“Pain is in the brain”
“Pain is the result of your body feeling threatened”
Both true statements, and both statements I have used in the clinic. Both statements that have likely been the reason the patient I said it to never came back… they probably thought I was full of you know what.
Pain science, I can hear you sigh, and see you roll your eyes. It’s hard, confusing and complex… plus patients just won’t get it... right? With this stuff, I feel your approach can kind of go one of a few ways, or flip flop between them like I did.
The cynic therapist – ‘It’s a load of garbage’
The defeated therapist – ‘I’ve tried, it’s just too hard’
The rushed therapist - 'I just don't have time'
I’ve tried all of these ☝️
I think the root of the problem initially was that I simply didn’t understand it. I have distinct memories of sitting in a ‘soft tissues management’ class and being walked through the “simple” foundations of pain physiology. Misleading title if you ask me… the discussion could have been slightly skewed this way, because the tutor of the class was doing his PhD in pain science. Interesting choice…
These concepts were so far above my head as a second year Physio student, they didn’t even ruffle my hair.
Personally, I think, as therapists, we have to go back to that mindset we had as early physio students, when the concept of ‘being a physio’ in your head was ‘fixing people’ by treating them with your hands. When the world was simple with black and white facts. That is often the perspective most patients will hold when walking into your office… Likely even more so if they’re in the chronic pain population.
The perspective of the patient and the clinician are at such different viewpoints on the same issue, you may as well be speaking different languages.
Starting your education process with “I’m not even going to touch you, that’s not the answer” or “Have you heard of chronic pain?” is likely going to lead to bad outcomes. This can eventuate in many ways (ranked from most pleasant to least):
Patient nicely pretends to listen, starts reflecting on the next therapist that came up on google, and leaves never to return
Patient sits with agitated body language, rolls their eyes and makes snide remarks insinuating what you are full of, then leaves in a huff.
Patient gets upset or angry as soon as you head down this path, abuses you and leaves within 10 minutes of beginning the consult (I’ve seen it, thank god it wasn’t me).
When working with this more complex population, one must reflect on their own life experience as a consumer. When have you felt the most upset about a service or product? When it didn’t work? When it was over priced? When it just looked better in the ad?
All of these things have one thing in common… this exchange greatly violated your expectations of what you thought was going to happen.
Think back to 20 year old trackie dack wearing uni student. Reflect on what you thought 'physio' was. By 'treating' with words when they expect manipulation, that’s like paying for a Ferrari and getting a Mazda 3 (also a great automobile. No offence to Mazda drivers, I drove one).
To me that is a key problem with how Physiotherapists try to do the right thing with delivering Pain education.
Here are a few things I’ve picked up with some epic and awkward failures in this areaof practice. These experiences have lead me to improving in this highly emotive and hotly debated area of Physiotherapy:
Actually assess them
“I’ve had this issue for two years...” Cue ears to stop listening and inner monologue to start screaming "THEY’VE GOT CHRONIC PAIN! let me just wait till their finished so I can tell them it’s all in their dorsal horn".
NO! Wait…LISTEN, ASSESS, KEEP LISTENING.👂
Yes, by definition, chronic pain is long standing pain, but therapists slap on the highly suggestive “sigh...chronic pain” label (AKA too hard basket) too quickly. Before doing this (not that we should ever dehumanise people to labels), use the skills you learnt at uni. You could change this person’s life for the better by actually diagnosing their very real, very treatable problem. Don’t be mislead into thinking it’s going to be a Dr House style condition.
Simple conditions can be missed.
Lets be real.. Hard to be diagnosed when the past 3 health care practitioners stopped listening in the first five minutes and haven’t assessed the person in front of them. Don’t be the 4th.
Centrally driven pain & Musculoskeletal conditions are not mutually exclusive
Picture the individual’s condition as a glass of wine at a pub where the generous bartender has poured over the ‘standard serving line’. The line represents the threshold at which this person begins to experience pain. At this point you see the bartender pouring the next glass, but he’s using the last bits of 5 different wine bottles. You may suddenly feel less special, but its a lesson in context.
Back to the clinical stuff, this walking talking overly full wine glass, has gotten to the point of pain (over the line, keep up) from a series of different contributing factors… some of those can be musculoskeletal, some psychological, some social and some behavioural (different pinot brands). Your job is to identify these contributors and address them to ‘bring the wine below the line.’ Metaphor over.
The lesson is, if you identify there is some centrally driven output based contributions to pain, yes treat it with education, but don’t stop there. You can still treat manually, prescribe exercise, and even use other ‘classic physiotherapy’ interventions to assist in reducing the contributors.
Know what you are talking about
Physios love to sound smart. Physio’s also love to educate. Einstein once said “if you can’t explain it simply, then you don’t understand it well enough.”
I am guilty as charged for serving up some 'half baked education cookies' before I completed the pain education unit within my masters. I was dropping terms like “nociceptors” and "descending inhibition" in randomly, maybe a little “central sensitisation” to really make the sell that I knew stuff. It’s a real forehead slapper to think about now
I will put my hand up and say, I still only understand the basics of pain science, and I am probably still at times being tripped up by the semantics of pain science world. However, I only try to impart the basics, and if I’m finding I am not getting anywhere with helping this person, I will employ others who specialise in this area. Always good to know your limitations.
If you don’t know the basics, or have forgotten, that’s cool. You can take the time to learn the key principles, or refer these patients on to those who may be better equipped. DON’T (like I did previously… sorry past patients) deliver convoluted, contradictory and inaccurate nonsense, that will add to this already suffering person’s likely warped perception of what is going on.
Make it relevant to the patient in front of you and their specific issue
It’s proven that we all remember narratives, metaphors and parallels better than we do random facts or verbal recitations of textbooks. Makes a lot of sense that our patients also do.
When working with someone, always take the time to explore their interests, hobbies and occupation. These areas can be a rich source of context when explaining these complex principles. I’ll give you an example (stolen from ‘know pain mike’ from knowpain.co.uk) for office workers discussing central sensitisation.
You know when the fire alarm goes off, and everyone has to leave the building, fire trucks have to come, only to find out, someone burnt the toast in the kitchen and set the smoke alarm off. That is kind of like your bodies nervous system when it’s in a sensitive state (add why here e.g lack of sleep, stress, previous injury). The response is greatly out of proportion with the issue. You’re nervous system can set up similar smoke alarms, this results in the high levels of pain your feeling
See what I mean… it’s more relevant that the old nociceptor and action potential threshold chat.
Thanks mike.
I’ve also found stories about yourself and humour really effective here.
It’s likely not the first time they’ve heard this spiel
You are not the first physio to watch Lorimer Mosely’s “why things hurt” video (great video) or read Explain Pain (great book)… don’t kid yourself.
If this person has had pain, and been trying to manage it, for some time, they’ve likely heard “the pitch.” So don’t patronise them like your cardio supervisor asking if you’ve heard of "the forced expiration technique.”
Actually ask what their understanding of pain is…
this will give you at the least, two important pieces of information:
What they’ve been heard (not what they’ve been taught, don’t be the scoffing physio)
· How much of a touchy subject this is
This information will greatly effect your choices on how to manage the next 5 minutes of the consult. I can’t give advice for all possible situations coming your way, but you may need to call on those "sensitive discussion skills" employed when you stumble into a casual discussion on religion and politics.
To be continued...
This blog is aimed at assisting young therapists and students develop their knowledge in various areas of their work, both clinically and non-clinically. If you have a topic you would like Enhance to cover, or would like to write a piece yourself, please contact us on enhancesport@gmail.com
Thanks for reading
The Enhance Team