Podcast Episode #23 Challenge Your Bias, But Still Remain Patient Centred
Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence informed practitioner, let’s dig into this episode.
Jamie Johnston 0:33
There are times when your beliefs get challenged. And there are times that you have to change the way that you do things.
I’ve been seeing, we’ve been seeing lots online lately, with people that are going back and forth between what the Noy group is saying and what other research papers are saying. And so we decided we would dig into some of this because as science should, we should always challenge our bias.
Eric Purves 1:37
Yes, and I agree that this, you know, I’ve been reading some of these guys, papers, and I’ve been reading some of their blogs for a while now, just because it provides a different thing than the normal echo chambers that we get stuck in. But it seems to me that
Jamie Johnston 1:00
So with that, we will look into a couple of papers that are both from Quintner and Wiseman. One called pain medicine and its models hindering or helping. And then the other one sort of just bringing the title up is pain is not a thing and how that error affects language and logic and pain medicine. So jumping into it, sorry, I’m going back and forth between notes here. I think the the biggest thing that I take from this is words matter, which we believe in anyway.
Eric Purves 1:57
like, it took me a while to really understand what the heck they were talking about. Because it just seemed that they were just kind of basically critiquing everything that was quite common language are quite common beliefs or ideas or ways of practicing in pain care. And so I was like, Well, what do you got? What do you guys saying? And I think it really a lot of it comes down to is the words that yeah, the words that are being used and how things are being described, as well as it seems to be that the things that they that this group in these researchers are arguing against, is I think they’re arguing against how often, like kind of biopsychosocial models are used in practice. But not I don’t see it necessarily as a problem in the I don’t know, they use I prefer framework, they don’t really they’re not really as it’s I don’t think it’s a problem with the framework itself, as much as it is how it’s often communicated to people in pain in practice. That’s so that’s where I see the splitting hairs kind of thing.
Jamie Johnston 3:04
Wandering through, because I looked at as I was reading through it, I was kind of there was some of the challenges that they were making, which is great, because we should challenge things. But I was reading it and going well who’s saying that? Because some of the things didn’t. I’m like, those aren’t the things that I would say to a patient or those that’s not the way that I look at it. So that part of me was wondering like Who exactly are you challenging? Because there’s, there’s some of the things for sure that that are, for lack of a better term splitting hairs. But I, but I’m not sure who it is that’s communicating to patients in the way that they mentioned in some of these things,
Eric Purves 3:48
right. And the thing that I the takeaways I got from reading not just these papers, but some of the other stuff from them, a colleague Monica sent me probably a couple of dozen papers that they had sent her and then she forward them to me and I’ve read not all of them, but I’ve read through most majority of them. And I mean no I grew up and kind of mostly in that group who uses a specific language to communicate the complexity of pain, like they talked about pain being this protective response and pain can be a learned. thing, you know, and and I see the argument from this, this group hear about how that can be problematic. But what I do see from what noi has done, and mostly in their research is they seem to have taken this really complex neurophysiology and this human experience of pain, and they’ve tried to make it something more simplistic for clinicians to think or reason or use in practice. And so it’s shifted that movement away from this pathway, anatomical tissues structural problem explanation more towards a, your system, systemic sensitivity. You know, when there’s like brain and peripheral and spinal cord stuff happening, that’s like the one thing, right? And then they try and put it in a way that’s teachable and use can be used in practice. And I think there is probably some oversimplifications of the words that they use. And I, but I like what you say like I agree with what you say their jammies, I think the, it seems that your average clinician out there, if they are saying those words to people, that can be a problem. Oh, you’ve just learned your pain, oh, you’re just stressed out, you start blaming the psychosocial things, and just trying to discount completely the bio. So I know these guys are talking about the nociceptive apparatus and the nociceptive system, you know, and there’s always going to be an activation of that and every pain experience. And I don’t think that anybody is necessarily really arguing too hard against that. It’s pretty much like they’re saying like, yeah, there’s some type of activation in your system. That’s, and then and then you have a conscious awareness of that. And there’s other psychosocial stress, other things going on around you, which can influence that. Okay, I get that. But when we talked, when, when you’re talking to patients, clients, whatever, like, are you? Like, are you trying to explain away their pain? Because I don’t think that is what people are really doing anymore? And if they are, then I think it’s a misinterpretation of like, analyze teachings. Yeah.
