10 Tips For The Practical Application Of Pain Science

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Knowledge about pain science is rapidly growing with articles and blogs aimed at everybody from personal trainers to doctors and surgeons springing up on the topic. It could be argued that anyone who deals with the body should have a basic understanding of how pain works.

We have criticism that we still have not gone far enough in this field and others seeing the pendulum as having swung far to far already!

Whilst it is important to digest this barrage of information, we also need to think about the real world application of the academia to the end user, e.g. the person you are trying to help understand all this information, and often this is the bit people find hard.

1. Pain Science Can Help Us To Understand What Not Ts Say, But Not What To Say

 

At the very LEAST a better understanding of pain science should influence us to know that what we say can have a profound affect on the way someone perceives themselves and their current state. Unfortunately words that hinder rather than help can often easily trip off the tongue as they have been used so many times before!

Just staying away from certain words may help to not create detrimental nocibo effects.

• Rip
• Tear
• Instability
• Damage
• Degeneration
• Chronic
• Out of place

These words have the potential to alter people’s perceptions of their capabilities, beliefs and expectations for recovery. ‘Thought viruses’ is a catchy term regarding negative beliefs and how they can be generated and passed between people.

What should we say? Well that is an infinitely harder question to answer and will vary between individuals, there are certainly are no recipes here.

Hence why learning what NOT to say is often a great start!

2. Learn More About The Subject!

 

A criticism of our current educational processes is that they do not teach much about the mechanisms behind the experience of pain at undergraduate level or in many courses that deal with injury.

While it is a start to watch a few videos or read a few blogs, using the concepts of modern pain science should be underpinned by a good working knowledge of how pain works. A few buzz words or analogies probably aren’t quite enough to get it across to the target audience, especially when they have a habit of asking tricky questions.

Here are some questions it may just be worth knowing the answer to or how to explain:

What is pain?
How does nociception work?
What is central sensitisation?
What is peripheral sensitisation?
What are the supra spinal mechanisms involved in the pain experience?
What are descending inhibition & facilitation?
Why do stress, context & emotion have an effect on the pain experience?

3. Explanation Of A Complex Subject Like Pain Takes Practice

 

Everything is hard before it is easy - motivational slogan on a clipboard with a cup of coffee

People can feel under pressure to be able to ‘explain pain’ like an expert. Firstly you need the basic science then you need to learn how to articulate it and this does not happen over night.

As Einstein says, “If you can’t explain it simply you don’t know it well enough”.

Complexity and confusion during an explanation may lead to confusion and uncertainty in someone’s understanding and actually increase rather than dampen down someone’s pain experience.

Perhaps it is something that should be practiced away from a ‘live’ environment to build your own confidence and communication skills? Fuck it up a few times, learn from this and be ready to roll it out when you need it.

All the best presenters practice after all!

4. You May Need More Than One Analogy

 

Analogies have been promoted as a great way to get across complex subjects such as pain. As we use analogy so much in everyday life this makes a lot of sense but it is good to keep in mind always that these things depend on the person receiving the analogies previous experiences, cultural factors and education level.

SO if it ain’t working then switch it up.

5. Challenge Concepts And Not People

 

A great way to ruin rapport, which can be vital to the success of what you are trying to achieve, is to tell people they are wrong or make them feel stupid. Beliefs can be like superglue and adding confrontation into the mix can make things go downhill quickly. If it is not working STOP, maybe you can come back to it later or drip feed in over time.

6. Always Find Out How Someone Has Perceived What You Have Told Them

 

This is vital, it maybe the information you have presented is perceived in precisely the way that you did not mean it to be! Prof Kieran O’Sullivan promotes a most sensible course of action by asking “What would you tell your friends and family about what I have told you”.

This means any miscommunications can be (hopefully) remedied before they turn into ‘thought viruses’ such as “they told me the pain was all in my head”.

7. There Are No Recipes Or Protocols – It Is About The Individual

 

What works for one person may not work for another. Perhaps a plus for pain science is it points towards being person centred rather than having a specific protocol across humans such as more protocol based approaches do.

Strategies that have been promoted from the fields of psychology involve techniques such as exposure therapy and expectancy violation. We have to be careful that the patient/client identifies the specific fears and beliefs to be addressed, and hopefully inhibited, and this is not seen as a general concept.

8. Changing Beliefs Is Not An Instantaneous Process, An Exact Science Or Even Always Possible

 

As discussed in point 5, beliefs can be sticky and contagious between friends, family and work colleagues (even more so with Dr Google!). Rarely do people walk out from chatting with their therapist or trainer and suddenly change their outlook and opinion on themselves or beliefs they hold.

It could be a slow and laborious process (likely!) or in fact never happen at all!

