A Practical Guide to Persistent Pain Therapy

Know Pain

#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 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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Mutual Maintenance: When is enough enough?

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Yesterday, I had the pleasure of speaking to a range of healthcare professionals at the Primary Care & Public Health Conference at the N.E.C in Birmingham. It was strange to think that the last time I had visited the venue, I had attended Crufts Best in Show. Sadly, there were no dogs on display this time around. However, whilst walking around the event, which I must say was a fantastic display of interprofessional collaboration, I did witness a great deal of healthcare maintenance products to rival the most frequently pampered of pooches.

The array of affordable massage machines and other electronic devices that go “PING!”, as Monty Python once hilariously put it, offered instantaneous solutions to all manner of problems from instant relief for stiff necks, weak backs & arthritis, to promises of improve blood circulation and reduced cellulite. This should come as no surprise.  With an ever expanding population of people experiencing ongoing aches and pains across the planet, there is bound to be a thriving market for relief. When asked, “What do people in pain want from healthcare professionals?”, Yelland (2011) found they sought pain relief. My experiences of working with a tiny fraction of the 15 million people in the UK living with pain would certainly support this.

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So. Where’s the issue with the promotion of passive devices to help people feel more comfortable?

Shouldn’t we be providing people with what they want?

Yes of course we should.  However, we have a professional and moral duty to look beyond short-term gains.  We broadly achieve this with other long-term conditions such as asthma and diabetes. Why not pain? We must begin to view pain in a similar context.  I will never forget the gentleman who came to see me determined for me to continue his longstanding history of passive treatments. He worked in retail and, despite repeated and unsuccessful long or even medium-term outcomes with this approach, he considered it his consumer right for me to continue on the same path, rather than explore new ones. He expressed how, if I entered his store and asked for a large, V neck jumper in purple, he would be professionally obliged to give it to me. The customer is always right.  

I wish healthcare was so simple.  However, healthcare is not a simple, consumer product. In much the same way that a mechanic would have a professional and moral responsibility to turn down your request to cut the brake cables, whilst also highlighting the problems that lie ahead, we have a duty of care to challenge long held beliefs regarding passive healthcare maintenance and dependancy.  This is an often delicate but equally necessary path to tread.   

With this in mind, it’s worth noting that Yelland’s article also highlights people’s desire for healthcare professionals to provide understanding through acquired knowledge, an accurate diagnosis, social legitimisation (being believed) and, most interestingly, a positive shift in attitude.  To stand any chance of achieving these aims, we have a duty of care to scientifically inform people about the nature of ongoing sensitivity and to guide them towards meaningful, active self care.

I had an interesting discussion with one of the other speakers at the conference about the role of passive modalities and ongoing maintenance for people in pain. Whilst we both agreed that patient choice is key and that short-term, quick fix strategies should remain within our shopping baskets (click here for Louis Gifford’s work on the shopping basket approach http://giffordsachesandpains.com/download-material/the-shopping-basket-approach-articles/), we also agreed that, in 2015, with an epidemic of pain problems and a greater understanding of meaningful solutions for long-term conditions, we also have a professional and moral obligation to inform people that there are other avenues to explore. We can and should be doing better. 

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These avenues begin with a meaningful and robust reconceptualisation of pain that moves away from the damaged goods model that both patients and clinicians are drawn to and towards a hope inducing reframing of sore but safe sensitivity. The psychological reality is that the Devil always plays the best tunes. Many people in pain live a life in which they are constantly seeking threat information that confirms their schematic view of the world (Linton, 2005). This is why so many people are drawn towards that skeleton over in the corner of your clinic. “He looks like he could do with a good meal”, they often quip. Sadly, the troubling and anxious, internal monologue for many people reads more like, “Bloody hell! Show me where my osteocrumbly bits are, and make it snappy!” (No manipulative pun intended). For more on the implicit threats that adorn many clinic walls click here: http://knowpain.co.uk/mind-the-gap-the-misleading-language-of-pain/

The unfortunate reality is that many people who live with persistent pain experience an endless loop of healthcare escalation where intervention drives concern and often empties pockets.  Eccleston & Crombez’s (2007) perseverance loop (see below) brings into sharp focus our need to hold people’s hand whilst they work out how to step off healthcare’s not so merry-go-round.

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Louis Gifford left us all with a wonderfully coherent series of 4 things to consider….

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It really is as simple and as difficult as that!

I can think of very few clinical encounters over the years where these questions aren’t central to my thinking. I show these questions to patients, in both 1:1 and group settings. I ask them to consider if we (me & them as a collaborative unit) have adequately explored each point. If we are openly engaging people within these discussions and framing the wide variety of tools at our disposal in a way that is honest, scientifically informed and compassionate, we are doing a great job. If however, we are promising the elixir of good health and the lasting solution to “stiff necks & weak backs” in the form of ongoing, short-term adjuncts, we should prepare for the modern pain epidemic to rise beyond our social control.

In a world full of people looking to scratch a perceptual itch, there are bound to be plenty of itch scratchers. I have no problems with this. I am quite partial to a spot of itch scratching myself and, I am certainly far from telling people how they should decide to manage their patients. However, we should surely all be striving to provide people with scientifically informed choices that offer hope and don’t break the bank.

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

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

—Yelland, M. (2011). What do patients really want? International Musculosketetal Medicine. 33 (1).

 

Tales from the Painmobile

Kia ora koutou kata from beautiful New Zealand,

As some of you might be aware, I am currently travelling around NZ in what has affectionally come to be known as the “Painmobile” (see below). For those of you who follow me on Twitter and didn’t know about my travels, this has probably now cleared up why my daily tweet rate has dramatically plummeted. 