Jamie Johnston 6:37
And I think like, just when you touched on it there, like, that’s one thing that I switched. The way that I explained it years ago, is that, you know, the psychosocial things can influence your pain, it’s not a causative thing. And I know in the one paper they talked about, like the mind body connection, and, and that they’re like, well, that, that my understanding of how I read it anyways, is that it’s it’s not what, what we should be saying to patients, but yeah, they’re also saying the biomedical model doesn’t work either. Yeah. So I get that. I mean, in the, in the one paper, they, you know, you go through and they make some good points, like, you know, they go well, I, when I look at what they’re saying, for words matter, like one of the statements was, when core concepts employed within a field are open, there’s potential for inaccurate or misleading uses of terms, which then can be amplified with the patient. And that talks about like pain, and it saying a stimulus in and of itself is not painful. By contrast, it’s the experience labeled pain that is painful. Yeah. Right. So it’s what the person’s going through is painful. Yeah, it’s not necessarily the stimulus. And then they break it down further with different objections and saying, you know, that it’s a noxious stimuli that causes the pain, that it’s a stimulus that as damaging, or threatens to damage normal tissues, which is the definition of a noxious stimuli that is capable act of activating merseysiders. Yeah, I don’t, I don’t think anyone that Noi group or or others are saying that that’s not true.
Eric Purves 8:15
Yeah, and this is where this is where it gets confusing, right? So what’s, what’s the argument? Their argument is, I think more about the well, they talk about the reification of pain. So pain being a thing. That’s that’s this, you know, this one papers called pain is not a thing, how that error affects language and logic and pain medicine. Well, pain isn’t a thing. I mean, pain is an experience of pain isn’t a tangible thing you can grab your hands on. But I failed to understand and maybe I just need to think about this, reflect on this a bit more, maybe I did just spend more time with this. But we use the term pain, because that’s an experience that people are aware, like, we all know, what pain is a pain for each of us is different. Yeah. And is anyone saying that? It’s not like, you know, and, and there is, there is lots of studies that show that, you know, there’s certain areas of the brain that are activated when someone’s experiencing pain. And then there’s lots of studies that I’ve seen that looked at like the transition from these kind of sensory nociceptive, dominant areas of the brain, and acute and then as things transition to a more persistent, there’s changes, those sensory areas go away, and there’s now activation in the limbic system and other areas of the brain, you know, and these i, and then, what I get from this group here is that they’re saying, Well, you know, you’re, you’re saying that people are thinking differently about their plant or pain or the pain is an output of the brain, you know, and that and they’re saying that that’s not true. And you think, Well, it’s, I get that argument, okay. It’s might not be true, but we do know that there is. If pain is a lived experience of somebody, then there’s going to be something happening in the brain and in the mind of that person. That could be sensitizing the overall system. Whether that’s a peripheral nociceptive or a central or cortical All thing that’s stimulating nociceptive activity? Does it? I don’t know, does it change? How we think does change how we communicate? Is it changing anything that is it something new. And I don’t think that it really is changing anything too much. Because a lot of the stuff that the kind of the last decade of pain information, there might be a little bit too much brain focus. But no one is saying that pain is not a lived experience of the person. I’ve never heard anybody be like, I’ve never I’ve never encountered anything like, Oh, you’re you’re just thinking your pain, you’re making your pain up, or your pain is an output of your brain. Yeah,
Jamie Johnston 10:38
and I know that. We’ve talked about it before where, you know, I’ve been communicating with a with a person, and probably use the long the wrong language where they went. So you’re saying it’s all in my head? And had to backpedal and go? No, no, no, no, no. So you know, if they’re making some very valid points, that the way we communicate with patients is very important. Because we don’t want people believing that it’s all in their head, but the brain is still going to be involved in whatever that pain experience is that the person is going through. And, you know, going through just looking at some of the stuff, they make the argument of the use of the suffix susceptive. They’re saying that that’s the property of a receptor, but it’s often tied to a stimulus. And this leads to an argument that the nociceptive stimulus is one that activates those receptors. But that’s what a noxious stimuli does. But that’s not a language that I would ever use with a patient. No. So I mean, important for us to have that knowledge. And I think one of the big things that they’re saying is, when we’re looking at research papers, this is the language that should be used. Yes. And I can’t disagree with him in that regard. But again, it’s not it’s not ever a way that I would communicate with a patient.