9. People Often Have Their Own Epiphanies Away From You

 

Reconceptualizing can happen in mysterious ways with mysterious triggers, a bit like an apple falling on your head! You may have to wait for someone to come to their own realizations about the information you are giving them rather than expecting an epiphany in front of your eyes.

10. You Can’t Talk Tolerance Into A Tissue

 

One of the major parts of the BPS model is the B for biological. Just because you can help someone understand they are not fragile does not mean they suddenly develop an enhanced capacity for moving. The less you move the less likely you are to be robust at moving, that’s the SAID principle in action.

Someone once said “you can’t talk tolerance into a tissue” a very true statement. But you may have to talk to someone first to get them to do that work and get the tolerance!

11. BPS Model Is Still In The Minority Away From Social Media

 

For the eagle eyed yes it did say 10 and this is number 11!

It may feel like social media is awash with pain science from every angle to the delight of some and not to others! Go out into the wider world of the internet and shock, horror the actual real world and it feels like the information being delivered in the medical and training world regarding pain is still pretty traditional with structural and biomechanical factors being promoted.

Articles Of The Week August 9, 2020

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If you’ve been following this blog for any length of time, you know I love this guy. Here’s another great video on being a movement optimist when it comes to the low back and spinal flexion.

“Do You Need To Worry About Spine Flexion And Low Back Pain?” – Greg Lehman

Some new updates on helping people with persistent pain…however, patient centred care remains at the centre of our focus.

“Commonly Used Treatments For Chronic Pain Can Do More Harm Than Good And Should Not Be Used, Says NICE In Draft Guidance” – National Institute For Health And Care Excellence

When we look at some of the causes and issues around pain and specifically low back pain, things can seem fairly complicated. However, when we look at the modern research around this, it really doesn’t have to be.

“Simplifying The Treatment And Management For Low Back Pain” – Eric Purves

Inevitably we’ve all had a patient come in asking for “deep tissue massage”. But, what is this really?, it can mean different things to different people. Well, this is a great description and a modern narrative we can use when discussing this with patients.

“What Is A Deep Tissue Massage? A Modern Narrative” – Heather Thuessen

Do you have patients who are regular gym-goers, or athletes who come in for treatment because they’re sore after a hard workout? Well, there may be a dangerous condition result if they push too hard.

“High-Intensity Workouts May Put Regular Gym Goers At Risk Of Rhabdomyolysis, A Rare But Dangerous Condition” – Christopher Gaffney

 

Making Movement More About The Person, Not The Exercise

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So I was on Facebook the other day.

And I saw somebody trying to make the argument that this exercise with a Theraband should be retired from anybody’s rehab toolkit.

And their argument was that there’s far better exercises for a rotator cuff injury.

And I’m sure there are, and I’m sure that you could even use this in different planes and do different things in order to help a rotator cuff injury.

But what we have to understand is that it’s not necessarily about the exercise itself.

It’s about the person who’s standing in front of us and we have to make that exercise meaningful to them.

Because maybe their biggest goal is to just be able to put their groceries away pain free, or maybe it’s to pick their child up and if this becomes a meaningful exercise to them that helps build capacity, build resilience and makes it so that they can do those activities we just talked about, then this is just fine as an exercise.

 

 

How Changing Our Habits Can Change Our Practice

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Change can be difficult. Like, REALLY difficult.

In fact, we’ve written posts on here a few times regarding different ways therapists are stuck (or refuse to change) the way they practice. Quite often because of not wanting to include research in their practice, or committing to the new narratives around pain science etc.

If we did change, it often feels like a daunting task where the things we have been doing for so long have to change, and in turn there is sometimes fear around how our patients would react when this change occurs.

In the past, I’ve often chalked this up to the methods we use, or techniques we love become part of our identity and thus we don’t want to change.

While I still believe this to be true, it can’t be the only reason.

While reading a book recently, it dawned on me there could be another reason, which most of us probably don’t even realize. Mainly because this occurs subconsciously, it happens routinely, is performed regularly, and most of the time just happens automatically.

What I’m referring to a simple word that most of us don’t realize we are doing with every patient who comes in to see us.

Habits!

Little Seeds Of Change

Quite often when teaching or discussing different concepts around manual therapy with other practitioners, inevitably the topic always comes up “how do I incorporate this in practice”?

I’d say this is especially true with Massage Therapists and discussing how to begin including movement and exercise into treatments (this is just my take on discussions I’ve had with therapists, not the general rule).

There is usually a concern where the patient comes in and just wants to get on the table and get their treatment going. Even to the point of looking at their watch in an attempt to make sure they get their full hour on the table.

