A vet’s approach to fear, pain and mobility

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I was delighted when Dr Marianne Dorn, a veterinarian and physiotherapist, got in touch to discuss her work with me. Having listened to my Physioedge podcast with David Pope (http://physioedge.com.au/pe-035-know-pain-mike-stewart-part-1/) Marianne was keen to discuss her experience of working with distressed animals and has kindly written a guest blog to share a vet’s approach to fear, pain and mobility.     

Healthcare professionals who work with fellow human beings regularly encounter behavioural and linguistic displays of vulnerability from people in pain.  Ben Darlow and colleagues recent work – Easy to Harm, Hard to Heal: Patient Views About the Back (2015) (http://www.ncbi.nlm.nih.gov/pubmed/25811262), reveals such displays. 

This characteristic vulnerability that so frequently accompanies pain led Louis Gifford to the formation of his Vulnerable Organism Model. In his 2005 editorial for the Physiotherapy Pain Association’s News publication entitled, The sickness response and the vulnerable organism – When you’re low you hurt more easily (https://giffordsachesandpains.files.wordpress.com/2013/07/issue-19-editorial-vulnerable-organism.pdf ), Louis suggests: 

“The notion of a ‘vulnerable organism’ should provide a management opportunity – with the underlying goal for the patient to feel strong, confident and fit and the goal for the therapist being to help get them there. A simple change in mood may be enough – it’s surely a common clinical observation!”

Whilst there are obvious distinctions between human and other animal responses to pain experiences, there are also some striking similarities that highlight our need as healthcare professionals to provide reassurance through the detection of vulnerability, and through skilled verbal and non-verbal communication. This includes touch!

Therefore, it gives me great pleasure to introduce Dr Marianne Dorn’s guest blog.  

 


 

A Vet’s Approach to Fear, Pain and Mobility

Working in the UK as “The Rehab Vet”, I help restore comfort, confidence and mobility to dogs and cats referred to me with all kinds of orthopaedic and neurological issues. I am forever searching for strategies to understand and help my canine and feline patients, and so was interested to hear Mike’s views on the Physio Edge podcast.

One point that he brought up was the link between fear, pain and reduced mobility in his human patients. Now this is also a key concept for my small animal patients – so I just had to get in touch with Mike and share something of my experiences from the veterinary field.

Many pets feel anxious at times, even if their family and health-carers have the best intentions. This is particularly the case in those experiencing chronic pain and/or mobility issues. Just getting around the house and, for cats, negotiating home territory, can become frightening. For dogs, fear of slippery floors and steep steps is a very, very common problem. Unfortunately, visits to the vet clinic cause many of these animals yet more stress for all kinds of reasons.

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Above: Just getting around the house can be stressful for an older animal

 

Before they can begin to feel confident, dogs and cats need to take their own time to “sniff out” the situation. They check for olfactory cues and look about to read the body language of people and other animals when they find themselves in a new situation.

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Above: dogs take time to sniff for clues when they meet someone new…

The typical hurried approach within the vet examination room can come across to the animal as quite frightening. Having worked for many years as a general small animal vet, I’m aware that this can be a tense environment, with vets and vet nurses constantly completing tasks against the clock and always ready for the next emergency to come through the door. If the animal reacts to this stress by turning away or wriggling, then they’ll be firmly “held down” or “held still” for examination, and this restraint makes the pet even more frightened.

There’s a further problem for the painful animal who visits the vet clinic. How, as vets, can we know exactly where the animal is hurting? Careful observation and history-taking is extremely useful. But the quickest method is to put the pet through a series of pain tests and, as vets, this is what we have been taught to do. So, for example, a dog that is lame on his right front leg will be firmly restrained while the vet pokes and prods each structure in that limb and manipulates each joint every which way. When the dog flinches or yelps in pain then we have an answer.

Every vet that I have met clearly loves animals, and most are kind, generous people. Vets hate the idea of putting any animal through pain or fear. However, these firm restraint and rapid pain-testing methods are standard practice.