Eric Purves 11:55
Yeah. Well, and this is goes to a lot of the stuff that we have in research and in our, in our world of pain, and rehab, and movement and all that stuff, is that there’s really cool information. Yeah, but how much of it is really clinically relevant? You know, so based on, you know, like, this is some of the some of the stuff we talk about in our courses, and we teach and, you know, we communicate with others about it. But in terms of like, how relevant is that to us clinically? Is this providing new? Not really, I mean, I would say maybe I’m, I am maybe a little bit more aware of being less brain centric, but still, you’re still like neuro immune centric with this information, because that information coming from the nociceptive activity is being received within the system. And then that is that awareness of that. And meaning of that is, comes from the person and their experience. So I, it’s good, I think it’s good to get out of the echo chamber and think it’s good to challenge stuff, but it’s just I still don’t see it hasn’t changed, how I would do a lot. But I want it to like, I would love to read this and be like, I’m open book, what do I do differently? What do I do better? What do I get throw away? What do I adapt? Very slight, very slight.
Jamie Johnston 13:13
And, you know, as we look through like, does it just because I made a whole bunch of notes on this, when they’re talking about like pain sensitivity, insensitivity hypersensitivity and pain threshold, things like that, because you know, we we’ve all had those, those people on the table, that I’ve got a high pain threshold, you can dig your elbow into me, and I like that. So one of the points that they they made is, is the threshold, the quality of the stimulus or the quality of the response. So if the person has a low threshold, which means the person’s which actually means a person’s ability to tolerate the experience, they’re saying we should use descriptions like pain inducing stimulus and intensity, with more specific terms that refer to the type of stimulus which would be like mechanical, thermal, thermal or chemical. But again, that’s that probably has less to do with us digging our elbow into them more to do with how they’re experiencing pain in the outside world. And what what things are inducing pain for them or creating pain for them? Yeah, yeah.
Eric Purves 14:12
And this goes, this goes back to what we talked about all the time, is in is, there’s not a right or wrong, like a person has a high or low or insensitive to touch. What’s the right touch for that person as us as massage or manual therapists? Well, the one and the person likes the one that they can tolerate. So it doesn’t matter what their level of sensitivity is, or is it maybe just it like it just as a clinician, if you understand that there’s these different sensitivities and everyone’s going to respond differently and there’s a world around this person, there’s a person who’s experienced that might be sensitizing their system. Then all we need to really understand from this is that you always are adapting your your touch or your treatments or your you know, interventions and strategies to what fits best for that person. That day, just to help the person have a better lived experience.
