under: Uncategorized
Reblogged from Mind The Gap:
Patients often don’t get the respect they deserve. Take the subject of patient engagement. Just about everywhere you turn in the health care literature these days we are told how physicians and other providers need to do a better job getting patients involved in their own health. But is that really their role? PATIENT ENGAGEMENT IS NOT THE JOB OF HEALTH CARE PROVIDERS&HELLIP;Read more… 509 more words
This post rang particularly true for me - both as a patient myself (who isnt from time to time?!) as a clinician involved in helping people develop self management (which includes health literacy), and finally, as a researcher looking at the ways people who are resilient despite their chronic pain cope with their health condition. Whew! Sorry for the long sentence! I dont know that I completely agree that patient engagement isnt for health care providers, because plenty of people are ambivalent about enacting their good intentions. This is where what we do counts most. Listening, helping establish what is important to the person, then supporting them to "take the next best step" for their health. This might mean giving them a call a couple of days later to see how theyre getting on, helping them set specific actions to take (time, date, what, when, where), and then reviewing how this is working some time in the future. Being proactive. Thoughts?
Teams are a feature of healthcare, and nowhere more so than in pain management. This is because, at least for chronic pain, no single profession can claim to have all the answers. Many of us know we need to rely on one another to address patient/client concerns and to provide a consistent approach for the person to have some confidence in. However (you knew this was coming!), teamwork isn't easy and some groups of professionals appear to have a good deal of difficulty overcoming implicit attitudes and assumptions about other disciplines. Now before I'm annihilated, I acknowledge that the attitudes and behaviours within every group of practitioners varies in a bell-shaped curve! I had occasion, recently, to address a group of health practitioners who shall remain nameless. This group were discussing sharing of health information, and an approach to inviting patients to be part of a programme of self management in which health information sharing is a component. To my perplexion, I found that there were two major concerns about this approach. * That "all" health information would be shared by all team members rather than being selected by this group of clinicians (the risk being identified was that mental health and sexual health information would be shared along with cardiology, musculoskeletal, immunological and so on) * That inclusion on this programme would not be "controlled" by this group of clinicians. In other words, that patients would be able to decide _for themselves_ whether they wanted to participate, and that _all_ their health information would be available to other clinicians was viewed with anxiety. I'm venturing to suggest that this reflects a lack of trust in both other health professionals, and in their patients, with the latter being a somewhat outdated paternalistic view, IMHO. I took it upon myself to have a quick flick through the literature on health professionals attitudes towards one another, and there is a wealth of it! Unsurprisingly, studies about biomedical attitudes towards professionals of other persuasion dominate, so I'll summarise just a couple and let you draw your own conclusions about how widely the findings might apply. Moret, Rochedreux and colleagues (2008) found that while physicians delivered diagnosis and prognosis (and nurses agreed), nurses thought they provided additional explanations about diagnosis, information on investigations, and benefits and risks of treatment to what physicians provided, while physicians appeared unaware of the contribution of nurses. Concerningly, MORE THAN 20% OF PATIENTS WERE NOT SATISFIED WITH INFORMATION ON BENEFITS AND RISKS OF INVESTIGATIONS AND TREATMENTS, AND WANTED MORE. This report suggested that lack of physician-nurse collaboration affects the quality of patient care, and that both professions should recognise the contributions of each other. Gaboury, Bujold et al (2009) examined the collaboration between medical doctors and _"complementary and alternative medicine practitioners". _ (For the skeptics amongst us, these are the practitioners included: naturopathy, massage therapy, chiropractic, and traditional Chinese medicine, including acupuncture. Other practitioners coming from a biomedical healthcare background, such as nurse practitioners, physiotherapists or pharmacists were also eligible participants. I make no comment on whether these practitioners provide useful/helpful input, kthx). They found that _"awareness of one’s own limitations related to one’s healthcare paradigm and similarly limitations in colleagues’ abilities … affect[ed] the level of collaboration among the clinic staff."