In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

To Predict Chronic Pain, Look to the Brain

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.

Motor Learning Pitfalls and Autonomic Resilience

Sometimes, I’ve found that teaching a movement cue to a client can backfire.

Coaching a neutral pelvic position or a braced core to do exercise, for instance, are great techniques to perfect a squat and deadlift and train a person to lift a heavy load. However, if a client experiences pain or discomfort out of a regimented exercise setting, are these necessarily the best strategies to focus on?

Very often, I’ve seen individuals become extremely hyperaware of their body mechanics, whether it was due to cues from a clinician or because the assumption is that patterns from high-load fitness routines need to be maintained outside the gym.

My experience is that this can result in a couple of problems.

Pain Science

 

One is a concept that you’re likely familiar with by now; that being catastrophization. If we, as clinicians, don’t mind our language during our movement coaching, often enough, a person can develop a belief that anything outside of these trained movement cues will result in injury.

As you can guess, believing that “losing form” will equate to pain can lead to that belief becoming a reality. This is classic fear-avoidance coping and is why someone can perform a 300lb deadlift and then throw their back out when they finally bend their spine to tie their shoes.

For this reason, it’s important to educate clients about the resilience of the body to perform non-deliberate movement as well as to mix these types of movements into their exercise programming. While it’s important for me to teach many of my clients how to do a proper hip hinge, it’s equally important to recondition them on how to round their spines to pick up a sub max load.

At the same time, it’s also crucial to teach clients that these cues are not meant to be minded for every movement in day-to-day activity. Again, this would enforce these fear patterns and lead to what we discussed above. However, it also enforces a reliance on deliberate thought to perform these movements, which takes us to our second point.

Autonomic Neuroplasticity

 

Once we remember to add in these additional “natural movement” cues to accompany exercise instruction, there might still be a disconnect between the clinic and real-world conditioning.

What we need to consider is that the conscious focus on movement in the clinic or fitness setting (whether it be a traditional exercise or a natural back bend) doesn’t necessarily translate to the nervous system being able to replicate those cues in a safe manner, subconsciously.

This boils down to neuroplastic deficits within the central nervous system itself following an injury, with altered motor patterns becoming the new norm (Grooms, 2016). We can describe this by thinking about the thought processes that lead up to movement. In an “exercise” environment, the signals that precede movement are directly to do with that specific motor pattern; sending the signal to the muscle and joint on what to do and how strongly and fast to do it. Outside of this environment, these thought processes are much more complicated and the movement will need to follow more complicated reactionary signals. For instance, often we will need to simply extend our arm, reactionarily, in order to catch an object rather than having that moment of anticipation to ready the nervous system and compute the necessary speed and force that will be required beforehand.

What this implies is that being able to do a back bend in the clinic when all of your focus is on it only gets us part of the way toward being able to do the same thing at home when relying on autonomic function instead of deliberate action. This is why athletes who have undergone ACL reconstruction and rehab can be, clinically, cleared to return to play yet still be 40 times as likely to reinjure their knee compared to their peers (Wiggins et al., 2016).

Clinical settings commonly revolve around focusing on internal cues when learning movement patterns, such as relaxing one muscle, stiffening another, or bending deeper at this joint. However, external cues, such as “reach for the floor”, “aim for the target”, or “focus on the field” have been observed as being incredibly important in sports settings. These cues help to bring the attention away from the body and to the environment instead, creating a more practical situation by decreasing conscious body control.

With ACL reconstruction, again, being the studied example (Gokeler et al., 2019), it is found that relying solely on internal cues does not provide the best outcomes for when external factors are finally challenged again. Even when rehab conditioning is extremely sport or activity-specific, an ability to do a maximal sprint in a controlled environment might fail someone when they attempt to do the same thing with real-world distractions added. For this reason, a lot of rehabilitation research is actually starting to involve the use of virtual reality (Grooms, 2015) to retrain autonomic capabilities.

Obviously, we don’t expect every clinic to equip itself with a VR headset. So that brings us back to the importance of mixing in external cues with the internal ones as we educate our clients in new motor patterns. The clinical setting can take a lot of great lessons on how to do this from the performance world, with a mixture of the two types of cues, periodization of a program, and an understanding of individual variance being hugely important factors.

Takeaways

 

So from all of this, we can understand that mechanical cues and deliberate exercise patterns are still a step in the rehab process. Throughout, however, we need to reinforce that a client’s well-being is not dependent on these patterns being maintained around the clock or that conscious control does not need to be exerted over their maintenance.

Finally, we also need to remember that the quiet, clinical environment is usually not one that our clients spend the majority of their days in, so we also need to prepare them for the real-life hazards, distractions, and mental states that their normal workplace, sport, and home settings will challenge them with.

A client’s life is individual, and so is the preparation for it that we provide.

A Simple Guide To Patient Centred Exercise

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient-centered care’ or PCC for short.

Now for a buzzword, it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient Or Person?

Most of the available literature in this area discusses “patient-centered care” but I much prefer “person” centered care as it turns the patient well ….into a person and a much more ‘real’ entity in a two-way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlight the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What Actually Is PCC?

Maybe by definition, PCC is tough to define for all? What is person-centered for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centered care has previously been defined as:

“willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems” – Stewart 1995

“the physician tries to enter the patient’s world, to see the illness through the patient’s eyes” McWhinney 1989

Two-person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz, and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient-centredness”

  • The biopsychosocial perspective (the patient’s life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC Is Not

There are some criticisms of PCC that seem to centre around the idea of consumer-driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain the problem
  • Present options
  • Discuss the pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer the decision
  • Arrange follow-up

 

What Do People Really Want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end-user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel, and ultimately need.

This is a really interesting paper regarding a two-person perspective in back pain Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership With Practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask Me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

‘Understand Me’

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen To Me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   – Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction

Does It Matter?

A question I often hear asked about person-centered care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an effect on outcomes we don’t know if PCC specifically improves the most common outcome measures, but, in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function, or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the person’s experience in healthcare (which might be an outcome measure in itself).

 

The Application Of PCC

Maybe we should NOT see a person-centered approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead, it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting With The End In Mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently, and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding is, in my opinion, the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system”  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert-driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” – Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully, this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals, is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person-centered approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared Decisions And Responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to have an influence on exercise outcomes “Autonomy: A Missing Ingredient of a Successful Program?”. Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move, and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally, it is a therapist’s responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each other’s responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family, and social pressures. One of the best ways to implement a BPS perspective is to realize that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort, and sacrificing something else.

People don’t just need something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place, and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from From’Non‐encounters’ to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low-cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than a healer can be really helpful for many!

Support & Motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite of walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” – Holopainen 2018

 

Conclusion

 

  • Person-centered care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down

10 Tips For The Practical Application Of Pain Science

 

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.

Making Movement More About The Person, Not The Exercise

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.