Jamie Johnston 15:04
And then always, yeah, like you said, that comes back to their experience. So whether the painful experience that they’re having when they’re not with you, that’s their experience and the experience they’re having while they’re on the table with you, is their experience. So that’s where that communication aspect comes in. Of does this feel good to you? Is this a good experience for you? Those kinds of things when we’re doing manual therapy with somebody always comes back to that patient centered care. Yeah, what experience is important for them? What is it valued? experience to them was a meaningful experience for that person on the table? Yeah. Easy. It’s interesting, though, because some of the things that we’ve talked about so many times like pain catastrophizing, they they make the point that is catastrophizing, a part of the pain experience or a reflection upon the experience. And is this purpose to serve the experiencer or the observer? So if we’re talking if we think as the observer that somebody is catastrophizing? Is that more important to us? Or is it more important to the person? Person? Yeah, yeah. But it’s something that we should try to take into account. But it doesn’t also doesn’t necessarily mean we’re going to look at them and be like you’re catastrophizing right now. No, right. Yeah.
Eric Purves 16:27
And that’s a really, I mean, yeah, that’s a really important distinction, because we like that kind of moves. Like we want to move away from that operator. perspective, or we’re putting our judgment or beliefs onto the person, which would be so if we said, oh, you’re catastrophizing, that’s us putting judgment onto onto the person. It can provide us insight into thinking well, yeah. So say you’re doing the pain catastrophizing scale, and it says they have a high score on that. What it’s how is that going to that is actually can be useful information for us, because it lets us know, as a clinician, this person is suffering from their pain, and how they how they feel about how they’re experiencing their pain. But it doesn’t tell us what their level of pain is. It just tells us how it’s impacting them. So I don’t again, I don’t see how that really, you know, unless you told somebody you’re catastrophizing. Yeah. Which you wouldn’t that which
Jamie Johnston 17:39
could have a massive impact on somebody? Yeah.
Eric Purves 17:41
Then it’s just we have to be mindful of using our words, for sure. Yeah.
Jamie Johnston 17:45
Yeah. Yeah. Which leads us into also, the comments that they make on kinesio phobia or fear avoidance, they make the kind of make the same point that is that a judgement of the observer or judgment of the person who’s experiencing it. Just reading here for it says it doesn’t deny the importance in challenging challenge of interpreting the behavior of a person experiencing pain. So they suggest that we explore the person’s cognitive appraisal of their own predicament in their words. So listen to them, and whatever they tell you is what they’re going through. Yes, so comes back to that patient center character.
Eric Purves 18:25
Yeah. And that’s what we’ve I mean, that we’ve learned that before from you know, having interviews with people like like Keith Meldrum, who it’s, you know, talking about the, you know, the lived experience, the dog was every year at San Diego Pain Center, they always have the pet or the almost not always, but many years, they have that panel of people their lived experience. And that’s always emphasized as being the most important thing, like you can know all your stuff about pain, you can know all your treatments and all the things to say and do and not do. But what what matters most is really trying to be in that safe space for that person for their lived experience, and not taking that away from them or not trying to replace that with your own views.
Jamie Johnston 19:09
Yeah. And so I like how they put some of those things in there that you know, is it the role of the observer, or the role of the person who’s going through it? And there’s definitely going to be some instances where it’s our responsibility as the observer to recognize that something might be going on. But it also doesn’t mean that we have to communicate that specifically to the person in front of us.
Eric Purves 19:33
Not unless we get their permission now, unless they want to know, which is person centered again. Yeah.
Jamie Johnston 19:40
So it’s, I know this very interesting because I’ve seen this big, these big debates and arguments online. And the Yeah, I mean, the the people make some great points in these papers, but I think in the long run, we’re all saying the same thing.