I do notice high muscle tone and awkward postures in frightened dogs and cats. Animals already suffering from musculoskeletal pain will go home feeling worse after a stressful experience, and it is likely that fear may contribute to chronic pain syndromes in pets.

Here are just some potential causes of anxiety for the animal at the clinic:

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Subjectively, I get the impression that animals feel less painful once steps are taken to remove the real and perceived threats. Pain-scoring in animals is difficult. I’m going by subtle changes in their posture and body-language and in the way that they react to being touched. What’s more, animals become ready to move in a more balanced and efficient way once the perceived threat has gone. There’s a close connection between fear, pain and mobility.  

Things I do to reduce the patient’s fear include positioning myself really carefully when working with them, Tellington Ttouch techniques and careful attention to flooring and to any restraints.

Taking enough time over each session is also helpful. Animals are so used to being manhandled at the clinic that to have a veterinary professional help them into a comfortable position and then just sit quietly with them must come as something of a relief. This also gives me a chance to talk to the owner about how they are coping and to discuss the home care regime.

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With plenty of time allocated to each session, I have a better chance of locating any painful areas without forcefully restraining the patient. Initially, I get clues from watching the animal walk, turn, stand and change position. Then I settle the animal into a relaxed position and use my fingers as gently as possible to assess the neck, back and limbs for discomfort, watching for subtle flinching, muscle twitches or gentle behavioural signs (e.g. for dogs, repeated lip-licking) to show that I’ve touched a sore spot.

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It’s all very well reducing the stress in the clinic, but what about at home? An important part of my job is to teach owners ways in which they can use their own hands, body position and voice to make their animal feel more comfortable. I also explain something of the animal’s body language to his or her owner, and suggest how they could respond to it. Home visit check-ups offer the opportunity to assess the home and garden environment for causes of stress, from slippery flooring to awkwardly-positioned bedding.

Frightened animals tend to adopt a tense body position, ready for a panicky “fight or flight”. This posture varies between individuals, but often involves a dramatic tightening of the neck and shoulder muscles. Not only is this muscle tightness uncomfortable, but standing like this does not lead nicely into efficient, pain-free movement.

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Above: Frightened dogs adopt tense body postures

Many painful pets already have tight shoulder and neck muscles, and stress tends to make this even worse. Rather than scaring them so that they practise their tense fight or flight posture, I help them into functional, efficient positions during the examination and while I talk to the owner. To allow for this approach, I do take a whole hour over each session, and have the luxury of treating most of my patients in the comfort of their own home.

So, should vet clinics be avoided? That’s not the case at all! The standard of veterinary care is constantly improving, and vets do wonders in diagnosing and treating dogs and cats. However, do choose a vet clinic carefully. A good practice will not only excel from the clinical point of view, but will also have staff who are ready to listen and to address these quality of life issues in a practical way so that, each time you visit, you and your pet can go home together feeling that bit better.

 

Dr Marianne Dorn BVM&S PGCert SART MIRVAP MRCVS

The Rehab Vet, Herts, UK

Website: http://TheRehabVet.com

https://www.facebook.com/therehabvet

Twitter: @therehabvet

Choose Movement!

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As the cult movie Trainspotting once taught us, life is about choices. Our modern world is full of them. What colour sofa to buy? How big should my TV be? Tea or coffee? Whether to change the bed clothes today? Chicken or fish? The list is endless! 

Amid the myriad of choices we encounter, the decision to increase our activity level is all too often overlooked. It’s easy to see why this might be. For millions of people, long hours at the office, family responsibilities and countless deadlines all take precedence over regular physical activity.  Some of this has to do with the modern day perception of what “exercise” is. Much of it has to do with how our societies have embraced technology over movement. For many, exercise equates to pounding the pavements with sweat dripping from every pore. I’ve lost count of how many times people recoil at the thought of heading to a gym. 

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If we are to stand any chance of reducing the global epidemic of persistent diseases that relate to inactivity, we need to change people’s perception about movement and make activity a normal, fun and engaging part of everyday life. This is why the work of people like Dr Mike Evans (http://www.evanshealthlab.com) and Ann Gates (http://www.exercise-works.org) is so important. 

