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Articles Of The Week January 26, 2020

All too often we are blaming back pain on things like degeneration, aging, injury, and using surgery and opioids in treatment. But, as he usually does, Dr. Peter O’Sullivan sheds some better light on back pain.

“A Refreshing Take On Back Pain With Peter O’Sullivan” – Steve Katasi

We discuss pain around here quite a bit and there are many arguments that can be made regarding different aspects of pain. In this post wants to put the sensation vs perception debate to rest.

“Sensation Vs Perception Debate” – Richard McIlmoyle

He has taught us a lot about pain science over the years, but with this post, he shares his own experience with pain (which is really important for us to understand as clinicians).

“Personal Chronic Pain Update” – Paul Ingraham

Researchers have identified a new target of alcohol in the brain. A new study reveals alcohol blocks the KCNK13 potassium channel within the membrane of dopamine-releasing neurons in the ventral tegmental area.

“New Target Of Alcohol In The Brain Identified” – University Of Illinois

You may not deal with head injuries every day in your practice but you will probably see a few in your career. This article shows how football players can be affected by CTE (and it’s symptoms) as the case history of 111 NFL players demonstrates

“111 NFL Brains: All But One Have CTE” – Joe Ward, Josh Williams, and Sam Manchester

6 Steps In Preventing Harassment From Happening To You

 

“ If you let me go and leave, I’ll pick up the phone and tell the police I accidentally hit the panic button with my leg.” This was me, negotiating my safety with a predator who was a regular patient of mine. 

I was given the opportunity to pair up with theMTDC after reading posts that I feel are becoming more of an unfortunate regularity on Facebook. Those posts about therapists being subject to disgusting behavior or uncomfortable situations and I wanted to share my experience of being a female massage therapist, the situations I have had to deal with, and tactics you can use if (hopefully never) those times occur. 

Before we jump into details, just want you the reader to be aware some of these experiences may deal with sexual content and nonconsensual/ forceful touching. Read at your own discretion. 

 The Protection Of School

When you are a fresh RMT, building a practice takes priority and when uncomfortable situations come up, it can be really hard to confront those patients. I know when I was a recent RMT, I didn’t want to lose out on a patient; I wanted people to like my treatments so I would get referrals. 

A lot of the time when patients said off-color things, I would just awkwardly laugh and redirect the conversation. When I got asked out on dates, I would use the CMTBC by-laws or “I have a boyfriend, sorry,” as an excuse. I wasn’t well versed in establishing and maintaining my boundaries as a young therapist because school made me more fluent in muscular anatomy and postural dysfunction than it did with establishing boundaries. The tactics I remember vaguely were; redirect the conversation, get them to focus on their breathing, and if things were really bad, tell them the treatment is over and why, and leave. Instructors often shared their experiences, but unlike MTAR, there was no specific protocol if severe situations were to arise. 

As a student, I had male patients rub my legs when I was treating, make lewd comments about happy endings, and in one case, I had a male patient grab my face and kiss me as I was trying to help him put his shirt on after the treatment was over.

My instructors were great, always there to jump in and deal with patients, but this didn’t set me up for practice when I would be by myself. I was met with remarks like “ This kind of stuff you’ll very rarely have to deal with in practice. The general public has a way better understanding now that massage therapy is health care and not something sexual.” Said from a male instructor. In his experience, I’m assuming, that is probably true. My experience speaks differently though.

 When Real Life Hits

I have been in practice for 6 years now. I have dealt with the following; male patients ejaculating onto sheets, asking if I have ever had to deal with other men asking for happy endings, patients actually asking for a happy ending or if I knew a place nearby that would offer one, men calling in and asking for “ a petite or Asian female”, patients asking if I did house calls and saying “ don’t worry, I’ll change the sheets when we are done”, telling me “ If my wife ever saw what you really looked like, she would never let me come here again” or flat out asking me out on a date or if I had a boyfriend. I’ve had my butt grabbed and had a patient pull me into his lap during a seated shoulder technique I was performing. 

