So we’ve discussed pain science and some of the things I’ve learnt working with those struggling through it (If you’ve not read these previous blogs, head back to the ‘blog’ section and read Part 1 and 2). Those pieces are great to get your ‘synapses firing’, but theory and application and two very different beasts. You can’t apply theory without understanding it, but you can understand theory and still stuff up the application. I thought I better put my money where my mouth is, and show how I apply the skills I’ve discussed to a clinical case.
We’ll call this patient Charles. I’m going to let him speak for himself, and chime in with footnotes explaining my thought process as the story unfolds. Kind of like a subjective interview. I am trying to show you where my mind is taking me. I have left Charles’ story exactly as he wrote it, because the language he chooses to use shows his personal understanding, beliefs and perspectives. This is the gold I think we need to start appreciating as clinicians. This allows us to ‘walk in their shoes’ and move closer to true empathy for their experience. Then, I find anyway, I can be much more effective.
DISCLAIMER
This piece focuses on the pain science aspects of Charles’ story, as well as the pain science aspects of management. It should still be clear throughout that Charles’ pathobiology and physical examination played a big part in the assessment and management. Please make sure you don't forget the ‘bio’ in ‘biopsychosocial,’ and don’t forget to use the core physiotherapy skills you learnt and are good at.
A recent systematic review by Wilson et al (2018) (link at bottom) showed that incorporating a psychological intervention within the physiotherapy management improved results in function for this population (not pain… function). An important thing to note from the findings, the more effective interventions involved specifically trained physiotherapists, or clinical psychologists. This stuff is good to be aware of and understand. However, remember you skill set and level of training, and don’t be afraid to refer on when needed, but also don’t stop being their physio when you do refer on!
Some Background knowledge about Charles for context:
Charles is a former sub-elite level Australian Rules Footballer who also, at the time of this episode, had recently transitioned from a more laid back job to working full time in finance. Therefore, Charles does fairly hefty hours at his desk, followed by 2-3 hour training sessions 2-3 x weekly. He’s a busy man.
He’s an intellectual and a thinker, also happens to be a close friend. I know, ‘don’t treat your friends and family right?’ but he asked for help, and I wanted to help, because things weren’t working. I’ll let him take it from here. I’ll see you throughout with some clinical commentary.
Take it away Charles…
I first started experiencing lower back pain in my early 20’s, mostly as a result of long car trips. I would find I would need to stand or walk around regularly when on long bus trips or on flights. However, these long trips were an uncommon occurrence, so I didn’t think too much into it. I could continue to run and jump, and do all the physical activities I always needed to do without any issues.
This gives a nice perspective of a healthy mindset to postural back pain from unaccustomed ‘out of the ordinary’ load. These are ‘healthy’ beliefs we should reinforce. Avoid trying to solve problems that aren’t problems, especially when people say express it’s not an issue for them.
At age 23, I started to experience pain during activities where I had to stand for long periods. There was no incident I can remember that brought this on, it just appeared. It was the same feeling as prior pain, however just starting to become more prevalent. This became an issue in my work, as once a month I was required to stand and present for hours at a time. Again, I didn’t think too much into this, as I sat mostly at work and could take breaks whenever I needed to. This didn’t impact my football either, as soon as I warmed up at training the pain would disappear, and I could continue competing without any back pain or stiffness.
Again, this is not what I would call abnormal or even ‘clinically significant,’ if this is not worrying someone. Thus, these people often won’t even present. Note how Charles justifies his lack of concern by explaining it is not impacting on his quality of life (see underlined). This is starting to show us what he values and how he prioritises the pain experience. Note this for later.
The trigger for my low back pain was actually an unrelated back injury. I had an issue with my upper back which came from a shock football incident in 2017. Unfortunately, I don’t remember an incident, I really tried to. I remember my upper back pulled up sore following a game. I don’t remember a specific incident from the game (Saturday), but I trained with some discomfort the following Tuesday, and then woke up the next day and could barely get out of bed…… Strange, I thought ‘I must have been okay because I remember training through no worries and drove home feeling okay’……It seemed like nothing at the time, but by the following training session two days later (Thursday), I could barely walk!
