A Practical Guide to Persistent Pain Therapy

Know Pain

Meanings of Pain

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I would like to invite you all to like the @Meaningsofpain Facebook page. The page is linked to the forthcoming book, Meanings of Pain (Springer 2016). The book aims to improve understanding of the link between meaning and pain, and to stimulate further research in this area.
 
The isolating and unpredictable nature of pain frequently leads to a chaotic narrative where people seek meaning. Without this sense of meaning, the experience of pain often remains unexplained and invalidated.
 
I am delighted to have been asked to write a book chapter entitled, Seeking Order Amidst the Chaos: The Role of Metaphor Within Pain Reconceptualisation for the forthcoming book, Meanings of Pain.
 
As with the entire book, I hope that this chapter takes you on a journey of discovery. A journey from chaos to order. A journey unlike any other where we’ll attempt to unravel the complexities of communicating and understanding pain & distress.
 
As you’ll discover, it can be an extremely hopeful & optimistic journey. Yet, at the same time, it can also be a terrifying & pessimistic voyage. Metaphors can help or hinder people’s understanding of pain. This chapter will aim to develop your understanding of this dilemma, whilst also highlighting examples from within practice to guide you.
 
Ok. We’re not really going on a journey, nor are we going to unravel anything. Actually, come to think of it, nor are we going to stand underneath anything. Words such as ‘understand’ act as a reminder that metaphors live a concealed existence all around us. They are an essential part of human communication and can be crucial to how we communicate, learn, discover and create meaning.
 
Metaphors are used when conveying experiences most resistant to expression. Pain is one such experience!  

Today, I am angry: A guest blog by Marie Bourgeois

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A guest blog by Marie Bourgeois.

Today, I am angry.

As medical practitioners, we are often not equipped to deal with human complexity. We were taught to deal with pathology. We were told we would have to explain to our patients what they have to expect for their future. We were told that we might not be able to fix some people and that they will probably need surgery. But we were not prepared for the enormous teaching role that our work involves.

Six months ago, I saw a teenager. 17 years old, a student beautician, wanting to have a long and beautiful life with a future husband and children.

First time I saw her, she was paralyzed by fear. She couldn’t move really more than 10° in each lumbar plan, she was dealing with an awful pain… And she didn’t want to be here. She cried during all the session… and yet, I didn’t even ask her to move more than what she did to come to the clinic.

She was crying because of fear and anxiety. She was crying because she already had a physical treatment and – as can happen – it hurt her, without any benefit.
She was crying because she had been told that, as her dad had to go (twice!) to surgery because of a herniated disc, it would be probably the same to her – sooner or later. She was crying because she had been told that a job as a beautician, with low back pain, is not a job for her.
She was crying because she had been told pregnancy would be difficult to her because of her lumbar spine. She was crying because she had been told the day she would give birth she will not have epidural anaesthetic because of her lumbar spine.

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17 years old, and she was paralyzed by fear. 17 years old and she couldn’t picture any future she wanted without pain and suffering in either her private or professional life.

I was angry. I was sad. I felt ashamed because the practitioners she was examined by were probably thinking they were doing the right thing. As I have done to other people: I have told other patients, for their own good, they had to change the way they live.

« For their own good »…

We are all guilty of overly paternalistic care and one-way advice giving at some point. We are not prepared to deal with humans. Only with pathology… And sometimes, when we don’t know, it is easier to say that this activity is bad to the patient than saying “I doubt I am the best to help you to do this again.”

I changed. I am far away from perfect, and I have a lot of things to improve. But changing helped me to deal with this young girl. To help her to feel better. This helped me to not focus on the pathology but on the human I had in front of me.

She worked hard, and she is smart. She understood a lot of things. She felt better, she smiled again, and she finally was feeling better than before her pain crisis. Everything was fine…

… Until she experienced pain again.

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I had a session with her yesterday. She spent the entire session crying again. She had pain in her leg, “Like my dad”. She had paraesthesia, “Like my dad”. Sometimes, her legs barely supported her, “Like my dad”.

