first and most importantly, the person with pain, then the funder, the medical practitioner, and the employer in no particular order. It was a computerised system that stopped the keyboard for five minutes with no over-ride. “59 drugs identified as analgesics were introduced from 1960 to 2009 and remain in use … only one, sumatriptan, was sufficiently effective to motivate the introduction of many similar drugs acting at the same target (triptans) … Very intensive research efforts directed at diverse molecular targets related to pain mechanisms produced thousands of publications, but those efforts have not yet yielded new analgesics with sufficient effectiveness … Morphine and aspirin, introduced for the treatment of pain more than a century ago, continue to dominate biomedical publications despite their limited effectiveness in many areas (e.g., neuropathic pain), and multiple serious adverse effects. This study found that pacing was linked to better psychological functioning but more pain and disability, but couldn’t comment on the direction of this relationship. The Aylward and Waddell piece I linked to was being used by Lord Freud in the House of Lords to justify the government’s welfare reforms – if Gordon Waddell is motivated by a sincere desire to help improve the lives of people who have often been sidelined, then he seems to have spectacularly misfired. Some people may not find these approaches helpful – but to dismiss them without trying them in good faith seems short-sighted. Spoons! The biopsychosocial model/framework provides some explanations as to why people are not “following the rules”, something that a biomedical model does not do.”. There were substantial changes in the way results were presented compared to the trials’ published protocol: http://www.biomedcentral.com/1471-2377/7/6 There have been a number of Freedom of Information requests for the results for outcome measures laid out in the trial’s protocol, and these have been denied for a range of contradictory reasons. In this non-blinded RCT four arms were compared, i) Specialist Medical Care only (a minimal intervention that involved diagnosis and some basic advice), ii) SMC + CBT, iii) SMC + GET, iv) SMC + Adaptive Pacing Therapy (a form of pacing that involved having patients keep activity diaries and advising them to do 70% of what they felt able to do). Can you be surprised when this approach is used to make life worse for sick and disabled people? Maybe it’s all manner of complicated things that are out of their control? Record your body's response and take an average of the activity amount. I’m afraid that I don’t really follow your summary of my concern about the way in which an increasing medicalisation of ‘pacing’ could be harmful. – I have chronic pain The BPS model is used as it is used, and I do not think that you have any more claim to it than Lord Freud. I think that I tend to be rather more critical, but I’d recently read something from a campaigner about the distortion of the BPS model that’s available here: https://dl.dropboxusercontent.com/u/32109159/Illness%20as%20Deviance.pdf. Patients who do not find an intervention that helps them, do not want to partake in the available interventions, or would rather spend the available resource pursuing an interest like painting or photography should not be blamed for this. It’s not – it’s the politicians and policy-makers who are making this situation, not the model. “Do you think that people are “medicalising lives” when…”. The sick role and our concepts of illness are social constructs. Bronnie, it will be interesting to see whether Dame Carole’s recommendation that the “sick note” be replaced by the “fit note” has been taken up in Australia and whether more people are returning to work as a result of it. Bronnie, thank you for an excellent summary of the current literature on pacing in relation to coping with being in pain. ( Log Out / – and the people we support – most often use. Brain, Behav Immun 2012; 26: 1202-1210. #10kcuts pic.twitter.com/DrqAA0OSFr. From this study, the authors suggested that avoidance activity may resemble healthy coping (and from this I deduced that pacing is considered “healthy”). What we have seen in the UK would seem to indicate that this is not the case. Self-management – the process of using pacing involves independently integrating the practice once the skill has been developed. I am saying that I don’t have to agree with people, and that maybe I can give an indication of some of the logical consequences that can occur if particular choices are made (because I’ve seen it again and again, and so have other researchers – who have reported on the experience of 1000’s of people with chronic pain who have given their time to contribute to research). While that’s not to say that no people will be helped by a biopsychosocial approach, the serious harm and quackery that has also occurred cannot be ignored. walk uphill• After some time you might consider walking on less stable surfaces e.g. [I am less familiar with this work on employment and health, so it’s possible my memory is confused on some of the details here. Now this is from people who have pain, not my words, but their words. @adiemusfree: There are still a couple of things I want to respond to here, and that even skipping over a lot, I’m afraid that this is another long reply: re non-BPS problems with the way in which pain has been/is treated: To me, these problems are a good reminder of the problems within our health systems, and the need to be as cautious as possible with claims of expertise and claims about our ability to improve the health of others. Until there’s some really good evidence that allows us to confidently say, I think it’s best to leave people to live their own lives as they see fit, without being psychosocially managed by the state. I think that they should have access to a safe place to live, and a liveable income. The interesting thing is that people I’ve worked with WANT to return to work. The data seems to support this, and it’s been my experience with people who have chronic pain that it is also highly important to them, but they lack confidence that they can manage work. I think that we can see how it is that ‘recovery’ can now be expected. Expanding healthcare to the routine medicalisation of the psychosocial aspects of people’s lives seems entirely the wrong response to this. We all have our own views about the value and purpose of life, and it shouldn’t be surprising that implementing a system in which health workers take it upon themselves to tell others that they should be able to do work that causes them abnormal pain (in order to be empowering of course) leads to people feeling abused. While simply the nature of interventions might be expected to lead to some response bias for those interventions encouraging patients to feel they had greater control over symptoms, in addition those receiving CBT and GET were specifically told that these treatments have been shown to improve the health of patients – homeopathy has been found to be effective under these sorts of conditions. I don’t speak for people without their permission, but it has often happened, that I end up supporting a decision to withdraw from a RTW programme because the person isn’t able to sustain the work. Murphy, S. L., Smith, D. M., & Alexander, N. B. At the trial’s press conference and in the trial’s information leaflet patients with a score of just 60 were described as “back to normal”. It disturbs me to hear that UK health policy makers and politicians have further distorted what was originally intended by Engel to provide a useful framework for discussion or aide memoire between patient and clinician. Of course, with a more functional hat on, I’d like to see “exercise” considered equivalent to “activity” or “occupational engagement” because this invokes lots of those wonderful contextual elements including motivation, emotion, cognition and so on – and it’s more directly relevant to daily life and reducing disability. Also, the biomedical model does not assert that our medical knowledge allows doctors to judge the totality of an individual’s personal capacity without regard for their own history, social resources, etc. They used “anything that works” and picked and chose from all the various resources available. At the time I was delighted to see that finally the medical/impairment-based stranglehold on health and disability was being challenged, but I completely agree that omitting people with health problems is a grave error. I think there’s a culture of disability just as much as there is a culture of medicalisation. “Overall, present treatment options result in modest improvements at best, & part of chronic pain management should include dialogue with the patient about realistic expectations of pain relief, & bring focus to improvement of function … Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients … do not always occur with concurrent improvement in function … These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain & to have a major effect on physical & emotional function in most patients with chronic pain. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0040808, Now to look at the questionnaires used as the trial’s primary outcome measures.
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