Pain Science

[helenrshep]

Hi guys! I got totally called out by this article. It basically says pain neuroscience education + cognition targeted motor control training is significantly better for patient outcomes than general education (biomechanics, anatomy, etc) and “best practice” exercise for chronic spinal pain. Pain education is something I’ve struggled with for a while – like how to implement it without the patient thinking you’re saying “its all in your head” or “your pain isn’t real.” What do y’all think? Do you guys focus on pain education with your chronic spine pain patients?

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[Taylor Blattenberger]

This was a really good read. I think we are really evolving our understanding of how to apply the science of pain to the patients that walk through our door. This study touches on many ideas I think are important to the application:

-Providing accurate information about pain
-Minimizing the nocebo of the biomedical explanations we have
-Practicing what we preach in clinic by grading exposure to provocative positions and encouraging less fear of movement

Helen – You’re right: it can be very difficult to covet some of these messages without coming off as dismissive or making the patient feel attacked. It’s also hard to balance movement training and education with soft language and a solid explanation of symptoms.

I typically try to paint the picture through the lens of “sensitivity.” An analogy I’ve been using more in practice has been that of a sunburn. “When you’re sunburnt, warm water can be painful over that area, but you aren’t actually doing any damage to the skin. This is similar to movement in that the muscles/joints/back is sensitive and those forces
are uncomfortable right now.” If you can frame it as something they already understand, they can be more accepting to the education.

[awilson12]

Thanks for the share! Definitely gets me thinking about how I approach chronic low back pain compared to my knowledge on what the evidence says. I think a lot of times I let my lack of confidence in delivering this message be a reason that I tend to fall back on to a more general approach and explanation rather than dive into pain science education. This definitely is a tricky subject to approach as you don’t want to be just another health care provider in the medical system that is invalidating to the patients experiences, so I feel like it for sure takes some practice in delivering this message in a way that is more likely to be accepted and understood. I think it also points to the importance of the subjective exam to identify beliefs and fear avoidance patterns that need to be addressed.

I like the idea of framing ideas about pain, hypersensitivity, etc. in a more relatable way. I have had a few patients during my internships that fall under the chronic non-specific LBP category and have had varied success in trying to use analogies. One patient in particular that it didn’t work well with just seemed to be unaccepting of any explanation that din’t give her some sort of specific diagnosis of something that was wrong or damaged that she could cling to. Have y’all had any success in breaking through with these patients?

[Kyle Feldman]

With pain science education, address the elephant in the room. If you are thinking the patient believes you are telling them it all in their head, say it. Say to them, I know you are thinking that I am saying “its all in your head” Emphasize clearly that this is not what you mean at all.
By addressing what they are thinking, you can help clarify and get them on your page.

Since adding this to my pain science education, I have had patients much more receptive and less guarded during our conversations.
Most patients will say, “I thought you were saying that, but when you mentioned it and tried to show the difference I understand better”.

Question for reflection:
Do you think that talking about something a patient relates to has any effect as to why the education is better (pain science vs biomechanical education)? When you talk about the labrum, flexion, rotation, and cartilage, how many patients have a strong grasp on these concepts?

[awilson12]

Kyle- I think for sure that talking about something the patient relates to makes our education more effective. From a scientific standpoint the connections between emotion & memory definitely points to this and something that is more meaningful to you is going to “stick.” Understanding of medical terminology is for sure situational dependent, but I would argue that even those who have a better understanding likely have some misconceptions as well.

A good take away from thinking about making education relatable is that you have to get a good grasp on the patients understanding, beliefs, goals, etc. in order to decide what you should/can talk about day 1, what might need to be chipped away at or addressed further down the line, and what delivery method is going to work for them. Easier said than done though with so much to think about during an initial eval.

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