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Well that was quite a weekend
Post your take home, practice evolving, thought provoking highlights from your weekend
Thanks
Eric
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Coming in to this weekend, I was expecting to hear a similar pain education talk that I have received multiple times throughout PT school and lectures at CSM and boy was I wrong. I was not expecting to delve so deeply into the “bottom of the iceberg” but figured it would be focused on the visible portion of the iceberg or the area of pain science focusing on teaching us how to portray this plethora of information to our patients. I was struggling with this throughout the weekend until I changed my mindset.
Looking back, it was naive of me to think that this course would just hand me a few sentences or phrases to explain the pain phenomenon to my patients. Even if we did receive those sentences or phrases, would those sentences or phrases even resonate with our patients without a better and more in depth knowledge of what pain truly is? Lorimer Moseley gave the example about dry needling and I paraphrase (poorly), even without the needle as long as the PT believed that they were in the correct spot and that they were affecting change in the tissue then it had an effect on the patient. Can this apply to the topic of pain science and education? For example, if we were to have been given a few sentences and phrases to tell our patients (top of iceberg) but didn’t know or believe how the bio, psycho, and social aspects of the human and pain interacted (bottom of icebergurg) would that therapeutic pain science discussion be beneficial to the patient?
Lastly, I came into this conference thinking that I was pretty decent at giving a therapeutic neuroscience pain talk to my patients. I would always use the kitchen smoke detector as an analogy, for example:
Me: “Pain is the alarm system in the body, it does not always mean that there is damage in the area but is more so telling you that there is a potential for damage. Have you ever been cooking on the stove top and you put some olive oil on the pan and it starts to smoke a little bit and then all of the sudden the smoke detector starts to go off?
Pt: Nods head
Me: “Imagine the smoke detector as pain alerting you that there is a potential for danger. In this case, the smoke detector is telling you that there is a potential for a fire so go check it out. The same way the body tells you there may be something wrong, check it out (go to a doctor, they run scans, perform different tests, etc.)
Me: So you hear the smoke detector and the first thing you do after yelling at it, is to check the sources for danger. You realize that the oil in the pan is smoking but there is no actual fire but just a potential for it. So in your case, you have gone to a doctor and/or me and we have checked for the “fire” (red flags, fractures, etc). Now that we have made sure there was no fire, lets turn down the stove and get rid of the smoke, aka lets start some gentle movements in order to get back to what you want to do.”While I still like my analogy and I have been given good feedback from my patients, after this course I believe I will need to go back and change some things up. I really like the visual and idea of how pain creates a larger buffer and alters the threshold of when it is experienced. I’ll keep you all updated if I think I have something that works well.
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I guess manual therapy really doesn’t matter.
Just kidding!
I agree with Brandon that I was expecting more of a how to, but then I realized his approach is for you to really understand the problem and figure out how you want to deliver it. More responsibility on our end, but probably leads to better outcomes.
One of the things I realized I was doing was using the bio-psycho-social model inappropriately. The way I discussed this with patients previously was to tell them they had an initial injury that was being upregulated or downregulated by all the other contemporaneous factors. My spiel was usually “Take two people with the same injury. One isn’t sleeping well, smoking, not working out, depressed, stressed, not enjoying life and the other one is doing all of those things. Who gets better faster?” It’s intuitive that the second person is in a better position, and it was always a good “in” to start talking about other factors that are affecting care.
The main reason I did this is because there is no way for the patient to accuse you of it being all in their head. It’s a safe way to navigate dangerous waters. After seeing these talks go horrible wrong, I have a bit of fear avoidance when talking about people’s fear avoidance.
However I learned that this approach is probably not effective given some of the studies he showed and what take home message participants end up leaving with. It doesn’t get at the core of the problem because I’m doing the switcharoo with tissue damage vs. protection that’s easy to fall in.
While I’m not sure how to use this on a person who is in the thick of Chronic pain after 25 years, I do realize that its easiest application is on patients before it starts. We can actively steer people away from chronic pain venues by tackling MRI reports, irrational thoughts, and contextual factors early instead of letting it spiral out of control. We can be more careful in our choice of words and make sure people are instilled with resiliency and safety instead of fear and fragility.
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I went in to this weekend expecting some in depth knowledge bombs on the mechanisms of pain, but I completely underestimated the scope of the bottom side of the iceberg. I think persistent pain is a topic that we talked about in classes, but we never really delved much deeper than the general “don’t tell them it’s in their head” and “don’t use the word pain” for their symptoms, so this course really helped open my eyes to some of the other factors that play into this cycle of persistent pain.