Eric Purves 19:58
Yeah, and It is, you know, I know in this this this pain medicine and it’s models paper, which is a bit old now I think it’s 2010 or eight or something, it’s a while ago, it’s really an argument against the linear process of bio cycle socialism. Right and that is true that you know, in the bio psychosocial when you first encountered as a clinician, you’re often looking to be like, is this bio is a psycho is a social and you’re looking to explain pain via one of those domains. And it becomes and so they’re like, oh, no, the bio psychosocial is more inclusive, whereas traditional biomedical if the Descartes Cartesian model was very linear, so that whole was explained. And Biomedicine is very linear. But biopsychosocial is just as linear. You’re just looking to find something new to caught to blame. And I’m thinking, well, maybe it may be that some people are applying it. But that’s not how I don’t think how it’s supposed to be implied. I’ve never understood it to be applied that way. It’s more like holistic, like whole with a W like looking at the overall person, their experience, and how is the world and the person how is everything around this person is shaping their experience? That’s how I see biopsychosocial. I don’t see it as this linear process, but maybe how it’s taught or maybe how the people understand it is different. And maybe, you know, if I think back to my early days, maybe I thought it was different, too. But I know you can. It’s hard to remember we used to think not yesterday. Yeah, where am I?
Jamie Johnston 21:28
Yeah. However, and we can, I think we can go off on a little bit of a discussion about this, as well as at the end of one of the papers I there’s a statement that they made that I absolutely loved. Because I think it’s applicable to so many more things in our profession than just this one topic. They said one of the more powerful therapeutic tools available to the clinical pain practitioner, irrespective of their background discipline, is to present a clear and honest explanation that is as close to accurate as possible in the current state of knowledge. Yeah, I think that is beautiful. And I think that we, we have to take that and almost apply it for lack of a better term globally to what we do. And for those that are that are out there saying, I don’t need to look at research because I know what I do works. Ones that are still using old narratives of how their technique works. This right there, it if that doesn’t tell you that you need to change. I don’t know what else could because we have a responsibility as healthcare practitioners, to give as honest an explanation of what’s going on with the person in front of us as we can with the most updated current state of knowledge.
Eric Purves 22:47
100% And we have an ethical obligation to do that as healthcare providers, right, we should have, you know, as you learn new information, even if you look at our, like our competency documents and stuff that they have here in BC, the you’re supposed to use research and incorporate into your practice regularly. And as as you learn, you’re supposed to be able to adapt your knowledge based on your current on, on adapt your practice based on your current knowledge. And the and as we learn more if we learn stuff that contradicts or challenges what we used to know or what we used to do, then we have to, we have to change, you have an ethical obligation to change and people come to seek our care deserve that.
Jamie Johnston 23:30
And which is the exact reason why we wanted to discuss these two papers. Yeah, is in the hopes that it will either challenge or make us change. And it probably has to a degree but probably not to the degree that I thought it was going to.
Eric Purves 23:46
Yeah, and I think so too. I agree with that as well. I was trying to really my reading through these things before really trying to really trying to challenge my bias. And but as I read through this, I’m thinking No, that’s kind of what I already that’s kind of what we already say and what we already do. And and it’s good to question the stuff obviously, like we said before, it’s good to not just sit in an echo chamber but the one issue I have with these guys writings is that they don’t really they don’t really give you any further information about like here’s things moving forward. You’re fine you can fix that. Yeah, it’s very philosophical and very like well this other way is not right. But I would like to see them come up with like an idea or like a like a Knowledge Translation plan or something moving forward that says this is how this information could change your practice or could could be applied to your practice. I would love to see that because when you when it’s just challenging and saying like, this is this is wrong bla bla bla but without a que What do you replace it with? Then then it becomes harder to to incorporate into your to your practice. I think the message is gonna get lost. I think that’s why In like the, you know, RC world that we live in, is that when you’re teaching stuff, you have to find something else to replace it with. And I know, early in my career trying to just give people information hoping they would change. They don’t change, you just try and give them some information and be like, and this is how we try and use this in practice. This is how it shapes what we say and what we do and how we think. But with the absence of like, what do we do with this information? I think he gets lost in a lot of people. I think that’s probably part of the problem, at least from my anecdotal observations of this, how this stuff works in social media, when people are arguing about it. It’s like, Yes, so what do you tell me then?