Most of these uncomfortable conversations ended the same way; I would freeze, maybe let out an uncomfortable laugh or redirect conversation, get them to focus on their breathing and after they left, I would send them an email saying that they were being referred out to someone who could better help them focus on their treatment as we weren’t a good therapeutic fit or something along those lines. I would never see those patients again.  If this sounds familiar to you, keep reading. 

I had the terrible opportunity of dealing with a professional predator. A new patient to me who found me online and became a regular. At first, our interaction was normal and professional, but slowly conversations started to drift into his dating life. I would redirect when this would happen, but one day he asked for my advice on how he should approach women and I said that was out of my scope of practice and that I could refer him to a counselor if he wanted to discuss his frustrations.  

Then he started talking about things that I was interested in, and I thought, “ Wow, what a small world. I never met anyone who liked a lot of the same stuff I do.” And treatment became comfortable with this patient again.  

The night before I was attacked, I called my mom to catch up; I had moved out recently and hadn’t talked to my family in a while. My dad needed to use the phone because someone was parked outside (not in the driveway, but on the road) in front of their house and my dad thought it was a drug dealer and wanted to call non-emergency. (Classic Surrey) 

I said good night to my mom and went to bed. 

The next day, while I was wrapping up with my second to last patient, my last patient arrived earlier than usual. My colleague and patient were just leaving when she said:

“ Have a good night! Can I lock you in with your last one?” 

My last, now knowing we were alone, probably thought this was his opportunity to attack. Now that I look back, he never did earlier because he never actually knew if I was alone because all the treatment room doors would always be shut if they weren’t in use and we had a central music system that would always be playing.

Treatment was typical, but this time he was asking me about hockey, and if I was a Montreal Canadiens fan. Surprised, I said I was, and he suggested, since he was my last, we should catch the game at the pub, he would even drive me home to grab my jersey. 

I froze; I asked, “ How do you know where I live? And how do you know I have a jersey?” 

He looked up at me and I’ll never forget the smirk, “ You tagged yourself in a picture of you and your dad watching the game. You should really talk to your family about their privacy settings on Facebook; Anyone can see everything.” 

I told him the treatment was over and he grabbed my thigh, “ No no no, I’m just kidding, c’mon let’s go watch the game.” I stepped out of his grip and said, “ You’ve breached our therapeutic and professional contract, I’m going to step out and you can leave” 

I run out of the room and the patient is quick to follow. (context here, I was treating his lower legs so he was fully clothed, probably now a thought out reason why he had me work on them, even with his shoes on), I just manage to press the panic button under the desk when he grabs my arm and pulls me in really close. 

“ I’m taking you out for dinner and I’m not taking no for an answer.”

My mind, going a thousand miles an hour through the Rolodex of previous experiences or something, ANYTHING relatable to grab onto and use, goes blank. 

The phone rings. 

I look him in the eyes, “ That is the Police. If I do not take that call, they will be here in 3 minutes. If you let me go and leave, I’ll tell them that I accidentally pressed the panic button with my leg. But you HAVE to leave now.” 

He lets me go, I pick up the phone and tell dispatch I accidentally pressed the button with my leg, and he smiles at me and leaves. 

Knowing Your Rights

It’s easy now, even as I write this to go, “ Jocelyn, tell them this guy grabbed you!” But when you are in an enclosed space with a predator, 3 minutes is too long. I was too embarrassed after that to ever say anything. All I told my colleagues was that I was no longer seeing this patient and if he calls, to refer him to someone else. I didn’t know my rights as to what action I could take, and as a newer RMT, I thought that the College could take away my license because I breached patient confidentiality if I reported this person to the authorities. So I tried to let it go.

It wasn’t until much later when my anxiety was so crippling that I sought counseling, I was made aware of my rights. However, when I was going to pursue legal action, this patient had lied about everything identifiable on his intake form, including his name. He always paid cash. There was no way of tracing him. He was a professional predator who was grooming me and knew from the moment he saw my photo online that I was going to be his target. 

I want to take this opportunity to share with you readers what my actions are and what my plan is when a patient makes me feel uncomfortable or unsafe. 