_; and that _"capacity to acknowledge one’s own limits was identified as a MAJOR PERSONALITY CHARACTERISTIC [my emphasis] that stimulates appropriate patient referral and safer care for the patient." _ They also state that _"comprehensive understanding and knowledge of colleagues’ healthcare abilities, and perspectives based on their healthcare paradigm appeared to be vital to the team cohesion."_ Sharing patient records was found to enhance collaboration, and patients were asked to agree to this. However, relating directly to my experience regarding power relationships, this study identified that _"…even though patients could self-refer and specifically request to see a CAM specialist in all of the five clinics visited, the designated entry practitioner for two clinics was the medical doctor. One manager interviewed depicted his clinic’s referral system as if the medical doctors were the orchestra conductors responsible for ensuring continuity of care and integrative care."_ There appears to me to be an easy assumption by the medical profession that they are at the top of a decision-making hierarchy in a healthcare team. I'm not sure this is justified in all situations (I don't mind if a doc decides for me if I have acute appendicitis!) - but it's an attitude adopted very early in medical training. A study of medical students by Weaver and Peters (2011) looked at factors contributing to medical students developing sense of professional identity. They found two main elements could be identified : professional inclusivity and social exclusivity. By professional inclusivity, they meant that as students participated in clinical placements and were treated as "members of the team", and social exclusivity, they meant medical students tended to socialise with one another. A commentary by Bleakley in the same journal suggests that _"as medical students are drawn further into associating with those in medical culture, so other associations are denied or lost", "as trainee doctors, medical students become ‘clinical reasoners’ and this, traditionally, identifies them and distinguishes them from others."_ Bleakley says _"Medicine has claimed a degree of autonomy that has progressively provoked its consumers – patients."_ He goes on to say _"When a student in the study … remarks that the medical profession is ‘something to look up to’, one wishes that this student had described it as ‘something to look forward to’. ‘Looking up to’ can so easily progress to ‘looking down on’, where meritocracy hardens into autocracy._" Bleakley writes strongly about the need to challenge medical students' social exclusivity saying _"The excluded ‘other’ (health care colleagues, patients, cultures other than medicine) should be a major focus for inclusion in medical education; otherwise students will continue to progress habits of exclusivity in their work as doctors, indicated by relatively poor communication with patients and colleagues". _ Really, I couldn't say it better myself, so I'll leave the last word to Bleakley:
Belonging to the medical team is an issue of professional identity, whereas belonging to the wider health care team is an issue of interprofessional identity.Applies to all of us, doesn't it? Bleakley, A. (2011). Professing medical identities in the liquid world of teams. Medical Education 45(12): 1167–1173 Gaboury, I., M. Bujold, et al. (2009). "Interprofessional collaboration within Canadian integrative healthcare clinics: Key components." Social Science & Medicine 69(5): 707-715. Moret, L., A. Rochedreux, et al. (2008). "Medical information delivered to patients: Discrepancies concerning roles as perceived by physicians and nurses set against patient satisfaction." Patient Education and Counseling 70(1): 94-101. Weaver R, Peters K, Koch J, & Wilson I (2011). 'Part of the team': professional identity and social exclusivity in medical students. Medical education, 45 (12), 1220-9 PMID: 21999250 Filed under: Chronic pain, Interdisciplinary teams, Pain, Professional topics, Research Tagged: biopsychosocial, Clinical reasoning, Health, healthcare
Chronic pain is abnormal. Living well with chronic pain seems a myth, a bit of an impossibility. After all, chronic pain starts with the kind of pain that most people would expect to go away - acute pain. Acute pain is normal and most of us will experience some painful episode today. Acute pain goes away - either by itself, or because we've done something to remove the stimulus that triggered the cascade of neurological events that eventually reached the brain that produced the experience of pain. Because chronic pain begins just like any other pain, and because acute pain generates our attention and stimulates some sort of problem solving process so we can take appropriate action, it makes sense that we apply the same problem solving strategy to the problem of chronic pain. Eccleston and