Hannah Kennedy is a Senior Occupational Therapist and Research Officer at the Interdisciplinary Persistent Pain Centre, Gold Coast Health. Hannah’s focus on pain education and empowering people with pain to develop useful self-management strategies lead to her researching the use of the Protectometer tool through a Masters of Medical Research at Griffith University, under the supervision of Prof Michel Coppieters and Dr Daniel Harvie. Her team is currently investigating the impact of an immersive Virtual Reality platform on pain education and rehabilitation. Please enjoy Hannah’s contribution to noijam. Thanks, Hannah!
I was sitting in a room among young people, mostly aged 13, listening to them share their DIMs and SIMs during a pain management program:
| *DIMs | **SIMs |
| ‘I’m never going to get better’
‘No one understands’ ‘I don’t want to leave the home’ ‘Going for a long drive without stopping’ ‘Feeling lonely’ |
‘Play games with my family’
‘I can do this’ ‘My hobbies are fun and I will keep at it’ ‘Pacing’ ‘It’s okay to be a glow stick, sometimes you have to break before you shine’ |
Two things stood out: 1) how quickly and effortlessly the young people could list a wide range of factors involved in their pain experiences, and 2) how similar these sounded to many of the DIMs and SIMs expressed by adults with chronic pain in their pain management programs.
Now before we get too far, a few definitions. *DIMs and **SIMs come from the work of Professor Lorimer Moseley and A/Prof David Butler, as part of The Explain Pain Handbook: The Protectometer1. DIMs represent ‘Danger In Me’, and SIMs stand for ‘Safety In Me’, with the notion that pain is an experience that occurs when credible evidence that the body is in danger, outweighs credible evidence that the body is safe1. The aim of the Protectometer is to explore personal DIMs and SIMs, modify and/or remove DIMs as much as possible, and gather and/or increase attention towards SIMs, with the goal to temper the pain system towards a less sensitive state1. For one of my favourite posts on how this tool is used in daily life, see here https://painchats.com/dim-sim-therapy-for-pain/
Coming back to those earlier reflections, we realised that while the Protectometer was being used in a variety of settings and with a wide demographic, there had been no research about the types of DIMs and SIMs that were elicited. Were there differences between young people and adults? How do they align with a biopsychosocial approach?
So we (myself, Daniel Harvie and Michel Coppieters) undertook a retrospective qualitative analysis of 1,215 written DIMs and SIMs, collected from two community-based pain management programs (a young person service and an adult service) completed between 2019-2021. The results, published last month in the British Journal of Pain, offer useful insights for clinicians working in pain rehabilitation.
Firstly, we found that DIMs and SIMs could be grouped into four main themes: (1) Engaging with the environment, (2) In my body, (3) My emotional health, and (4) Activities and behaviours2. These themes reflect the biopsychosocial model of pain3,4 and describe a wide range of contributing factors to a person’s pain experience. These four broad areas could be used as clinician prompts when eliciting those tricky-to-find DIMs or SIMs in clinical practice.
DIMs, we discovered, were different between young people and adults, with the majority of young people’s DIMs in the psychological (44%) and social (43%) domains, compared to a more even spread across all domains for adults.
A surprising find was that the social domain had the highest number of SIMs, for both young people (47%) and adults (49%). This result draws attention to the importance of the social domain, comprising of the physical environment (places), social environment (people), and meaningful occupations (activities) for people with pain. Clinicians can be encouraged to invest time in social-based interventions as part of pain management therapies for both adults and young people.
Kennedy, H., Harvie, D. S., & Coppieters, M. W. (2024). Do threats and reassurances reside in the biological, psychological or social domain? A qualitative study in adults and young people with chronic pain. British Journal of Pain, 20494637241263291.
While the four key themes provide an overarching view of the types of DIMs and SIMs, there were multiple categories within each theme. Clinicians could also use these categories to dig deeper when working with a person in pain to explore their DIMs and SIMs. DIMs were frequently found in categories of activity limitations and triggers, negative sensory experiences, negative social environments, withdrawal and negative healthcare environments. SIMs were most commonly found in active self-management skills, positive social environments, enjoyable activities and positive self-talk and beliefs. Exploring these categories for any potential cues of danger or safety can bolster the use of the Protectometer in practice. Bonus points if you can ‘bin a DIM’ or ‘switch a DIM to a SIM’ at the end of treatment!
A point of discussion in this paper was a number of DIMs and SIMs which described multiple domains of the biopsychosocial model. Of course, all human experiences (including pain) occur in a dynamic interaction between body, mind and environment. The ‘enactive model of pain’ provides a useful reference point for this complexity, and for a deeper dive into this area, see 5,6.
For now, take inspiration from these SIMs, from people of all ages with pain, to explore a wide range of person-centred ways to change the balance of your client’s Protectometer…
- Sitting on the beach late afternoon then watching the sun set
- I will go and play with my friends
- A little bit is better than nothing
- Taking time out for painting and sketching
- I am satisfied with the progress I am making
- Take my dog for a walk
- Engaging in life and enjoying it more
- I am going to get better!!!
– Hannah Kennedy
Senior Occupational Therapist and Research Officer
Interdisciplinary Persistent Pain Centre, Gold Coast Health
Find me on LinkedIn
References
- Moseley GL and Butler DS. The Explain Pain Handbook: Protectometer. South Australia: Noigroup Publications, 2015.
- Kennedy H, Harvie DS, Coppieters MW. Do threats and reassurances reside in the biological, psychological or social domain? A qualitative study in adults and young people with chronic pain. British Journal of Pain. 2024;0(0). Link here
- Turk DC and Monarch ES. Biopsychosocial perspective on chronic pain. In: Turk DC and Gatchel RJ (eds) Psychological approaches to pain management: A practitioner’s handbook, Third Edition. Guilford Press, 2018, pp.3-24. Link here
- Palermo TM. Cognitive-Behavioral Therapy for Chronic Pain in Children and Adolescents. Oxford University Press, 2015. Link here
- Stilwell P and Harman K. An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences 2019; 18: 637-665. DOI: 1007/s11097-019-09624-7
- Coninx S and Stilwell P. Pain and the field of affordances: an enactive approach to acute and chronic pain. Synthese 2021; 199: 7835-7863. Link here
Further relevant reading
Noijam: Spotting the ‘psycho’ and ‘social’ factors – but what do I do now?
Noijam: Introducing the Explain Pain Handbook Protectometer
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