  1. Always go with your gut. If someone’s behavior, conversation or actions make you feel uneasy or unsafe, don’t shrug it off as just creepy or weird as we tend to do. 
  2. When your gut tells you something is off, don’t deflect or redirect. Address the concern head-on.  “ I would prefer if we moved away from this topic of conversation because it is not relevant to your treatment and is inappropriate for this setting.” Be firm. Don’t laugh it off, because they won’t take you seriously or think that is okay. If they say they are just joking or call you cold or that you are being too sensitive, tell them the treatment is over and you will be following up with an official discharge email. If you give them an inch, they will take a mile.   
  3. Don’t use the College or a relationship ( ie: I can’t go out with you, my college says I can’t date patients, or I’m married/have a partner etc..) as an excuse for why you don’t  want to do or engage in something. It’s easy for someone to follow up and say, “I won’t tell if you won’t”, and then the conversation goes in circles. Decline and say, “ I would like to remind you that this is a clinical setting and if you are seeking anything more than what I offer, which is only therapeutic treatment, I will refer you to someone who can continue your care.” 
  4. Know your surroundings and have a strategy prepared. I had recently posted my strategy on the BCRMT Facebook page. I suggest you meet up with your colleagues and have a plan ready, role-play situations and get used to saying those phrases; that way, they just come out easily when you need them too. 
  5. Never make it obvious that you are alone. Close another treatment room door and put music on in that room. If patients ask if you are alone or if they are your last for the night, say no. Colleagues, if you are locking another colleague in by themselves, don’t announce it to everyone in the office, just leave a note and lock up or have this as a known clinic policy that if someone is by themselves to lock them in. 
  6. Unfortunately, sometimes you can’t avoid when someone decides to attack you, self-defense lessons are a great idea. Under the law, you can fight as hard as necessary to protect yourself and get away safely. Your rights to safety and self-preservation under federal law are above any by-law. 

Finally, my intent for this post is not to scare or alarm you therapists out there; it is to prepare you. We are so knowledgeable in how the body works and can apply critical thinking to our manual therapy, but we need to have that same knowledge and strategies when it comes to our safety and boundaries. Do what you must to get comfortable dealing with uncomfortable situations, as I am not going to tell you that this is a rare occurrence. If it is in your experience, I say, it’s better to be prepared than it is to find yourself negotiating your safety with a predator. 

 

Articles Of The Week December 15, 2019

 

There is many a myth in our industry, and while I’ve written about and tried to change some opinions around them, I haven’t been able to cover them all. Fortunately, people like Daniel Wonnocott are trying to do the same and did a great job busting this myth.

“Mythbusting: Massage Reduces Cortisol” – Daniel Wonnocott

I’m sharing this because it’s simply an amazing cause that involves our profession. A group is Rwanda is training visually impaired people to be massage therapists, providing them with a career they may not have had otherwise.

“Seeing Hands Rwanda” – Seeing Hands Spa

There is no shortage of modality classes you can take to learn a different way to touch your patients. However, what if we paid more attention to the concepts behind a treatment application, rather than just the modality itself? I for one think this is FAR more important than any modality and fortunately, this article agrees with me.

“Modalities vs. Concepts in Massage Therapy” – Tania Valasquez

This seems to be a hotly debated topic at times, but it’s a necessary one. It’s important for our business, but also as this article shows, charging for late cancellations is also important for the therapeutic relationship and our mental health.

“Why I Charge For Late Cancellation” – Megan MacCutcheon

While I know (well, at least I hope) none of us are on our cell phones while talking to patients. However, there’s some good advice here about communication in general, and yes, we can apply this to when we are talking with our patients and improve not only our communication but probably our outcomes as well.

“Put Down Your Phone: Why Presence Is the Best Gift You’ll Ever Give” – Will Aylward

 

The Truth About The SI Joint That You Shouldn’t Ignore

Early on in my career, I’d have people come in with hip pain and like it was a script, I had an explanation ready.

I had a couple of go-to orthopedic tests, (Gillet’s, Standing Flexion, and Supine To Sit) and I’d boast about how their Ilium was rotated to their Sacrum. This, of course, resulted in a leg length discrepancy and had to be the source of their pain!