There is a notable shift in the narrative here, from ‘I didn’t think much of it’ to ‘I could barely walk’. Even the use of the word ‘shock’ illustrates an emotive aspect of the story. Latent pain (pain that occurs after or the day following an activity or incident) is a common cause of concern for people. Often, this is because there is a disconnect between ‘cause’ and ‘effect’ in the individual’s mind experiencing pain.
As humans we fear things more when we don’t understand them. Consider falling over and rolling your ankle, it hurts, but you understand why. Compare that to sitting and watching television, and then experiencing increasingly intense pain in your knee. The latter would induce more confusion and anxiety due to its lack of ‘A=B’ explicit series of events.
At this point in Charles’ story, I would note to myself (often jot down on a piece of paper) to consider explaining the process of the inflammation and how it can cause pain following exercise, and is infamous for causing pain first thing in the morning. This could add understanding to this pain experience, already reassuring him this is more normal than what he is currently perceiving as ‘strange’. I try to avoid interrupting clients when they’re telling their story. Practically, it can throw them off their point in the story, but it also is likely something they’ve experienced before and causes frustration. They want to be heard and understood, let them speak.
I was told rest was initially key, to wait until the pain subsided before getting back into running. I was given an anti-inflammatory steroid to calm down the pain quickly, so I could begin my core strengthening regime which consisted of reformer-style clinical pilates. This did feel like it helped in the early stages.
Clarifying ‘rest’ as ‘relative rest’ is key here. We know the deleterious effects of complete rest for any injury, especially for someone at this level of sport where maintaining a level of ‘chronic loading’ is protective to secondary injury. ‘Training around the injury’ should be implemented ASAP.
Exercise improves pain management systemically, but also challenges the ‘I’m broken’ perception that may begin to emerge in the psyche of the injured athlete. We need to respect the significant psychosocial effect that injury can have on one’s self-perceived identity and worth, especially in team sports.
Charles reports improvements with the pilates. Always note down what the individual feels worked for them in the past. This can give you an entry into ‘buy in,’ with the individual expecting a positive effect. This is powerful for outcome (Check out an article about this below).
The issue was, this anti-inflammatory drug was banned for competition use, and it needed to be out of my system before I could return to competitive play. I don’t distinctly remember the explanation for my pain or management plan. At a much later date, I found out they were fishing. They sent me to a specialist who I thought was a back specialist, but I found out later his profession was early arthritis specialty or something. He had a confusing medical title I didn’t understand. He told me there was no risk of arthritis, he told me ‘let the inflammation settle by not using the back as much as possible and take these steroids.’
Again, on reflection, this management probably wasn’t properly looked into, because the ‘12 week rehab plan’ was due to the banned substance taking 12 weeks to clear my system, not because of the rehab plan. All of this information which wasn’t known about until I took the initial tablet. Frustrating.
IMPORTANT PARAGRAPH (hence all the underlining).
This paragraph shows a breakdown in communication, understanding and trust between the medical team and the athlete. Again, let’s remember, this is one side of the story, so keep in mind explaining and understanding are two different things (as I’ve covered in the earlier blogs). There may have been a nice explanation, but this clearly wasn’t understood by Charles.
This is where we should ask ‘can you tell me your understanding of the plan we just went through, and do you have anything you need clarifying?’ This is a critical point where, as health care professionals, we can lose the athlete or patient, and things can quickly flip from ‘being on the same team’ to ‘athlete v medical team’ in the blame game of why things aren’t progressing.
As a result of this issue, I had a twelve-week timeframe to return regardless. It was decided that I would have a slow precautionary progression back into training. I was ‘off-legs’ for around 6 weeks. In this time, I did mostly swimming, massage, needling and seated boxing. I then eased into weights, low-gravity running and Pilates before returning to straight line running by week 10.