I am angry because of the communication problem there was with this young girl. I am angry with myself because I seriously thought she had overcome her fear. I am angry at the system because we are not prepared to deal with the complexity of human emotions, to deal with the brain. I am angry because she knows it’s going to be better. She knows it’s hard, and yet her pain is going to improve again. And she is still as scared as the first time I saw her. She is still thinking her life is ruined. And yet, nothing is damaged inside her back. But she is now paralyzed by fear every time she feels pain.

I am angry. We, as medical practitioners, are inducing and conditioning fear in others. Even though our bodies are equipped with some amazing abilities to self-repair. We, as medical practitioners, are inducing ongoing pain… by doing what we think is the best for our patients. I am angry. We never learned how to deal with human conditions, how to explain complex problems to somebody, to explore feelings, to overcome fears, to promote happiness. As a student, all I was taught was how to deal with the pathology, and to ensure that, “You don’t involve yourself too much, you have to put a therapeutic distance between your patient and you.”

I am angry. And I will try not to forget this young girl next time I have to explain something. Words are like toothpaste. Once they’re out the tube, you can’t put them back in!

Thank you for reading.

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Marie is a French physiotherapist who works in Toulouse.

The Voldemort Effect: A Guest Blog by Jack Chew

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It’s not news to anyone aware of my podcast, previous blogs or twitter feeds that I’m quite the fan of ‘stirring the pot’, and that my contrarian tendencies often walk me into glorious and inglorious disputes and debates. Some bear fruit and progress ensues, others quickly descend into snide remarks and a dozen emojis… But recently, I’ve clashed with colleagues who are my usual allies over one particular topic; one that I refer to as ‘the liberal use of language’. 

To clarify from the off, I loathe the suggestion that ‘the pendulum has swung too far’ when it comes to professional and societal understandings of pain, function and more broadly, human health. BUT, I am certainly concerned about the tactics being used by some ‘thought leaders’ and their followers as they try to move beyond the ‘hurt equals harm’, tissue-centricity that remains commonplace. This concern is related to their apparent willingness to implement whatever strategies they like to achieve this goal; at times this includes the overlooking of both logic and evidence. 

To simplify a little, I’ll focus specifically on what I see as a self-induced phobia of talking about human anatomy. An example to set the scene: 

A 30 year old laborer was assessed by a therapist following an injury at work. He was in a tight corner lifting breeze-blocks that would normally require assistance but instead, he tried to wiggle it out of the space alone. He did so with a flexed and rotated spine then felt sudden back and leg pain which he had not experienced before. A few weeks have passed with little resolution, he is now off work and, as is the nature of modern society, every friend, family member and shopkeeper’s dog have given their take on diagnosis and proposed solution. Fortunately (ish) he has seen his GP who has prescribed some medication and advised him to avoid bed-rest. His social consensus diagnosis of ‘slipped-disc-trapped-nerve’ is neither supported nor refuted by his doctor but fortunately (ish) he was encouraged to see a local Physiotherapist. 

4 weeks later, subjective assessment by said Physio reveals significant concerns regarding work, sport, general ADL function and what the future might hold for him. All of which are completely legitimate and sensible concerns when efforts are made to view the problem through the patient’s eyes, especially in light of his current education regarding pain, injury and bioplasticity. Objective assessment reveals certain directional and positional preferences, tenderness in the lower lumbar spine and buttock, a positive straight leg raise but fortunately, no sign of significant neurological compromise such as myotomal weakness, reflex changes or overt sensation loss. 

Now it is far beyond the scope of this blog and far beyond the reach of my current patience to discuss exactly how this patient should be treated and managed. Instead I will draw a line in the sand here and say that in my opinion, any failure to explain the likelihood of this man having had a disc injury that is affecting a nerve root is nothing short of dishonest. 

How we go about doing this is where the conversation gets interesting of course, but any purposeful avoidance of the words that the patient brought to the conversation, is linguistic gymnastics that are very likely to make you (as well as the team, company and profession that you represent) look like idiots. 