I’d do a muscle energy technique that would cause a loud “pop” from their pubic symphysis and this look of relief would wash over the patient’s face as if I had just done some sort of magical repair.

But, as time goes on not only have I started to realize that most of the above concepts were wrong, I was SUPER wrong for believing I was doing some magical repair (I’d like to think my ego has shrunk since then).

So, the question begs, what’s really going on with this darn S.I joint!?

Well…here’s what I’ve found out.

Rotation Of The Ilium

Whenever we talk bout the ilium rotating we are discussing nutation and counternutation.

Nutation is when the sacrum is moving in anterior/inferior…think to nod your head. The interosseous sacroiliac ligament (which is one of the strongest in the body) connects the sacrum and the ilium and prevents this movement from happening.

Counternutation is the opposite, moving in posterior/superior…think looking up at the ceiling. The posterior sacroiliac ligament connects the PSIS and the iliac crest with the sacrum and also prevents counternutation.

This is essentially what we were told to test in college and it was all about how the ilium rotated on the sacrum. So, we have to ask the question, how much rotation can there be?

The degree of movement is typically measured through the axis of rotation occurring through the second sacral vertebrae so the sacrum is performing its nutation or counternutation in the sagittal plane (the body in half from head to toe). The amount of movement is thought to be anywhere between 15° and less than 3°.

There is even discrepancy as to the direction of movements as one study showed that when a patient is forward flexing (like we do for some of the SI special tests) the sacrum was just as likely to nutate as it was to counternutate.

However, there are extenuating circumstances that would allow more movement in the joint such as those who have S.I. Joint disorders (which we will get into later), but when we look at healthy individuals who are perhaps experiencing some pain in the area we see much different numbers. One study actually showed in healthy individuals the average total rotation was only around 2°. They even examined 25 patients with sacroiliac joint syndrome and found the movement range to only be 1-3° with no difference between the symptomatic and asymptomatic side.

When we look at a goniometer or a protractor to see what 1-3° looks like, it’s pretty minimal and I dare say REALLY difficult to see with the naked eye.

So, we have to ask the question, are the aforementioned orthopedic tests accurate or valuable for us to use?

Well, a systematic review showed the use of Gillett’s test to evaluate movement of the SIJ to have a 47% intertester reliability, which shows this test to be unreliable. Because the movements are so limited and minute it is even suggested the movement would be impossible to see. 

Even if we’re doing tests to look for some sort of dysfunction, another review showed the most typical tests used were: Faber, distraction/compression test, focal SIJ tenderness, seated and standing Gillett’s, femoral shear, and modified Gaenslen’s were not reliable to show the likelihood of SIJ tenderness unless three or more of those provocation tests were positive, the pain was unilateral, the pain is below L5 without lumbar pain, or if pain increases with rising from sitting. 

Now that’s a lot to take into account especially if there is no history to suggest any kind of a pain or dysfunction disorder.

Of course, some of our patients will be referred for imaging, but even that isn’t helpful in the evaluation of SIJ pain unless looking for tumors, infection, or fracture, but hopefully, you’ve ruled some of this out with your intake by ruling out red flags.

What Should We Be Looking For?

If we look at a broader term, pain around the SIJ can be referred to as Pelvic Girdle Pain Disorders (PGP).

Specifically, when we look at this, the cause is around pregnancy, trauma, arthritis, and/or osteoarthritis, but excludes things like gynecological and urological disorders.

Pregnancy is one of the factors that we know can influence women to experience PGP as the effect of hormones (higher serum levels of relaxin and progesterone) affects the ligaments in the pelvis to increase their laxity, and possibly influences stability of the pelvis, but more research is needed to clarify how the role of hormones may differ in various presentations. However, this decreased joint stability can be compensated for by a change in muscle function. There is also evidence to show some of the risk factors associated with developing PGP during pregnancy is a previous history of low back pain and previous trauma to the pelvis.

When it comes to specific pathological issues like inflammatory arthritis, sacroiliitis, fractures, or infections there’s really not much we can do as therapists as manual therapy can’t address the underlying pain mechanism of the disorder, so, much of what we are doing is most likely helping with symptoms as opposed to rectifying the cause. 

