I’m delighted to welcome Liam Swain to the Know Pain blog. I had the pleasure of meeting Liam recently having arranged a Know Pain workshop together in my home county of Kent.
Here, Liam reflects on an experience where he unintentionally instilled a worrying belief that led to his patient linking pain with instability. His story acts as a reminder for our need to attend to what we say and how we say it.
Before I begin to explain the moment I realised the importance my communication, let me first introduce myself. I’m currently a Band 6 physiotherapist specialising in MSK, working for the NHS and privately for Rainham Physiotherapy Centre.
During this blog I will take you back to when I was a very new band 5 physio on rotation to the outpatient setting. I can recall this assessment vividly, I have done and will continue to use it as an example to colleges. I was referred a pleasant 35 year old lady with low back pain, roughly 4/10, worse in the morning and after prolonged sitting at her desk. She presented with no red flags and no neurologically signs and a very limited medical history.
Her objective examination was generally good but she basically needed to increase her activity level, flexibility and global strength. At this point in my career I used ‘Core Stability’ exercise as a common treatment option for LBP patients. Now I have weaned my use of this “bandwagon” and I will discuss my use of this in later pieces. I’m not really sure how I fell into the overused treatment, perhaps it was bias from a clinical educator from my student days, or did I not look at the whole picture, was it a popular and easy choice? Probably a combination of the above, back to the point…
I can remember my last 10minutes of my first assessment with this lady;
“So what you need to work on is your ‘Core Stability’… basically the muscles that support your back are weak, so we need to get you stable”
WOW did I just say that? YES!
So 2 weeks later she returns;
“I’ve been very careful Liam, trying to keep my back stable as its weak like you said”
In the last 2 weeks of her life I made this lady catastrophise. Was her spine unstable? No. Were my exercises wrong? Not completely (although I wouldn’t give them these days). So what was wrong? My communication.
Let’ s pick apart the term stability;
The dictionary states; not likely to fall or give way, as a structure, support, foundation. Able or likely to continue or last; firmly established; enduring or permanent. When used at the Shoulder we would think it risks dislocation or subluxation According to Darlow et al’s work (2013) patients perceive the word instability as “likely to pop out”, which this poor lady was imagining! And was it? No her back wasn’t like Tiger Wood’s sacrum that could be popped in and out! (again another poor use of communication). Bearing this in mind how would it make you feel to be told your back was unstable? I’d be scared and the last thing I would want to do is move. I’d brace myself, hold my breath and not move my back…all of the above drive a pain response, and this is what happened.
So what has changed?
Firstly my treatment choices have improved but far more important my communication. How reassuring is it hear “there’s nothing untoward going on in your back, it’s just a case of some simple exercises and modifying your activities, you’re sore but safe”.
I’m a firm believer that first and last impressions are essential. Leaving on a negative note i.e. you’re ‘unstable’ leaves this message with the patient regardless what you’ve previously said to them. It can increase catastrophizing, worry and fear, hence my patient was worried sick every time she moved, from anything to getting the milk out the fridge to getting out of bed.
Since this I have attended a Cognitive Behavioural Approach course and more recently Mike’s weekend “Know Pain” course, and without sounding like a shameless plug, I would highly recommend and my practise has changed greatly as a result. With less than 1% of undergraduate time being spent on pain education how can we as a profession be confident in educating patients in the one thing most have in common? PAIN! I am now far more aware of the nocebo effect and how my language (both verbal and non-verbal) affects what patients take home, we all have and probably will use terms like ‘slipped’, ‘unstable’, ‘wear and tear’ and it’s so vital to remember what these simple slips in our communication can do to patients (Darlow’s paper from 2013 explains this brilliantly)
Upon reflection I listened to what my patient said to me;
* I’ve been told my pelvis is out of alignment
* My fitness magazine says Pilates will cure back pain
* My mate needed surgery
* I know people in a wheelchair because of their slipped disc and crumbling spine
Thinking about these sort of things made me realise how impressionable patients are and hence why communication is vital. Anything from a friend or family member having a similar issues, to what the GP said, to what the daily newspaper claims is the latest cure for pain. I think it’s vital to step back and think; would I be happy with this education if I didn’t know anything about the body? Would my mum understand what I just said? It’s too easy to get ourselves in the ‘physio mind-set’. That’s not me saying simplify everything, but be sensible and adapt to your patient, explain what’s going on, explain what pain is, how what you propose will help and don’t let a patient leave thinking their spine is “unstable”!
Hopefully that little case study has shown how I realised (the hard way) the need for better communication.
If you’re on twitter follow me @liamswain7 for bad jokes, biased football opinions and more frequently physio related discussions and evidence, oh and very bad puns.