Crombez (2007) proposed that one of the ways we can view the distress, loss of function and reduced quality of life is through a model of "misdirected" problem solving. Problem solving is often discussed as if the problem exists outside of a context. "Here's the problem, go solve it" fails to establish the frame of reference - why is it a problem? who has the problem? what contributed to the problem? what resources are available to fix the problem? One of the major contributions of psychology in the field of pain, particularly a cognitive behavioural model, is helping people view their problem differently. If a situation is viewed differently, the "problem" may go away, or at least be seen as manageable. BUT, in the case of pain, mostly people start by thinking that pain is something to be cured or fixed, the pain should go away, and life should return to normal. _In the case of chronic pain, when the pain persists, the same problem solving strategies that work so well for acute pain begin to get in the way of living._ Life becomes a merry-go-round of searching for relief (maybe an explanation, diagnosis, medication, surgery, new treatment), hope being raised, then very often being dashed because nothing has changed. Eccleston and Crombez describe this cycle in terms of the function of worry. _"Where such problem solving leads to success, pain and worry abate. However, when the problem solving attempts fail to find a solution, worry is fueled. A ‘perseverance loop’ is established in which the failure of a solution to the problem of pain amplifies worry. In this loop increased worry functions to strengthen motivation to persevere in solving the problem. Problem formulation becomes narrowed and inflexible, whilst greater effort is employed repeating the same solutions. If on repeated attempts a solution is achieved, again pain and worry will stop. "_ Over the past 20 years or so, cognitive behavioural approaches for helping people cope with their ongoing pain have focused on reducing distress and disability by helping people reframe the problem of persistent pain as something that can be managed. This takes the focus off trying to remove the pain, and broadens problem solving so that people begin to look at what else can help them live well. My research is examining how people who do live well with their pain manage to do so. While the people I'm talking with don't say no to new treatments, they don't seem invested in it so that their whole lives are focused on solving the problem of pain. Instead, they seem to view pain as "just another thing" that they deal with while they get on with the real business of living life. Some have found that having chronic pain has enthused them with a new direction in life. Others have a focus on family, or community, or work.
The context of chronic pain matters. It's the way that the problem of chronic pain is framed that situates and generates the range of problem solving options that are considered. If we ask a person "what's important in your life", and see if they're willing to _make room for having pain present_ while they engage in occupations or activities that allow them to live their values, we offer people a chance to live well with their persistent pain.Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model PAIN, 132 (3), 233-236 DOI: 10.1016/j.pain.2007.09.014 Eccleston, C (2011). A normal psychology of chronic pain The Psychologist, 24 (6), 422-425 Related Articles * Gene discovery may soothe chronic pain (futurity.org) * Race and Socioeconomic Background Influences Chronic Pain, Says Study (onehealthyblog.wordpress.com) Filed under: ACT - Acceptance & Commitment Therapy, Chronic pain, Coping Skills, Coping strategies, Occupational therapy, Pain, Physiotherapy, Psychology, Wellness Tagged: Chronic pain, Conditions and Diseases, Health, Pain, pain management
The past three weeks have been a swirl of joyous, passionate neuro-nerdy stuff! And yes, it's absolutely possible to call neuroscience joyous and passionate (just ask David Butler and the NOI crew). WHAT HAVE I LEARNED? Let's begin with the obvious: PAIN IS AN OUTPUT OF THE BRAIN. What does that mean? It means that unless the parts of the brain involved in deciding what we need to know about decide we need to know about a threat - we won't experience that unpleasant sensory and emotional experience we call pain. Pain is a complete biopsychosocial phenomenon. Our experience of OUCH! or YEEEOWW! is absolutely determined by a judgement call made by our brain, and the basis for that judgement call is on the degree of threat we are facing. If we're purposively allowing someone to etch a design into our body, we'll experience a sensation, but most people who have a tattoo say that it's not painful. It might be different if we were being held down against our will, and someone is etching an abusive word onto our flesh - the context would be different and we'd view it as a real threat to who we are.