‘It was decided’ is language that can indicate a few things. It could mean Charles did not feel like an active member of this rehab design team, and/or it could show an external locus of control. One or both show a suboptimal position to achieve positive clinical outcomes (this is a key point raised in Chester’s paper. Link below)
Now again, I am not looking to poke holes in rehab plans that I had no involvement in. I don’t know all of the factors at play. However, this is quite a long time to go without ground reaction forces of any kind going through a sensitive spine and sensitized pain system. This would lead to physical deconditioning, possibly increased sensitization and could ‘enable’ some fear avoidance beliefs. Without a significant structural diagnosis that needs to be unloaded for healing, this is not something I would advise.
By this stage, my upper back pain had all but gone, however my lower back pain was worse than ever. I noticed my lower back was getting sore around the six week mark of the 12 week mark. I didn’t get back on legs training until then, but I also started noticing it more standing on public transport around this time.
The lower back pain is interesting. Was the running, jumping and kicking of football training protective for Charles’ lumbar spine? Did the ‘off legs’ training lead to more sitting, that created more incidences of the ‘long drive’ type situations that already caused Charles pain? Who knows when looking from afar.
Charles is acknowledging that this pain is affecting his everyday life in this last statement. This illustrates this issue has ‘escalated’ in his psyche.
I was sent to get an X-Ray and had some blood samples (ordered by the specialist), however nothing was found, and the symptoms hadn’t changed. I had to continue with my running and strength regime with the proviso to stop when pain became too much. My straight-line running sessions would start okay, but gradually the pain would get more intense, and I would be told to stop for the night when it feels bad. When I came off the track, I was asked to describe the symptoms. From what I understand, they were still trying to figure out what was going on. They told me my running would progress, but it didn’t progress.
The continued investigations of these kinds of conditions can feed into the feeling of helplessness. This is especially true when the athlete feels they are ‘fishing.’ It can infer that the medical team is just ‘throwing the kitchen sink at it’. Whilst this is done in the best efforts to find the driver of the pain, I believe there must be a strong clinical justification for each investigation, and this should be explained prior to the investigation, and results explained after. This gives the athlete insight into the clinical reasoning process, and shows them there is a ‘process,’ not just a ‘see what sticks’ approach. For the clinician this also forces an explanation to make sense. More than once, I have changed my mind on decision after talking it through with a patient.
In regards to the running, it appears the team may have decided to go down a ‘pacing’ or ‘graded exposure’ approach. This is a nice decision when there is no specific structural issue, and a degree of sensitisation is identified. However, using pain as the measuring factor, especially high levels of pain, you can end up sensitising the individual to that activity more. I have found predetermined, non-pain based progressions (e.g. distance or duration) work better. Also stopping if the pain comes on at a less severe rating (4-5/10) is often better to avoid further association of that activity and threat.
I was getting through my longer running sessions, but the pain was there always, slowly building up until I couldn’t take it anymore. The intensity of running was fine, it was more the duration. I could run slow or fast but the longer the sessions got, the less I could cope. No explanation was really given, I was just told to put my hand up when I felt pain and the session was done, not to run through it. I was going faster, but the pain was not going away.
This phrasing is consistent with the concept of ‘temporal summation.’ This is the neurophysiological concept that demonstrates an increase perception of pain to repetitive or sustained painful stimuli. Basically, the painful stimuli of running will become more painful the longer it is present. This is considered by some to be a hallmark sign of central sensitisation.
Note his use of the term ‘cope.’ This is different to how painful something is. Checking to see if an individual is ‘coping’ will provide a more broad stroke illustration of their internal (athlete perceived) load. Not just physically, but overall psychosocial load. This is good to monitor, either formally or by a casual chat to the athlete. When someone struggles to cope, they stress, when someone is stressed, their pain system further sensitises.
My final progression was changing direction and ground balls. This was my last week of a 12-week rehab before I would get back to playing. When I commenced the change of direction running, I was getting through it, but experiencing sharp disabling pains whilst doing it. I didn’t report these pains because I could see the light at the end of the tunnel with planned return to play coming up. I was close to playing so I just wanted to get through the session.
Charles is eliciting behaviours here of a ‘no pain no gain’ approach. This often leads to a ‘boom bust’ cycle. Where the athlete pushes themselves so hard to get through something, that they sensitize an area so much they can’t recover to perform a subsequent rehab or training session. This can be termed a ‘flare up’. This ultimately leads to them ‘spinning their wheels’ and not progressing, or even going backwards.