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We now treat discussions with patients regarding anatomy, tissue physiology and structural injury with kid gloves. While our good intentions make us sensitive to the contemporary understanding of pain, and keep us from labeling disruption of structure as the only causal factor in pain experience, I argue that we are beginning to do society and our profession a gross disservice. 

And so to my naming of this blog and the suggestion that many in the MSK industry are succumbing to what I call ‘The Voldermort Effect’. 

Odd as the comparison may sound at first, failure to discuss structural injury, at least initially, in the terms that the individual has come to understand it, is doing the same disservice that members of the magic community did by refusing to mention Voldemort’s name in JK Rowling’s Harry Potter books. By refusing to label him, they prevent an open and honest discussion from taking place about possible solutions. And that is where mainstream Physio reformers find themselves today with regards to morphological and patho-physiological lexicon. The idea that we must avoid words that are well established in society due to fear of mortally wounding patients is rank hypocrisy that patients are very likely to see through. 

How does this sound?: 

“Your body is strong and robust with a wonderful capacity to adapt to the stresses and strains placed upon it. It will adapt regardless of your age and given the right stimuli, it is amazing what biomechanical and morphological quirks it can accommodate. 

But your mind will latch irrationally onto words, regardless of the context in which they are discussed. Because unlike your body, your mind is invariably fragile and so we mustn’t take any chances.” 

This ‘new-age dualism’ is bound to push patients back towards the pseudo-truth-tellers who, through ignorance and/or laziness and/or profiteering, will continue to attribute cause of pain to specific tissues. 

‘He who shall not be named’ came back with a vengeance and the denial of his existence facilitated his reincarnation. Similarly, the failure to discuss anatomical structures in a patient’s own familiar terms is bound to give fuel to our nemeses and thwart the progress that we all dream of. 

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I must point out that I have landed on this analogy through my interest in Liberal Democrat MP candidate; Maajid Nawaz who makes the same comparison to President Obama’s inability to name recent acts of global terrorism as ‘Islamic Extremist Terrorism’. I welcome you to draw the parallels between our causes, as always, I have my take, but most importantly it would be unfair of me to not mention his influence on my use of the term. So if you’re interested, this short clip explains his own use of the analogy very well: https://www.youtube.com/watch?v=6BQWqFyRpFQ 

And yes, I’m suggesting we should talk about structures regardless of presentation and duration of symptoms if that’s what the patient wants to talk about. Because patients kind of matter in the whole ‘getting better’ process, right? The merry dance that some clinicians have found themselves doing to avoid certain words is very impressive, but the notion that a therapist would be admired for opening their explanation of assessment findings with ‘well, pain is emergent and we’ve come to understand that every person is influenced by biological, psychological and social factors’ makes me shudder and genuinely fear for the future sanity of my soon to be burnt-out colleagues. 

I’ve long banged the ‘mind your language’ drum across all media, but I would suggest that I’ve been misunderstood if it has been thought that my mission is police language in an oppressive manner. 

Mainly because words are just words. 

Many are aware of the brilliant research of Ben Darlow and others regarding the impact that language can have on patients; and I am not for a second countering this work, since I have long promoted it. However I feel that a simple but intellectually dishonest interpretation of such work has infected the minds of many well-meaning reformers who seem to attribute power to words that they simply don’t have. 

Words are just a series of letters. Letters are just a series of lines. It is our history, culture, language, consciousness, emotional maturity and many more factors that have led to some words having more meaning and connotations attributed to them than others. Forgive my over-simplification here but it is through this complex sociological process, coupled with complex individual biological and even metaphysical processes that some words can sometimes influence beliefs. 

(This is what makes language so incredibly interesting, but I won’t assume that anyone is nearly as geeky as I am about the topic, so I’ll skip a chapter on linguistic theories… this time.) 

But I can’t help but prioritise a plea for recognition of the widely respected concept that it is when words influence beliefs and when beliefs influence behavior that we should be most interested. Because these processes of influence can be demonstrably affected by our interactions, and therefore the impact that we have on any individual’s life. 

