Thanks to those who took the time to read Part 1. An extra special thanks to those who offered feedback, both positive and constructive. For those who have not read Part 1, Welcome, but what follows will make more sense if you head back to the 'Blogs' page and read Part 1. Let's not make this intro too 'painful.' Let's pick up where we left off.
Education does not mean ‘hands off’, enlist the power of touch
When did ‘hands on’ and 'hands off’ physios and treatment methods become a thing?
We are not light switches.
Dichotomies, black and white, absolute do’s and don’ts. They're kind of like afternoon discounted sushi… always be wary!!
With the explosion of the understanding and integration of pain science into practice, a professional witch hunt begun. Those utilising physical interventions on those with long standing pain became the hunted (social media hunted).
Hold up everyone, lay down your keyboards. Don’t join the twitter warfare before you think FOR YOURSELF about where YOU put YOUR STAKE in the ground.
HANDY HINT: prior to said stake placement: Often the very end of either spectrum isn’t a great stake place (is that a thing?).
I was shot down on the good old ‘online discussion board’ (vicious arena of La Trobe student discussion) during my masters for suggesting manual therapy can be used as an intervention, or even an education tool, for those eliciting signs of centrally driven pain. Apparently... BIG MISTAKE
They came at me from all angles, quoting studies on how ‘massage is ineffective’ and ‘joint mobilisation doesn’t even move the joints.’ If they took the time to actually read my point of view, they would've seen their responses didn't match the argument.
Unlike academic discussion to be reduced to ‘strawmanning’ the other persons point of view 😏(google it, I had to the first time I heard it).
Humans (and animals really) comfort one another with physical contact. We also build trust in this way. It’s a powerful part of our therapy, granted, often in a nonspecific way. Tactile assessment and treatment is also very central to what the ‘cliché physio’ looks like in the general population's heads (no one else copped the ‘so you massage people all day?’ at a party 😡), so you may wanna 'give in' a little.
Yes, I can see how that last statement sounds a little 'sell out'-ish. Wait... HEAR ME OUT!
If I engage in manual therapy, I am doing a few things:
Allowing them to relax, and be quiet... allowing for an opportunity for discussion
Meeting an expectation of what they thought they were going to get (Refer to part 1)
Providing a non-noxious (not painful) stimulus to their nervous system (be gentle), which can lead to analgesic effects, which can lead to ‘buy in’
Providing a great opportunity to discuss pain science and their perceptions of pain without them in an uncomfortable office chair (people tend to offer more valuable subjective gems when they don't have to eye ball you)
The key is frame what you are doing accurately, and don't create inaccurate beliefs or dependence
If someone gets off the bed and says ‘I feel a bit better’ this is a great chance to explain that you structurally 'did nothing', but you have shown them the power of altering input into the nervous system. This could be a nice time to move into exercise and explain how it can have a similar effect.
Alright, now you can disagree with me!
Check they’re following you, let them ask questions
I’ll keep this one brief. You should really be doing this when explaining anything to patients.
After explaining the what you think is going on with the patient, ask them to repeat it back. You'd be amazed how what they've 'heard' compares to what you said.
This taught me how the answers to ‘what did the other physio say to you?’ is often answered with some serious funky shit. It might not be what the physio said, but it may have been what the patient heard that might be a little off. Don't make that arrogant face that non verbally says to the patient 'the last person you saw was an idiot'.
It doesn't help anyone.
Education 'progressive overload'
You want someone to eventually be able to squat 1.5 times their body weight. Do you ask them to step up with 140kg on the bar and have a crack first session if they've never tried?
Unlikely... So don’t do it in a cognitive sense.
You might be familiar with the words and language of biology and physiology, but not everyone is. Your maths teachers didn’t hit you with algebra in year 4. That's because because you had to figure out numbers before they threw in letters.
Drip feed them parts of the pain science story and do so in different ways. Find the thing that works for them. Videos, books, discussion, or anything else you can think of.
Do it slowly, us humans can only take on so much.
You’re not a psychologist. Stay in your lane. REFER
In walks patient X
"I’ve had back pain for 10 years, it all started when I was in a car crash with my sister, and she died in the accident. I have been reliving that moment every time I’m in a car and if I’m in a car for more than 10 minutes, my back is killing me!" Wow, just like onions... this problem has layers.
Is this a patient you think you can manage best on your own?
Maybe… If you’re a highly experienced musculoskeletal physio who also happens to hold degrees in psychology, social work and completed in med school in their spare time.
Is this a patient you think you can manage best on your own?
You don’t have to do it alone! So don't!