Beyond these specific pathological issues there is another group of issues classified as Non-specific pelvic girdle pain disorders:

  • Non-specific inflammatory pelvic girdle pain disorder
    • constant, disabling, non-remitting pain in SIJ, provoked with weight-bearing, pelvic compression, and SIJ provocation tests.
  • Peripherally mediated (mechanically induced) pelvic girdle pain
    • Localized pain to SIJ that in intermittent and provoked and relieved by specific postures and activities due to directional loads and weight-bearing.
    • Usually, they have a clear mechanism or time of onset due to repeated strain or direct trauma.
  • Reduced Force Closure
    • Associated with excessive strain to the SIJ coupled with motor control deficits of muscles that do force closure of the joints (pelvic floor, transverse abdominus, lumbar multifidus, iliopsoas, gluts).
    • Common with postpartum PGP and a positive ASLR (active straight leg raise) test.
    • Functional impairment associated with, sitting, standing, walking, or activities that induce rotational pelvic strain coupled with spine or hip loading activities like cycling, or rowing.
  • Excessive Force Closure
    • Localized pain to SIJ and surrounding tissues, along with positive pain provocation tests.
    • Result of excessive, abnormal, and sustained loading of sensitized SIJ
    • Negative ASLR
    • Compression and local muscle activation (pelvic floor, transverse abdominal wall, back muscles, glutes, iliopsoas) is provocative.
    • Commonly associated with the belief the pelvis is ‘unstable’ or ‘displaced’ but exercise, massage (although I wouldn’t recommend this for the pelvic floor as massage in this area is out of our scope), stretching helpful for pain relief.
  • Psychological influences on peripherally mediated pelvic girdle pain
    • May be associated with underlying stress and anxiety.
    • It can be associated with faulty beliefs, and passive coping strategies, so we have to promote accurate beliefs, relaxation, and active coping strategies.
    • If associated with positive beliefs, and active coping strategies, then focus can be on physical impairments and work on helping with pain control.
  • Central nervous system driven pelvic girdle pain disorders
    • Associated with widespread, severe, and constant pain that is non-mechanical.
    • High levels of physical impairment, social impact, and abnormal pain behaviours.
    • Dominant psychosocial factors (catastrophizing, fear, anxiety, depression, history of sexual abuse).
    • Requires a multidisciplinary approach with medical and psychological management.
  • Genetics
    • People with PGP are more likely to have a mother or sister affected.
    • Possibly a social influence here as well.

While this may seem like a lot to take in, it actually simplifies things for us.

If there is no history of pregnancy, trauma, or inflammatory issues (which we should be able to rule out fairly quickly in our intake process), then we can look at psychosocial factors influencing their pain. 

Now, I know where many are going with this…we can’t treat psychosocial (or many arguing it’s not in our scope).

Well, maybe we can’t treat it directly (okay for sure we can’t, refer out to a mental health professional for that) but we can recognize their influence and work on our treatment and communication from there. Many of these conditions revolve around beliefs, stress, anxiety, catastrophizing, depression, fears, and social impact. We can most certainly address these things by giving some proper education around what they are experiencing. Explaining to them, their hip isn’t ‘out’, their ilium isn’t rotated, they don’t have an inflammatory disease, and pain is normal. Giving them relaxation techniques, helping with symptom modification, and coping strategies can all have a large impact on helping our patients with SIJ pain. However, more importantly ‘promoting accurate beliefs’, might be one of the most important things we can do. All too often we have patients come in who have been told they’re rotated, out, or misaligned, which puts the responsibility on us to educate and correct those beliefs. Sadly, I used to be one of the practitioners telling them this. If I could go back and apologize to them I would, but many of those people I don’t see in my practice anymore. While I can hope this is because I helped and they’re doing better (and I probably did with some of them), I hope that whoever they are seeing now isn’t reinforcing those old narratives, but is giving them more accurate information. I know the way I treat SIJ now, is different than the way I did 10 years ago and now that you have this information, I hope it changes the way you do because updating our narrative is part of our responsibility as healthcare professionals. 