Jamie Johnston 25:41
Yeah, yeah, I agree. But I would say one thing, looking at it is my impression was that they were saying this is how, like, these are the terms that should be used in research, these are the team terms that should be used in papers. So perhaps, if, if that’s the approach is if they’re saying, well, from now on, when a research paper is done, this is the term that should be used, then gradually that would start to change, perhaps how we’re communicating with a with a patient or with the person in front of us. Yeah. But that was that was just my impression of what they were trying to say.
Eric Purves 26:15
Yeah, and that’s, and that’s, I think that’s a really valid point. Because we, I think one of our first podcast we did was about like, words, the power of beliefs and stuff. So yeah, if there’s better ways of kind of communicating the similar ideas or similar or same things, then, of course, let’s change it now become the new normal.
Jamie Johnston 26:32
Yeah. Yeah. But I, but I still don’t think it would change how I communicate with the person in front of me, because I would never look at a person and use words like noxious stimuli. And, and those kinds of things. No, unless, like you said before, unless they asked and wanted to get really educated on this stuff. You know, but I see the value of using it properly and research.
Eric Purves 26:57
Yeah. Yeah. And maybe that’s maybe that’s where this stuff will be beneficial. Moving forward, is maybe there will be some changes in how the researchers are doing the things. Yeah. Rather than clinicians and I mean, we look at all this stuff through a clinicians lens, not through a researcher lens. Yeah, I mean, these guys are, you know, Quiner and Cohen are retired. And Assaf is I think he works at a university in Israel. So yeah, yeah. Israel, I
Jamie Johnston 27:26
think witness Australia.
Eric Purves 27:28
Yes. I think Cohen is too. But anyway, yeah. So there’s, but it’s interesting, because I would like we get so caught up in the details about things like these like minutiae of the neurophysiology and the language and stuff. But I would, I can be very bold. I’m gonna say if you took this information to a psychologist who treats people in pain, terms like, yeah, who cares? It’s always with the lived experience. It doesn’t matter what this other stuff.
Jamie Johnston 27:58
Yeah, if you were talking to like a millennial, well, yeah, you would probably look at this and like, okay,
Eric Purves 28:04
yeah, they’re like you, they’re gonna say, Well, why are people arguing with this? Like, doesn’t matter, like, what matters most is the person is experienced? And how can we help shape that experience? And through their, obviously through the psychological interventions or ways? You know, this? So I think this, this stuff here is very, very, there’s a lot of people out there that treat people that help people hurt. Yep. This information, I would say would be specific to maybe more physiotherapy or medicine. But I would say, I would say a lot of these guys criticism, a lot of it comes towards the physiotherapy professions, because that is going to allow us directed towards NY and mostly is stuff and Butler stuff. So psychologists and other people are, who cares?
Jamie Johnston 28:51
What we do, because then that’s why we looked at the papers. Yeah, exactly.
Eric Purves 28:54
I think I mean, I think it’s interesting. It’s,
Jamie Johnston 28:57
yeah, so I think the I think we can look at the overall message of this specific podcast is that we can come to agreement that it’s the person’s experience, that’s going to be the most important thing for us to take into account. And just communicate well with your patients. And there are certain times where we need to be the observer and just listen to what it is they’re saying to us. Yeah. Which is
Eric Purves 29:22
good quality. person-centred Care. Yeah. And we don’t need to impart our beliefs on to people without their permission or without their wanting to.
Jamie Johnston 29:33
Unless, unless they ask, unless they ask. Yeah, and, you know, and, of course, the other thing is to always be open to challenging your bias and looking at new things and, and seeing how you can improve as therapists. Brilliant, perfect. That one actually went a lot quicker than I thought it was going to. Because it took me a long time to go through those papers. But yeah, I think that’s a that’s a good way to wrap it up and thanks for listening, everybody. We’ll see you next time. We hope you enjoyed this podcast. These kinds of topics are what we’re all about. If you’d like to learn more, go to our websites,
Eric Purves 30:12
themtdc.com or Ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.
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