I agree that clumsy use of jargon and structural reasoning has clearly demonstrated that we can have deleterious effects on these processes, but the answer is surely not to kick back so hard against it, as to stop using words altogether?! 

How about we instead aim for honesty? Human pursuit of truth is an incredible thing so why not aim for delivery of our very best guess at that moment in time? 

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This approach means that using the term ‘crumbling’ to describe a spine remains off the table, because it’s dishonest. But using the terms ‘bulge’ or ‘fracture’ surely can’t have such deep-rooted negative connotations that they mustn’t be uttered in case they do irreparable damage, even when they are immediately placed in context? 

Failure to talk about Voldermort did nothing to contribute to his existence and if anything, it fuelled the fear and mystery surrounding his power. We are seeing language being policed in all walks of life contributed to by ‘social justice’ movements and a new wave of Marxists suggesting oppression where it doesn’t exist. So instead of inventing our own brand of ‘political correctness’, could we instead reclaim the words, reframe them, attach reassurance to them, add humour to them, laugh at our historic mistakes and drive a process in which we are honest with our fellow human beings about what we think is going on at any given time? 

In a recent in-service training session with the brilliant IPOPS band 6 team, we discussed the concept of individuals and groups being happy to promote or condone dishonesty if they perceive it to be in the ‘right direction’. This is a dirty tactic that we surely can’t succumb to at an N=1 level in clinic. 

We all have our favorite topics attached to our specific agendas, especially on social media. The ease of the retweet to support our general narrative is something than no-one is immune from. But at a clinical level at least, a push for balanced honesty is surely the only way to stop the swinging pendulum of patient education becoming a wrecking ball. 

In a nutshell: think hard, be critical, be reflective and then say what you want!* 

*Including about this piece! 

Chewy

Physiopedia Interview

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Last week I had the great pleasure of chatting with Rachael Lowe from Physiopedia about pain education. I hope you find our chat helpful and thought provoking. 

Thanks for watching.

Bournemouth 20th & 21st August 2016

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I am delighted to announce a Know Pain course in Bournemouth

on Saturday 2oth & Sunday 21st August 2016


For more details about the course, please click the link below:

Know Pain Bournemouth


The course will be held at

Physiotherapy Department

The Royal Bournemouth Hospital

Castle Ln E, Bournemouth BH7 7DW

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Special Promotion!

20% discount (£220) for multiple bookings of 2 or more people.

Email mike@knowpain.co.uk and quote KPBOURNEMOUTH20 to

take advantage of this offer.


There is limited availability for this event so make sure you 

reserve or book your place early.

Click below for the booking form:

http://knowpain.co.uk/course-dates-2/course-bookings/

The 12 Know Pain Tips of Christmas

The 12 Know Pain Tips of Christmas

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So, it’s that time of year again. You’re working out how many kilos of Brussel sprouts to buy, whilst simultaneously planning a festive season to rival Santa’s workshop! Christmas is not the easiest time to consider your health and fitness, so here at Know Pain we’ve put together 12 handy tips to help you stay on Santa’s nice list.


Top Tips

1. Ready for winter? Preparing for bad weather can prevent a lot of trips & falls. Keep paths clear and buy grit salt to melt ice.

2. To help prevent falls check there is still tread on the soles of your shoes and slippers. Also check the rubber grip on walking sticks.

3. Keep moving! Make walking and stretching a regular part of your festive period.

4. The days of ‘No pain, no gain’ are gone. If it hurts to do exercise, then it’s the body’s way of saying “I shouldn’t be doing it that hard!” Hurt does not always mean harm so it’s important to get moving at a comfortable level. This applies to all activities (wrapping presents, shopping, cooking…the list is endless!).

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5. Physical activity is good for the mind, body and soul. Daily exercises will boost your fitness, mood and decrease stress levels. Motion is Lotion!

6. Tense your bottom muscles every time you steal a chocolate tree decoration! When it comes to exercise, little and often is the motto.