Articles Of The Week December 8, 2019

 

Resilient is one of my favourite words and it’s something we should be working to instill in all of our patients. However, what about when we need to be resilient ourselves? This article gives some great tips and advice on how we can become emotionally resilient.

“How To Become Emotionally Resilient” – Marta Brzosko

You know how much we love pain science around here and the group over at modern pain care do too. Fortunately, they’re willing to share their knowledge and this even comes with a downloadable PDF so you can keep it handy in your clinic.

“10 Steps To “Pain Sciencing” With Success” – Modern Pain Care

Athletes love their ice baths and quite often take them because they see images of their sports heroes doing it as well. However, this may not be as beneficial as we used to believe and may even be hindering muscle growth.

“Cold Water Immersion Cools Muscle Growth” – Alicia Filley

It’s no secret that our healthcare systems need to change it’s the approach to pain management and how patients respond to pain. We need a push to get away from opioids and use more conservative care using education and multidisciplinary care, so it’s great to see major media outlets publishing articles like this one.

“Our Dangerous Fear Of Pain” – James D. Hudson

This is a great infographic to dispel the myth of knees over your toes in a lunge or a squat is a bad thing.

“You’re Over The Line” – Physio Praxis

 

Pain Education – What Might Make It More Effective

 

Pain education is a valuable tool for some, but certainly not all, patients. It can help to provide a narrative or explanation for problems that may remain unexplained by ‘traditional’ medicine or therapy.

This paper HERE regarding chronic lower back pain explores what people are looking for from a visit to a therapist.

more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management”

How tough is this in many instances with no clear diagnosis or causation available?

Up to 90% of back pain is described as ‘non-specific’ for this very reason. We know that uncertainty is a big deal for many patients. Mishel first proposed this in the “theory of uncertainty of illness” HERE.

Carroll’s paper HERE How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury” also discusses the process of diagnosis, uncertainty and the subsequent effect on expectations of recovery.

But although data suggests pain education can help it can also be very tough to deliver.

This quote from Louis Gifford sums it up nicely.

“The patient that learned from their pain explaining therapist that their pain didn’t really mean anything, who suddenly got out of the chair, went home and went riding their bike for the first time in 5 years…just doesn’t really exist!”

SO HOW CAN WE IMPROVE THE DELIVERY OF PAIN EDUCATION?

A question I often ponder is have we replaced anatomy with neurobiology? Do we now bombard people with complex processes involving brains, nerves, and receptors rather than complex biomechanical stories? How much neurobiology or neuroscience is actually required?

In some cases certainly it will be useful, but in many cases maybe it could actually hinder. This does not mean that some of the key concepts such as plasticity, sensitization and the brain’s role in pain are not important but maybe the minutia of information that can be focused on is unnecessary.

Perhaps we can apply some of the information in this paper HERE. Simplifying MRI reports appears to have a positive effect on how they are received. This may also apply to the delivery of pain education. What does nociception or Ion channel mean to a patient? It could end up very similar to VOMIT (Victims of Medical Imaging Technology) HERE if poorly delivered.

Should the focus now be on the delivery and context of information rather than the information itself?

CONTRIBUTIONS

I thought it might be nice to get some other opinions on some of the key elements that go into making successful pain education and reached out to colleagues from around the world, using social media, to pitch in.

Some of the key components I already advocate, but I must admit some others I had not considered and provide valuable food for thought for myself and perhaps also the wider therapeutic community.

I was pleasantly surprised by the elements discussed, almost none related to the actual information itself but instead on the delivery and thought process involved.

Here they are

Slide1

LISTENING

The most consistent point made by the contributors as a whole was listening.

Listening is a key clinical tool. Although pain education is often thought of as the delivery of information, it should start with listening. I think this is advocated on many fronts but as we know patients can often be interrupted pretty quickly HERE and this is always worth keeping in mind.

The desire to be listened to also appears to be valued from a patient perspective and helps to build therapeutic alliance HERE. This is probably vital for those receiving and processing the information. delivered.