Dr Mike has launched a much needed campaign called Make Your Day Harder. It’s a simple message. As societies we sit far too much. We need to find little, helpful ways of moving more often. This needn’t involve a triathlon, just something small that means something to you. Check out the Make Your Day Harder website (http://www.makeyourdayharder.com ) for further information and some typically engaging and creative ideas from Dr Mike.

Speaking of engaging and creative ways to encourage people to move more here’s a superb video from the Stockholm subway: 

During my recent trip to Singapore, I had the great pleasure of working with the staff at the Khoo Teck Puat Hospital (https://www.ktph.com.sg/main/home). Prior to running my Know Pain course in Singapore, I was shown around the hospital and was hugely impressed by their innovative use of simple, positive health messages to encourage people to be more active. Here’s a few examples:

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As you can see, it doesn’t take much to get the right message across. So ask yourself: How could you do something similar in both your home and workplace?

I really do wish that I’d considered my choice of footwear for that last photo. Oh well, give me an affordable, positive health message over a mild fashion faux pas any day! 

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Turn Me On!

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“We don’t see things the way they are, we see things the way we are”  

The Talmud

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I felt very French last week. I live less than 40 miles from France and frequently pick up French radio stations in my Renault Captur. But last week was different. Not only did I drive the Captur south to Angouleme for my first ever Know Pain course in French, I was also kindly invited to live in a French home, eat French food, teach French healthcare professionals and greet like the French do (2 kisses for both men and women, unless you’re in the deep south where the number of kisses is anyone’s guess!).

For those of you who, after reading the title and opening paragraph of this blog, thought you were in for some sort of Cinquante Nuances de Gris, let me let you down slowly…

Whilst over in France I read two pieces of work which fascinated me. Firstly, Jorgen Jevne’s excellent and somewhat sexy article on what conservative management needs to learn from Baywatch (http://www.applyresearch.com/baywatch-conservative-care/), and secondly, Prof Alice Roberts piece in The Guardian on evolution and her personal encounter with MRI imaging for low back pain (http://www.theguardian.com/science/2015/may/31/human-body-marvellous-not-perfect-roberts). 

For me, these articles highlight the paradigm chasm that exists within contemporary healthcare. One offers hope by embracing the complex nature of pain experiences beyond structure, biomechanics and anatomy, the other clings onto the worrying and pessimistic belief that pain is linked to damage as seen on imaging. Sadly, as is so often the case within the media, the fear inducing story gets all the press. As they say, the Devil plays all the best tunes!

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Our beliefs and cognitive biases towards threat information is inevitable when we experience pain. Pain is an ideal habitat for worry to flourish as Eccleston & Crombez so eloquently put it. Unfortunately, we implicitly pour fertiliser onto this worrying ground through our words and actions. In short, it doesn’t take much turn on somebody else’s threat switches. Here’s an example to highlight the point…

On entering my French host’s home, I was soon taken up to my room to dump my bags. Whilst being given a guided tour of the maison something my friend said grabbed my attention…”here is the bathroom & towels, onto your bedroom now…here is your bed, desk and wardrobe. I am sorry, my Mother has placed this gigantic framed picture above your bed. I do hope it doesn’t fall on your head! Ok, we go now to the kitchen for some foie gras and Cognac!” 

Had he not mentioned the gigantic, potentially brain injury inducing picture that hung only inches from my head, I would not of given the slightest bit of notice to it. I suspect my Catholic upbringing might well have led to me throwing the duvet over my head in a desperate bid to ward off the evil, demonic nymphs depicted in the artwork, but this is altogether another story.

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It was too late. The cat was firmly out of the bag and my host had well and truly, without realising, turned on my cognitive bias towards the risk of things going, quite literally, bump in the night. I slept (on and off) for 4 nights in that room. Not once did the picture come crashing down, but that didn’t stop my nervous system from tuning into it. 

The Greek philosopher and teacher Epictetus argues that people aren’t distressed by things, they are distressed by their view of things. Those of us who work to empower people to take control of their persistent and troubling pain experiences can relate to this. Just as the picture minus the throw away, nocebo comment, would only ever remain a pleasant wall decoration, so too would millions of people’s degenerative discs remain a rather innocuous anatomical feature.