Also, in the fine words of Mike Stewart ‘those that fire together, wire together.’ Charles is repeatedly associating running, and change of direction with a pain stimulus in his brain. Now Charles isn’t Pavlov’s dog, but association is occurring. This leads to a lowered firing threshold of nociceptors, as well as a higher level of perceived threat by the frontal cortex, leading to the simple neurophysiologically conditioned equation… running + change of direction = OUCH!
Undeterred, I progressed to the ground ball drill, but physically couldn’t do it. The pain was that intense every time I stood up from a bent over position! I left the track mid-session and never returned. I took the next week off to sort my thoughts out about returning to play. Initially, my thinking was clouded by my rage and frustration with not getting better. Having had many prior body breakdowns, I started to question if it was worth it. After some thought, and the week went on, my mind was clear, and I knew I needed to retire. I weighed up the time and effort spent on physical recovery with no light at the end of the tunnel vs spending that time studying or working on my career where I could clearly see long term benefits.
‘physically not able to do it’ – If you ignore a painful stimulus (your bodies warning system) it will turn up the volume until you do what you’re told, and stop.
Charles illustrates the affective or emotional side of the pain experience. It is a personal subjective experience that only you, the person in pain, fully understand. When it is not improving, you can feel isolated and helpless. This psychological stress has a further sensitising effect on the individual. It is important to monitor, identify and intervene on these behaviours, actions and unhelpful mindsets, as these make the recovery process so much more challenging.
Charles also mentions a change in priorities and life focuses that could be as a result of the pain, or a life priorities shift coincidently happening concurrently. If someone is not seeing ‘return on investment’ (to put it in Charles’ terms), then why would they keep investing? Especially when they have other more fruitful ventures going on. Its commons sense really.
Important point for clinicians. Don’t mistake this shift in priorities as ‘giving up’ or something you need to pep talk them into changing. You can explore the motivations and the decision, but respect the decision if it is what they want; it’s their pain and their life.
In retirement, I spent more time in the office, more time at my desk studying… and more time at the pub. I decided I needed to relieve my body of the physical stress of elite level football training (no more high intensity 2 hour running sessions which normal people never do). I thought this was the answer, and I would get better. This did not turn out to be a successful strategy. It only got worse.
Lots of flexion habits that were already uncomfortable prior to this episode being described by here (see paragraph one).
Barstool Back… I know I’ve had that a few times, and I don’t even have back pain.
More ‘rest’ – a strategy that previously didn’t work, now it’s being done within in a context of a less incidental activity and unhealthy lifestyle choices. You can see why that outcome came along.
Walking was painful, standing on the train was painful, sitting at my desk was painful. After a full day of this I needed to go home and lay on the couch, as that was the only time I wasn’t in pain. This was a downward spiral, and I knew I needed help.
Now we are back to those activities of daily life Charles described at the start, except now they hurt. This understandably raises this ‘back pain issue’ up the list of priorities, and possibly inducing some anxiety or catastrophisation.
We fear the worst as humans, it’s not uncommon for those in this situation to be thinking ‘I have to take the tram to work every day for the rest of my working life, is it going to be this painful forever?’ We need to explore these thought processes and try to challenge these misconceptions and unhelpful beliefs.
Seeking out the opinion of professionals was tough because this was the first time I hadn’t had a club medical team to turn to in over 10 years. There are so many options to choose from that claim they can assist with low back pain. I consulted with Osteos, Physios and Chiros, but nothing appeared to lead to noticeable improvement. I don’t remember any real diagnosis being given, just continued to get meds or massage….and needling……I was needled for 45 mins twice, cost 80 bucks per session and literally no better. Waste of time.
Charles outlines a big reduction in his normal support network (teammates & club medical staff) for these issues. On top of this, he has to face the confusion many face as a healthcare consumer. We need to fix this issue as an ‘allied health/musculoskeletal therapy’ industry. We are all going to end up looking silly collectively when the public healthcare system and private health insurance providers leave us out in the cold because we haven’t shown any worth.