Neuroscience, and especially studies using fMRI, has been able to unravel some of that fringe stuff that lies between "psychosocial" and "biological". It's a research paradigm that has much to offer because it's uncovering how the structures in our brains respond to both internal and external events. Yes, thinking _can_ make something happen.There are limitations, though, and it was refreshing to hear this often throughout the two conferences I've attended. An MRI is a big, noisy machine. People have to lie down and be still during imaging. There is not a lot of room in the machine. Images only show how blood flows to various regions of the brain. It's not available to many people. They're expensive! The results require interpretation (but what testing doesn't require interpretation?!). _What this means to me is to interpret findings somewhat cautiously._ These studies don't examine the situations and contexts of the people I work with. Many of the studies use acute pain research protocols - things like thermal stimulation, cold pressor, capsaicin. The people being studied are often young, healthy volunteers - often undergraduate students. The experiments are short-lived, and they have an end in sight for the volunteers. People can't move about, or do the activities over time. The context is different from everyday living. At the same time, the experiments begin to uncover information about how our brains function - and maybe we can take the findings and begin to study correlates in the real world. I think this is much of what the Body in Mind group do. One of the problems, and criticisms, of translating neuroscientific research into the clinic (and probably one of the reasons occupational therapy suffers from a low profile in health) is that the real world is a messy, joyous, passionate, grim, untidy place. People are made up of their biology but modified by experience and context and opportunity and restriction. People bring this context into their treatment environment. And the treatment environment is also a context, and so are we as clinicians. It's unsurprising that some of what can be demonstrated in neat, controlled, rigorous clinical trials just can't be replicated with the people we see, in the world we live in, and in the activities and communities people are in.
This is where joining the dots between scientific methodologies is needed. Bringing together the artificial research methodologies used in fMRI and randomised controlled trials (double-blind, placebo) where standardisation and unformity are underlying assumptions - and the qualitative, individual, quirky and idiosyncratic methodologies that assume that my reality is mine alone, and that it's impossible to ever really experience it the way I do.Both methodologies have application. Both contribute to our understanding of how people and our world work. And somehow, our theory-building (which is simply a way to provide a metaphor so we can share understanding) needs to pull the multiple strands of knowledge together so that I, as a clinician, can work out how to help my fellow human. WHAT AM I SAYING HERE? Nerdy, sciency stuff is probably what I, as a clinician and researcher and teacher, need to immerse myself in. My passion is to help clinicians who maybe don't enjoy this stuff, maybe don't have the time to learn this stuff, maybe don't think this stuff has direct relevance to what they do, gain access to the implications of research. Not a theory of everything (or this)- but a practical translation of nerdy, sciency stuff into what a clinician might do. There. I think I've summarised my current reflections on all that neuroscientific goodness that has nourished my neurones. I'd love your comments! And don't forget, you can subscribe, join me on Facebook, or introduce yourself. Filed under: Chronic pain, Occupational therapy, Pain, Physiotherapy, Psychology, Research Tagged: biopsychosocial, healthcare, neuroscience, pain management
I love getting presents, and I love books, so what could be better than getting a book to review as a present! GRADED MOTOR IMAGERY (GMI) HAS BECOME INCREDIBLY POPULAR IN PAIN MANAGEMENT, especially for people with unilateral pain. It's a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence. For those who don't know - level B1 evidence means there are several RCT's, and at least one meta-analysis showing support for this approach. Back to the book. Like all the NOI books it's an unusual size, has groovy graphics and an easy-to-use layout. It's a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes. The illustrations and photographs are clear and provide excellent guidance for clinicians. Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler's favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment. Each chapter can stand alone, and it's not necessary to read from beginning to end - but of course, it does help! This book isn't for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain - and the translation into the "real world" - are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.
Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment. GMI has best application in people with unilateral pain such as CRPS and phantom limb pain - although it has been extended to other pains. These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.Back to the book again! I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI. His writing is clear and provides an excellent scientific basis for the approach. He doesn't extend his writing into psychological aspects of pain beyond the concepts of what he calls "neurotags", or "interconnected neurones … that produce an output". Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action). I have learned these associations as just that - associations between various aspects of learning and anticipation, and have called them the neuromatrix - but NOI have used the term neurotag, and I guess it's as good a name as any. The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written. While it's possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer's neuroscience, and Butler's metaphors, it becomes far more flexible. I like this. It is a chapter that I think many clinicians will turn to regularly - but as is emphasised throughout this handbook, patients/participants should read this stuff too.