This was also true as I started getting interested in pain science and while learning along the way had to change my narrative with patients. I was genuinely worried (also due to my lack of confidence) that patients would think I sounded like I was out to lunch and start seeing a different therapist.

Well, the reality is, when I started doing more of both, not one of my patients ever looked at me and refused to do a movement, or told me they thought I was out to lunch (they may have thought it but never said it to me), and they very well could have because I’m sure it sounded like I was vomiting all this new information at them.

However, there is a way to do this in a much better way than I did when I first started trying to incorporate these things into my practice.

When we are trying to create change with a patient it’s usually about planting little seeds of information and playing the long game. It’s not always about making huge, grand changes all in one session. It’s about incorporating small changes over a longer period.

Perhaps it’s making one small change in an activity of daily living until eventually several changes are made and your patient adapts to a new routine or exercise until it becomes a habit.

So, if this approach can and does work for our patients, what if we took the same approach with our practice?

Changing Our Habits

In his book “Atomic Habits” James Clear breaks down how to build good habits and break bad ones.

One of the things I found really interesting was a quote from the book talking about habit change, I couldn’t help but relate it to how so often our techniques become part of our identity in our practice:

“The real reason habits stick is that it becomes part of your identity, improvements are only temporary until they become part of who you are”

“When you have repeated a story to yourself for years, it is easy to slide into these mental grooves and accept them as a fact. In time, you begin to resist certain actions because “that’s not who I am”. There is internal pressure to maintain your self image and behave in a way that is consistent with your beliefs. You find whatever you can to avoid contradicting yourself”

Just about everything we do in our clinic is a habit without even realizing it.

The way we greet a patient when they come in, the way we sit in our clinic room with them when they first arrive, the way our hands make initial contact with them when they’re on our table…all habits. We’re probably more likely to call it a routine, but these are all habits we’ve created, which is also part of the reason you’re successful.

Your patients REALLY like this routine.

And the thing is, so do we! It’s comfortable and familiar, which makes change all that much harder.

However, if we truly want to grow in our practice, it’s a matter of us deciding we will change, not making the patient change (although this will happen gradually).

This can also be daunting because it can feel like we’ll get left behind (making it all that much easier to stay in our groove), which is overwhelming, I mean, it takes 17 years before research is actually implemented in most medical practices, so it’s not like we’re going to get left behind by attempting to change what we do in our practice.

In this book, James talks about how to create new habits by doing something called “habit stacking”. To do this you identify a current habit you already do each day and then stack your new behaviour on top of the current one. As you begin to master the structure of doing this, you create larger change by incorporating more of these small changes until these new habits are formed.

Could we just start by asking one new question during our intake and do it with each patient one day, then the next, until it becomes part of our normal conversation with a patient? Once this becomes our new normal, we could include one graded exposure movement before each treatment? When this becomes part of the routine, start to incorporate movement into a treatment, then homecare, etc. Even if all we do is just change by a small fraction each day or week, this can have a profound change in our practice and our patients over the long term. As this adds up you can have some breakthrough moments that not only make you a better therapist but can enhance your career. And the best part is, while you gradually make this change, your patients will change with you without them realizing it. These changes will become an expected part of your treatment and hopefully, they won’t be checking their watch at the start of the treatment.

If you’re curious or want to know more about habit change and how it can help you and your patients, I highly recommend “Atomic Habits” which you can get HERE.

 

 

Articles Of The Week July 26, 2020

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This is a great podcast from a pain researcher and an exercise physiologist so you can better understand central sensitization and pain. Great stuff!

“Central Sensitization And Pain” – Ben Cormack & Melissa Farmer

You know if there’s something regarding exercise and pain, we’re going to share it. This one I really like as it focuses not so much on a specific exercise, but physical activity, and the person in front of you.

“Exercise And Pain, An Opinion Piece” – Rhyesson Cornilla

I really like this one, as I have a disdain for insurance companies due to my former life before being an RMT. But, this shows us how to help those who have pain, yet no objectionable measure of pain to in turn satisfy said insurance companies.

“Secondary Gain, Really?” – Bronnie Lennox Thompson

We are constantly talking to patients recommending self-care. But, what are we doing for ourselves when it comes to self-care? Here’s some dynamite advice on how to do just that.

“How to Customize a Self-Care Plan That Works For You” – Aleksandra Slijepcevic

This pandemic has changed a lot of things. One of which is the way we provide first aid to people. For me at work, we’ve gone through massive changes in the way we do things at the Firehall. For those of us in sport, this outlines some changes we should take into account.

“Medical Care And First Aid: A Framework For Organised Non-Elite Sport During The COVID-19 Pandemic” – Steffan Griffin

 

Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

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This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

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