I’ve discussed this earlier in the pain blog series. I have no issue with passive/manual treatments being used in this context. They need to be an adjunct to exercise and education, and framed in a truthful and meaningful way.
I got an MRI scan because I wanted one (and Dave referred me 😉) and received some advice from trusted physiotherapists I had worked with in the past Dave Fahey and Mick Ranger.
Now before the imaging haters get into me… just listen. I referred Charles for an MRI for three reasons.
To build some trust and collaboration. He was getting that MRI, with or without me. To get some buy in and allow him to be at the centre of decision making I thought it was important.
It was learning opportunity for Charles. No matter the results that came from the scan. It would force a conversation that I was confident I could facilitate an improved understanding of his body, himself and his pain.
I knew Charles was an analytical man, a cause and effect man. I had to explain things in a context and a style that would appeal to his reason, and this could happen with this avenue.
Essentially my pain was explained to me in the simplest of terms, as well as reasons for why I would experience pain from long periods while in extension and flexion. It was important I understood why I was experiencing pain. I found these explanations important because I knew the reasons for the pain. These were explanations which I didn’t really get before, so I knew why the treatment would work and how it would work. I could understand & link the cause and effect relationship between the exercises I was prescribed, and the goal outcome, being reduced pain.
This is what I’m talking about above
My condition was a protruding disk with small microtears, along with a pelvic tilt. The issue with the tilt was that the exercises to correct the tilt would flare the disc, and vice versa.
Now this is really interesting for me to read. This shows perception v explanation. This is essentially similar to ‘the bones’ (pardon the pun) of what I described. However, when it gets simplified down to this statement, it shows how we must not judge how other health care professionals based on second hand patient explanations. I feel Charles’ understanding of his ‘condition’ (I did not use that word to him, I don’t like it) could be improved, but it gives him a somewhat pathbiologically plausible & biomechanical explanation to build a rehab program around, without the threat and misunderstanding of what it means.
I was given some unique exercises that would aim to strengthen my core and re-align my tilt, without triggering pain from my disc. I would do these as part of my gym routine. I also discovered that I could strengthen my legs and core by doing other activities/exercises they prescribed, like Mick’s famous ‘sliding around the house in socks’ exercise and I began to enjoy it. I put some extra support in my desk chair and began riding my bike to work. I found I could ride without irritating my back for over an hour at a time. This was excellent compared to running, where it would flare up within minutes.
‘correct the tilt’/’re-align my tilt’ – these phrases make me cringe a touch because I am never trying to ‘fix’ anything. That would imply a ‘pelvic tilt’ is a flaw or something is ‘broken’. However, this is what Charles’ understanding of my explanation for avoiding end range anterior pelvic tilt for prolonged periods of time, as this would irritate his extension based back pain.
I try to create a ‘gym program’ not a ‘rehab or physio program’ because it supports the perception they aren’t training if it’s an adjusted program. The power of language. Charles is describing the ‘training around the issue’ and working on risk factors away from the sensitive tissue.
Enjoyment!! – The holy grail of active self-management.
I also discovered rock climbing myself by chance. It was available at my gym, so I have it a go. It has been great for my core, flexibility, endurance and overall complete mindset.
Talk about bang for your buck! All the health benefits of exercise in a fun and ‘functional way’. Certainly beats TA activations. Note that he used the phrase ‘I discovered.’ I encouraged Charles to explore movement and do whatever felt good or didn’t make him feel the same disabling pain. I wouldn’t have thought of rock climbing, and Charles probably wouldn’t have tried if he didn’t feel ‘safe’ enough to explore his movement profile.
Notice the ‘mindset’ comment. Charles acknowledges the psychological impact this issue had on him. Acknowledging, addressing it, and talking about it is important. Especially for young males who try to avoid it. If you’re not weird about it, they won’t be weird about it!
There have been other adjustments such as my diet, to remove bloating, which had exaggerated my tilt. This was suggested by a former footballer friend of my father. He had similar issues late in his career. Also, I adjusted desk height and seat support.