You likely don’t have the skills or experience, and you’re doing a disservice to the patient to try. What's the harm in trying you say? Well the longer the person has pain and ineffective management, the less likely they are to get better, or trust those trying.
Know when you’re in over your head and look for the nearest pain service or psychologist. There are many who specialise in pain (we apply a lot of their research in the pain science area... except they’re HEAPS better at it).
Okay that's an extreme example. A much less severe case than this where you suspect a psychological contributor is still worth a suggestions of ‘have you ever thought about speaking to someone about this?’. Especially, by the 3-4th session and you feel you have gained some trust. Don't be afraid to approach this, if you get weird about it, they'll get weird about it.
It’s hard work… you can’t and you won’t win them all
For people to change, they need to want to change.
Profound right? It might be a cliche, but it is true. If you offer your best in terms of education and they want to push on with the quest to find the person who will ‘put that hip back in,’ then they have a right to continue, it's their health. I often will conclude these kinds of consults with a statement like “I have outlined what I think is the best course of action to manage your condition, and you don’t seem to agree. If you ever feel you’d like to try this approach, please feel free to make contact me"
I’ve had two who have come back so far, most don't. I'm not saying it happens often, but it’s better than laying down your sword and being their weekly massage that gives them 20 minutes of relief and contribute to their problem, or burn yourself out banging your head against a 'behaviour change brick wall'.
The other thing to keep in mind when working with this population, is the dishearteningly low success rates achieved in pain services.
The doctors, psychologists, psychiatrists, physiotherapists etc working in these services have dedicated their professional lives to being at the cutting edge of pain management. They often collaborate closely with patients in intensive daily treatment programs. The literature tells us that even with these amazing people and their work, it’s far less than the majority who achieve significant long term improvements for their patients.
So... Don’t take it personally, if things don't work out how you'd hoped, but DON'T BLAME THE PATIENT (it's the easy way out). ALWAYS offer them options for the future.
Don't give them false hope, but don't give them hopelessness
I have left sessions with individuals suffering chronic pain exhausted emotionally, and seriously needing a break (Praying to see someone with an acute rolled ankle next).
I truly do take my hat off to those who work exclusively in this area. You are special people, and I know I could not do it. But what you do is important and incredibly difficult, both clinically and personally.
Conclusion (this isn't a journal article, don't skip to this) 😉
Overall, I think Physio's (including me) need to do this better, or at the very least stay in our lane and 'do no harm'. We shouldn’t be shooting down others who are trying to help, and we shouldn’t be blaming the patient. Pain is a complex subjective experience which we have to validate and explore.
Pain education is a skill that requires years and years of practice, and will continue to evolve. So don’t be one of the therapists I described at the start of part 1. Offer what you can, and refer on promptly when necessary.
One last point, remember to consider this stuff when working with those with acute injuries. A lot of people with persistent pain all started with an acute injury. Education about 'what pain really is' from the start can really reduce the chances of this patients’ journey heading off course.
Happy educating!
Thank you for taking the time to read my blog. I am always learning and developing, like all therapists should. I would truly love any feedback, or suggestions from those with any level of experience. This piece has been fun to write, knowing it was one asked for by our readership. Please continue to suggest topics you would like to hear our thoughts on. If anyone would like to contribute by writing their own piece, we would love to hear from you. I would like to thank all the people smarter than me who have formed and continue to form, my opinion on this topic. Some works of their can be found below.
Thanks
Dave
Resources I have found have helped me and my patients understand Pain Science
Things for therapists
Peter O’Sullivan - Cognitive Functional Therapy: An Integrated Behavioural Approach for the Targeted Management of Disabling Low Back Pain Physical Therapy 2018
Jeremy Lewis & Peter O’Sullivan - Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? (Open Access) https://bjsm.bmj.com/content/bjsports/early/2018/07/17/bjsports-2018-099198.full.pdf
Know Pain Website - https://www.knowpain.co.uk/
Resources for patients
1. ‘Why things hurt’ – Lorimer Mosely - https://www.youtube.com/watch?v=1ylbrkstYtU
Drug Cabinet in the brain - https://www.youtube.com/watch?v=Gd2NaGZa7M4
Understanding Pain in Less than 5 minutes & what to do about it -https://www.youtube.com/watch?v=C_3phB93rvI
Explain Pain (Book) – Lorimer Mosely & David butler eBook - http://www.noigroup.com/en/Product/EPBEII
Podcasts
Pain Science & Sensibility podcast - https://ptpodcast.com/podcasts/pain-science-and-sensibility/
Several Episodes on BJSM podcast with various specialists
Mike Stewart featured on podcast
Physio Matters Podcast – Session 4 & 5
PhysioEdge Podcast Episode 35