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Whatever happened to those simple days where people, without frequent use of posh scanning equipment, returned to everyday activities with an uncomplicated “touch of lumbago”?

Let’s look at a typical example of how easily & implicitly our cognitive biases influence our practice:

Paul is a 48 year old office worker who’s been experiencing worsening low back pain for the past six months. He has recently received an MRI scan of his lumber spine and has gone to see his Physio for the results (both their thoughts & interpretations are shown in brackets):

Paul: “So, what did you find?” 

Physio: “Nothing to worry about. No serious damage was found. There is some degeneration in the L5/S1 area. Look here (points to image). But this is quite normal for your age.”

Paul: “Ohhhh.” (Oh no. It knew it was something bad. I was worried that my disc might have gone. Now it has!).

Physio: “It’s quite normal to get this type of problem when we consider the type of work that you do.”

Paul: “Ok. I see. What should I do about it?” (I should not work. This will harm my disc further. Maybe I should look for another job. What’s the treatment options?)

Physio: “Keep active but take it easy for a while.”

Paul: “Ok. Is there any other treatment for this?” (Rest until the pain disappears, then what?). 

Physio: “Unfortunately, there are limited options.” (Oh no. Think quickly. What is the best treatment choice?)

Paul: “Oh no. But I’m in so much pain!” (HELP ME!)

Physio: “Ok. Should we start easy and try this machine to ease your pain?” (So much pressure to do something today!)

Paul: “Thank you. That would be great.” (This confirms my belief that I should not do anything as I might cause more damage)

Do you recognise this situation? We’ve all been there. Unfortunately, despite a growing understanding and some appreciation for the biopsychosocial evidence-base, many clinicians feel underprepared for the challenges that they are presented with on a day to day basis (http://www.journalofphysiotherapy.com/article/S1836-9553(15)00017-X/abstract). Don’t worry. If there’s one thing that running Know Pain workshops has taught me, it’s that clinicians of all disciplines around the World are struggling to put into practice what the evidence-base shows we should be.

 

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It’s time to face the uncomfortable truth. If we are to stand any chance of reducing the modern pain epidemic, practice must change, research must change and the media must listen.  

Below is a short video that was produced whilst over in France last week. I further discuss the challenges that face clinicians when helping people make sense of their pain experiences:

  

Key messages:

  • Our schema provides us with a cognitive framework that helps organise & interpret information.
  • —These can be useful as they allow us to take shortcuts
  • However, they also drive preconceived ideas about people, situations, environments and context.
  • We exclude pertinent information in favour of our pre-existing beliefs. (Linton, 2005).
  • Cognitions contain attention biases towards schema-relevant information (Fox, 2012).
  • A “subjective social reality” is constructed from one’s perception of sensory input.
  • Cognitive bias distorts reality.
  • They are adaptive over time (Fox, 2012).
  • They serve to protect one’s schema (Gross, 2005).

Thanks for reading & remember to embrace the challenges we face whilst steering people towards hope at every opportunity.

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References

—Eccleston, C, Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model. Pain. 132 (3) 233-236.

Fox, E., Yates, A., & Ashwin, C. (2012). Trait anxiety and perceptual load as determinants of emotion processing in a fear-conditioning paradigm. Emotion,  12, (No. 2), 236–249

—Gross, R. (2005). Psychology. The Science of Mind & Behaviour. 5th Edition. New York: Hodder Arnold.

—Linton, S. (2005). Understanding pain for better clinical practice. A psychological perspective. London. Elsevier.


   

 

 

Know Pain France Video Chat

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Following the recent Know Pain course in Angouleme, I chatted to Guillaume Deville from Agence EBP (www.agence-ebp.com) about the challenges facing healthcare professionals around the World.

Here’s our discussion…

A Facebook page has been set up for French healthcare professionals who’ve attended Know Pain workshops so that they can continue to interact and discuss their ongoing professional development. Here’s a link: https://www.facebook.com/knowpainfrance 

Merci beaucoup!

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