Remember the ‘pinot’ reference in the blog. Address as many factors as possible. Don’t underestimate the power of someone’s suggestion who has ‘been there’ themselves. Don’t shoot down every suggestion from others just because it doesn’t have a systematic review to back it up. N of 1 case studies and personal experience of others can have it’s place.
I still manage my back, and I think I always will, but I’m now able to live a relatively uninterrupted life, including occasional recreational activities such as golf and basketball, which I thought I might never be able to do again.
‘I manage’- That locus of control is now firmly inside the client. Slam dunk!!! Go Charles!!!
The acceptance that pain in a sensitive area is part of the human experience is an important step. We all have our spots that let us know when we have done too much. Pain is part of life, it’s pathological when it’s controlling life & dictating lifestyle beyond what it reasonably should.
My biggest learning about the whole experience is that understanding where the pain is coming from is key. I was constantly told that the pain was in my head, or that it would go away over time. It wasn’t until someone took the time to listen and understand why prior treatments hadn’t worked, and investigate the ‘why’ further, that a solution that worked for me came to fruition.
Keep in mind; these are Charles’ unique personal ‘key things’. Everyone’s will be different. But the ‘key’ to helping someone, is finding out what those ‘key things’ are that are driving this pain, and working on reducing them. Not curing them, but helping them manage.
People need to feel like they are being listened to and understood. The role-playing in the psych subjects at uni did teach me something. We need to be good communicators and active listeners. For those who are thinking ‘active listening? What’s that?’ Maybe it’s time to chat to a psychologist; they are the pros in this area.
The End
After thoughts (Yes… reflective practice)
Now I know some people might be sceptical of the whole ‘pick your highlight reel’ patient. I chose this person because it is a great example of things done well and things done not well. It wasn’t smooth sailing of a sudden ‘Dave you fixed me overnight’. I know for a fact things didn’t sink in until Charles was given very similar advice by Mick, my manager, mentor and colleague. It gave more weight to the argument, and as a result, more buy in. I know there was things I would have done differently and can still improve on, but I hope this gives an insight into the clinical reasoning side of pain science, and how to apply the principles to a real life example.
Thanks for reading!
Further Reading
A great article giving some great insight into the sportsman’s mindset during rehab is below. Qualitative research is fantastic for areas of practice like this. I highly recommend you have a read.
Carson, F., & Polman, R. (2017). Self-determined Motivation in Rehabilitating Professional Rugby Union Players. BMC Sports Science, Medicine & Rehabilitation. 9(1).
An interesting multicenter study from the University of East Anglia (near me in Norfolk, England), that illustrated a key prognostic factor for improvement of those with shoulder pain was their expectation to get better. Expectation contributes to our outcomes.
Chester, R., Jerosch-Herold, C., Lewis, J.,& Shepstone, L. "Psychological Factors Are Associated with the Outcome of Physiotherapy for People with Shoulder Pain: A Multicentre Longitudinal Cohort Study." British Journal of Sports Medicine 52.4 (2018): 269-275. Web.
A write up about this article can be found on this link, this is an excellent website for keeping up with current issues: https://theconversation.com/physiotherapy-works-better-when-you-believe-it-will-help-you-new-study-110469
Wilson, S., & Cramp, F. (2018). Combining a psychological intervention with physiotherapy: A systematic review to determine the effect on physical function and quality of life for adults with chronic pain. Physical Therapy Reviews, 23(3), 214-226. https://www.tandfonline.com/doi/abs/10.1080/10833196.2018.1483550
A recent systematic review outlining the power of psychological intervention on improving function in those suffering from chronic non-specific low back pain
Stewart, M., & Loftus, S. (2018). Sticks and stones: the impact of language in musculoskeletal rehabilitation. journal of orthopaedic & sports physical therapy, 48(7), 519-522.
An interesting Editorial Piece from Mike Stewart about the power of language within these clinical situations
As always, any questions or feedback is greatly appreciated. I am continuing to learn and adapt my practice every day, so always happy to hear from others in the field, or even health care users.
To any students, new grads or experienced clinicians who would like to contribute, please don't hesitate to email us at enhancesport@gmail.com.