7. Don’t make exercise a chore. Exercise is your playtime – whatever you do make sure it’s fun!

8. Exercise is for life and not just for the young…you are never too old.

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9. Use your home gym! We all have gym equipment at home. For example, try repeatedly sitting & standing from a chair. Think…what does this part of my body do & then gently move it!

10. When watching TV – get up and walk around when the adverts come on. It’s important to change your posture regularly. You wouldn’t keep your finger pulled back for a long time. Your spine, knees & shoulders are no different.

11. Nothing changes if nothing changes! Think of something in your life that you’d like to change. Now make a list of the pros & cons of making that change.

12. A journey of 1000 miles begins with a single step…if you are attempting activities that are new to you…remember – Start easy & build slowly!


 

Have a wonderful Christmas & a Happy New Year!

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#selfmgt TweetChat 11th November 20:00 GMT

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Following the excellent discussion during our first TweetChat, Pete Moore and I have arranged another TweetChat at 20:00 GMT on Wednesday 11th November. This provides a great opportunity for people in pain and healthcare professionals to come together to discuss the issues that matter. 

For more information about this event, please click the link below:

http://www.paintoolkit.org/news/article/pain-toolkit-selfmgt-tweetchat

#PainTalk 8pm UK Time Wednesday 16th September

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At 8pm Uk Time on Wednesday 16th September, myself & Pete Moore from Pain Toolkit will be hosting a one hour TweetChat (#PainTalk)

to discuss 4 hot topics about pain management.

This online event is free of charge and is open to everyone.

Pete and I would like people in pain and healthcare professionals to consider the following 4 questions for the #Paintalk discussion…

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More information can be found by clicking the link below:

http://www.paintoolkit.org/news/article/tweetchat-paintalk-with-myself-and-knowpainmike-16th-sept-8.00pm-uk-time


We look forward to welcoming you to #PainTalk

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Beyond Words

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No matter which sense we use, most attempts to express our perceptual experiences fall short of the mark through words alone. Think about how people express their love for one another or how they attempt to describe the experience they have when drinking Merlot. 

Here’s an extract from an article in The Telegraph newspaper which highlights this point beautifully. The following words are those of J. Ray. As the newspaper’s wine buff, Ray felt obliged to provide a counterargument to the scientific discovery that wine buffs talk rubbish… 

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“How does one describe what scrambled eggs tastes like, or smoke smells like, without comparing them to something else? So it is that we wine lovers might describe a wine as tasting of truffles, leather, game and rotting veg. Well, dammit, that’s what old red burgundy often resembles. It certainly doesn’t taste of grapes.” J. Ray 

With it’s idiosyncratic and cluttered complexity, pain is very much alike in it’s desire for creative expression.

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Here’s an interesting read on the subject…

Finding a visual language for pain: 
http://www.clinmed.rcpjournal.org/content/2/6/570.short

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The French artist Henri Matisse (above) notes that, “Creativity takes courage.” I lose count of how many times I use this quote when teaching healthcare professionals. If we are to help people in pain to make sense of their distressing experiences, we must encourage them to step outside of language and explore other means of expression. Without this, we squander opportunities for empathy and therapeutic connection. 

So next time you find yourself sat in front of somebody in pain who looks like one of the faces you see below when you ask, “What does your pain feel like – sharp, stabbing, achey?” or, “How would you describe your pain on a scale of 0-10?”, it is time to get seriously playful and embrace creative practice.

Don’t forget that large dose of courage!

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FURTHER LEARNING

To hear more about the use of imagery and metaphor when helping people make sense of pain, listen to my podcast chats with Jack Chew and David Pope by clicking the link below:

http://knowpain.co.uk/resources-2/podcasts/

Also, you might like to test your metaphor knowledge by taking the metaphor challenge here:

http://knowpain.co.uk/resources-2/the-metaphor-challenge/

Finally, this wonderful presentation by Dr Deborah Padfield is a must watch:

 

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A Practical Guide to Persistent Pain Therapy

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