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On route to New Zealand, I spent some time in Singapore and ran a Know Pain workshop at the amazing Khoo Teck Puat hospital.  I had a great time with everyone in Singapore and learnt how simple, inexpensive health messages can make such a huge difference to the choices that people make. There is much more blogging to come on this once I’ve returned home! 

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Know Pain Singapore

So, back to New Zealand and the tale of the amazing paintball miracle….

Whilst travelling in the stunningly remote far north tip of NZ (Cape Reinga), my wife pointed out an article in one of those trashy, holiday magazines. You know, the sort that have headlines like, “My Dog ran up a £5000 bill on my credit card!”. Anyway, in amongst such essential holiday reading, Mrs KP highlighted a moving and somewhat bizarre story about a young girl’s pain journey. Not only does this story confirm how weird and complex pain is, it also highlights how essential it is for healthcare professionals to move beyond pain and develop the necessary psychosocial and facilitational skills to help people move forwards.

Here’s the story…

I loved to dance and did contemporary and jazz four days a week. Then at school a door hit my leg, so I saw the nurse. “You’ll live”, she said. But the next day my left leg was so swollen I could barely walk. My mum took me to A&E.

“It could be fractured”, the doctor said, and sent me home with a moon boot and crutches. Though the pain got worse, a scan came back clear. “Just keep doing physio”, the doctor said. But I was in agony. “What’s wrong with me?” I cried to my mum. “We’ll get to the bottom of it”, she said.

My leg was freezing from the knee down and mottled in colour and the foot was so swollen I couldn’t bear anything touching it. I couldn’t wear long pants, socks, or even have bed covers over me at night. The hair on my left leg stopped growing, as did my toenails.

Then Grandad had a heart attack. I was so worried about him. I also started to hate my left leg and felt really depressed. I longed to dance again but I couldn’t even walk! Finally, we got a call from the hospital. “I think you have CRPS”, said the head of vascular surgery. He explained it was a chronic pain condition that affects the nervous system. The brain tries to protect the injured limb, even when it’s healed, by continuing to send pain signals. It occurs after three things – immobilisation, injury and stress – in my case, Grandad’s heart attack.

I was admitted to hospital and began intense treatment. At one point, I was taking 37 pills a day. “Please just amputate my leg!” I begged the doctor. “You’ll get well, I promise”, he reassured. Then my Grandad got sicker. “You can do this dear – don’t let anyone tell you otherwise”, he said. Then he passed away. He was my inspiration to keep going.

In hospital, part of my treatment was goal setting. School camp was coming up so I signed up for it, even though I was on crutches and used a wheelchair. One of the activities was playing paintball. I’d forgotten to wear the box around my leg to protect it, but decided to play anyway.

“Just aim for the top of my body”, I told everyone. But my friend, accidentally hit me on my left calf. My whole leg went into spasm. “I’m so sorry”, she cried. I was in such agony I couldn’t even reply. But the next week in physio, something amazing happened. I could put my left foot on the ground – I’d not been able to do that in ten months. Then I began walking again! The doctors were amazed. They thought it would take me five years to walk without support. 

Mum was away at the time but when she returned, I walked towards her without crutches. “Oh my goodness!”, she cried in relief. “I don’t know what happened”, I said. “But somehow my leg being shot by a paintball got it working again!” 

Today, a year after my injury, I am still having physio but I’m dancing again. Now I’m just looking forward to being a teenage girl once more. 

 

After all these years of helping people to make sense of their pain, I am still utterly fascinated by stories like this. So, before I engage the Painmobile’s engine for my forthcoming workshops here in NZ, here’s a list of what we should learn from this case study….

  • Pain is weird
  • Pain is complex 
  • Pain demands an explanation
  • “Pain” is often the term people use to express a range of emotions. 
  • Healthcare professionals should seek to offer reassurance, guidance & hope.
  • Healthcare professionals must be careful not to strap scary timelines onto people’s recovery.
  • We must always remember the power of the forgotten medication – fun & meaningful activities.
  • We must develop our ability to support change & empower people to seek challenges. After all, nothing changes if nothing changes! 

I hope you’ve found this story helpful. It might make for a useful in-service training with colleagues and I hope it will stir up some discussion on social media!

Finally, I’ve been learning some Maori Proverbs whilst travelling around NZ. Here’s a very apt one in light of this story…

He ra ki tua (Better times are coming)

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As always, thanks for reading. 

Mike

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Cape Reinga, New Zealand

 

Physioedge Podcast

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It was a great pleasure to be asked by David Pope of The Physioedge Podcasts to talk to him recently about the practical application of pain neuroscience within physical rehabilitation. We certainly both had a lot to chat about, and I hope you find some helpful CPD nuggets to help your patients understand pain and get back to enjoying life.

Here’s a link to part 1:

http://physioedge.com.au/pe-035-know-pain-mike-stewart-part-1/ 

Part 2 is due for release soon. I’ll post it as soon as it’s live!

Happy listening!

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The Assumption Dilemma

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Pain is complex.  As clinicians with a contemporary understanding of pain, it is our duty to provide people with a scientifically informed understanding of why things hurt.  As Anne Carson quite rightly points out, “One of pain’s principle qualities is that it demands an explanation.”

But here’s the rub…

How many of us have an understanding of how to teach?

Do we truly understand how best to facilitate a meaningful understanding of pain’s all too worrying nature?

Would we benefit from a better understanding of educational theories to develop our patient education skills?

In my recent article published in The British Pain Society’s Pain News, I ask the question: Do healthcare professionals have the teaching skills to meet the demands of therapeutic neuroscience education?

Here’s a link to the article.

Assumption Dilemma

Thanks for reading. As always, your thoughts and comments are most welcome.  

Mike

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A Practical Guide to Persistent Pain Therapy

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