This is a good paper on ‘listening as therapy’ HERE

VALIDATION

A couple of patients also contributed to the discussion and they felt that someone listening to and validating their experiences was a big part of their recovery. This also ties into the paper above regarding a patient’s perspective. If symptoms cannot be ‘medically’ explained or solved by traditional interventions, then patients may feel that they are being seen to ‘make it up’ or exaggerate their painful experience. All pain is real and although it can often be hard to describe it is also exactly the way that someone says it is. It cannot be anything else!

INDIVIDUALISATION

Another of the key points consistently put forward was about individualizing the delivery and placing into a relevant context. Now I personally have a bias for placing pain education in context with someone’s current situation. By weaving it into their story and using their painful examples to tie in some of the key concepts I think we are more likely to get some elements of comprehension.

This fits well with the key component of listening. Without listening we cannot place the information in the context of the patient’s narrative.

The question is, is this more effective than information generically delivered? I just don’t know. I think this would be an interesting comparison to study.

ASKING!

One thing I must admit to NOT asking was simply “do you want to know more about pain?” This was brought up by a number of people. This may avoid the very real problem of ramming pain science where it is not wanted. Pain science should be judiciously applied where it is needed AND wanted rather than a therapist dropping knowledge bombs expecting an instant epiphany.

IT IS NOT A PASSIVE EXCHANGE

Remember there are two equal people involved in this. It is not simply a teacher-pupil relationship. Patients lived experiences are also important. The therapist can also learn from the patient, especially when it comes to the patient experiences. Perhaps it should be seen as a journey by two people to find mutual meaning in a negative situation rather than simply an educational experience.

PAIN SCIENCE IS A WAY OF THINKING NOT AN INTERVENTION

One of the criticisms that I have seen recently of the application of pain education is that it is seen as a standalone intervention. So rather than bombarding people with statements or analogies that have been previously heard for explaining pain, the concepts and ideas should affect the way we reason, interact, explain and apply the treatment provided.

EXPERIENCES ARE AS POWERFUL AS TALKING

It’s not just about talking; doing is also a powerful educator. Perhaps sometimes talking is needed before and after the doing, but without the actual doing, we cannot ‘prove’ the point. Beliefs about the body are a good example of this. Without SEEING or FEELING a different, positive outcome to that expected, potentially a number of times, a belief may remain in place.

Again listening is key. What are the key experiences that need to be reconceptualized in a physical sense as well as a cognitive sense?

FIND OUT HOW YOUR EDUCATION HAS BEEN INTERPRETED

As with any part of the therapy process, pain education has the potential to have a NEGATIVE outcome as well as a positive one. We may well baffle people with talk of brains and outputs etc and HOW they interpret this information is the arbiter of success, however well meaning or comprehensive the input by the therapist.

This may boil down to wording, health literacy, and therapeutic alliance. The list of potential influencers is endless, but essentially the ability to mitigate any negative effects could be dependent on simply asking!

We may be able to influence this interpretation by being clear and concise, using bite-sized chunks of information, avoiding confrontation regarding beliefs and also avoiding negative or long-winded medical or anatomical jargon and terms.

REFLECTIVE QUESTIONING

Don’t just provide statements, also use reflective questioning. This may help to facilitate understanding and apply this new information to their own personal experiences and think critically about some of the beliefs they may hold.

Let’s say someone has a negative belief regarding their back because of a slipped disk a number of years ago. We could suggest that structure and symptoms don’t always display a consistent relationship. We could follow this up by asking if their symptoms come and go (as long term back pain generally does) and would this be a sole cause if the ‘slipped’ disc remained a constant.

Of course, this is just some opinion/s but collectively they could be valuable!

KEY POINTS

  • People are looking for answers
  • Uncertainty makes things worse
  • Pain education may provide some explanation
  • It is tough and often fails

SOME THINGS MAY MAKE IT MORE EFFECTIVE

  • Listening
  • Validation
  • Individualisation
  • Asking if it is wanted/needed
  • It is not a passive exchange
  • Pain science is a way of thinking not an intervention
  • Experience is as powerful as talking
  • Find out HOW your education has been interpreted
  • Reflective questioning