WORTH GETTING? YES, I THINK SO.My caution lies in over-interpreting the application of GMI beyond the evidence-base. If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her. Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain. Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world. After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport - where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment. Where to get it? Go here - and let 'em know I sent you. Filed under: Book reviews, site reviews, Chronic pain, Clinical reasoning, Coping strategies, Motivation, Pain Tagged: Graded motor imagery, Health, laterality training, medicine, mirrorbox, science, self management skills
This week I've been at the NOI Conference 2012 - a real blast! A week of neuroscience-backed biopsychosocial practice, and nerdy passions. My brain is nourished, in fact, it's replete. And now to digest. Why the headline?
Well, throughout the conference, over and over again I heard about physiotherapy and psychology - and nary a murmer about occupational therapy's contribution (from the profession's inception) to the biopsychosocial model of practice. It's like the profession simply does not exist.One very brave young occupational therapist voiced her concern that there is a disconnect between the occupational therapy profession and the consciousness of other clinicians. IN A PROFESSION THAT HAS ALWAYS WORKED FROM A BIOPSYCHOSOCIAL MODEL, HOW IS IT THAT THERE IS SO LITTLE MENTION OF IT IN A CONFERENCE WHERE THIS IS AT THE HEART OF AN ENORMOUS CHANGE IN PRACTICE? Lorimer Moseley's response was to say that occupational therapists must research more and publish in non-occupational therapy journals. I have to agree. I know there will be a chorus of "yes but…" from people, and I recognise the challenges. As a profession we struggle with our epistemological and ontological orientation because we argue that our interventions are so tailored to individual needs that we can't measure their outcomes. That every individual has unique needs so we can't measure outcomes empirically. And after all, individuals say they like and need what we offer. We can't do large-scale research because we don't get research funding, or we're clinicians not researchers, or if we do a good research study we can't publish because major journals won't accept our publications - all yes but's! Before I get torn limb from limb, I haven't published - yet. And as a clinician I know how difficult it can be to pull a research proposal together, particularly without good support from health administrators. I know this - and yet, Lorimer has a very good point. Occupational therapists need to become far more visible but the way to do this is not by claiming "oh but we do X" - or Y or Z. The profession simply must begin collaborating with people who have leverage - like Lorimer Moseley and his collaborators. The profession must begin to critically appraise what it does, how it does it, and then begin to do therapy better. The profession needs to train both clinicians and researchers and clinician-researchers. A scientist-practitioner model is not out of the question - in fact, I think it must happen or the little respect we are afforded will be lost, and the profession will be absorbed into other disciplines. What are the interesting hypotheses that need to be explored in occupational therapy practice? How can we contribute to the greater awareness of the "person-in-context" that other professions have right now? How can we answer our own questions about whether we are effective, or simply "nice people" who help others through nonspecific effects rather than specific occupational therapy? These, and other curious questions, must be explored and publicised. As Dr Fiona Wood said at NOI 2012 - Blinkers off, game on! For more info on NOI 2012 - go here for 80 pages of transcript via Twitter. A powerful medium. Filed under: Chronic pain, Occupational therapy, Pain, Physiotherapy, Professional topics, Psychology, Research Tagged: Lorimer Moseley, NOI 2012
Intuitively, most of us know that when we're actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst - or pain. In the very early years of occupational therapy, this "distracting" factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars. Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation's sake was often left behind. More recently we've begun to learn more about how occupation might be a good thing. First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing. Then we found that through positive psychology studies that the state of "flow" popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance. Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management. This is interesting to me for several reasons - firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004). Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual. Let me explain: usually it's recommended to maintain a consistent level of activity. Sometimes this is called activity pacing. Yet there are times when it's appropriate to suspend the use of pacing - when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours). We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam. Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity. Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues. Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus. Two different colours were used, one of which had been associated with a painful stimulus. Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing. To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud. If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made. This was the "nonpain task goal", or activity/occupation. The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted. In other words, they were not as quick to respond to things that they had previously viewed as a potential threat. This is a really interesting finding - while it's a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat. Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used. Their findings were that "engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. " It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management. Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025 Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227. Bradshaw, D.,Chapman, CR., Jacobson, RC., and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain. Filed under: Coping strategies, Motivation, Pain, Pain conditions, Research Tagged: coping strategies, goals, Occupational therapy, Pain, Psychology, Research, treatment