Biggest take home nuggets for me:
– “healing is unstoppable” attitude creates shift in the patient’s perspective/understanding and gets them curious about what else might be going on
– Belief in what we are doing whether the evidence supports us or not, our belief in our treatment selection plays a huge role in the patient outcome with this patient population
– Pain is kind of like an onion lots of layers and pieces and parts and neurotags that come together to make this stinky thing that can be difficult to work with
Clinically, I think these concepts aren’t just going to pop up for me overnight. I don’t really have the “spiel” thing going, so I really want to get better at recognizing the patients that might be ready to have this conversation about where they are and what’s really happening, and then just be aware that my words are so much more important than I thought. I think this weekend was a great way to build a framework for what pain science education should look like and sound like based on the science of what is happening at a much deeper level. -
One thing I will take from this course was the idea of using imaging as a green light as opposed to the absence of a red light. I think it is definitely more skilled than it sounds because in the past when I downplay imaging patients can perseverate further as if I missed something. Probably more important to bolster this with WHY its not a big deal (base rates, healing, etc.).
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This course was tough for me! Like Lauren, I didn’t really have a good spiel or ready made examples to use when talking with patients about their pain. A lot of times I was too concerned to broach the topic, thinking patients would hear “it’s all in your head” so I stuck with the anatomy education and discussion of biomechanics. I think my patients have really been missing out. I really wanted to come out of this with a “spiel” but realized that it’s not a one size fits all type of thing. I think really understanding the current literature on pain will allow us to adapt our discussion to be specific to each patient. Yes we might use a metaphor as part of that, but not the only part.
Other take aways:
– I like the buffer – it seems encouraging that your body has this buffer system where you can’t (usually) cause more injury because you get the “stop” signs way before tissue damage.
– I like the “your body is an unstoppable healing machine” statement. I think a lot of our patients don’t know that.
– I like the idea of talking about this stuff gradually, like while doing manual stuff, and not just sitting them down for 30 minutes to educate them.I need to keep reading my notes and digesting…
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There were so many incredible things to take away from this weekend that really got me thinking about my patient care on many different levels. I love that he was so open to, and even hoping for, that dissonance or unsettling feeling to happen for everyone because of something that was brought up. I feel like this had a big impact in multiple ways- 1) it helped me to realize that change is rarely (if ever) going to happen if we aren’t open to question things that we are both familiar with and unfamiliar with and 2) it kind of puts us in the shoes of our patients who are receiving this “pain” message and struggle with accepting it because it is not what they have been convinced of for so many years.
It was also a great, but challenging, experience to dive deeper into looking at some of our practice patterns and thinking about them in a more scientific method mindset. I feel like this really plays into test-treat-reassess in that every time we are doing something with the intention of achieving whatever outcome it may be, we need to take it a step further and say is what I did truly having the effect that I think it did. At first I really struggled with this and kind of had the mindset of “well I just graduated and am just trying to figure out how to be an efficient PT with what I have, I’m not ready to add this on top.” But once, thanks to the amazing Lorimer, I questioned why I was having this unsettling feeling and dissonance I was able to more fully understand this concept and the implications on my practice. It for sure has the potential to change your practice and dispel myths that you were bought into (which is 100% necessary for growth), but it also can just help you be more efficient with the tools that you do have by thinking about their effects with the background of a sound theoretical model.
I also loved getting to dive deeper into the intricacies of pain and the current framework for all of the contributing factors. In school we learned, on a basic level, that there are many modulating factors that either facilitate or inhibit pain but didn’t dive much deeper than that. With this information I felt like I still knew more than the patient, but not much more, especially if they grasped the concept as well. Now with learning about the “bottom of the iceberg” I personally have a greater understanding of how, for example, stress interacts with pain and don’t just know that it affects it because that is what someone told me. The idea of neurotags and all of the different interwoven connections through the brain, spinal cord, and body is amazing to me and I can’t wait to go back and review the notes to reinforce and continue to grow my understanding of this all. Personally, knowing the science and framework behind pain (and the iceberg analogy) helps me to have more confidence in talking about pain to others. It was super helpful to end the weekend with some take home points of how to approach this topic with patients in a simplistic way despite our understanding that this topic is anything but simple.
Another thing that I learned a lot about that I wasn’t expecting was public speaking and patient education. I loved that he went through and had us think about all of the influential and validating techniques that he uses while presenting to 1) get the audience thinking 2) keep people engaged and 3) make each person feel some sort of connection to what he was talking about. While he has many, many years of practice to make this look easy (and I will definitely never be as smooth doing any of it), using these techniques can be helpful in both presentation type scenarios but also just in everyday patient care. I now feel like I have a better way to judge my actual presentation of material to patients based on external criteria and can use this to help me become a better educator. One of the my favorite points he brought up was ensuring that the patient really understands what you are saying, rephrasing if necessary, but always sticking with repeating the message that hit home with them.
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Great points Anna. I love your point about dissonance. A lot of the things we do are being called into question, and thats a good thing. We aren’t alone, as other providers are also being challenged as information (good and bad) becomes more available. That’s why it’s so important for us to get comfortable with the uncertainty and be good consumers of information so we can provide the best care for our patients.
One of my favorite sayings: We will rarely be RIGHT, let’s just try to be a bit less wrong each day.
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The part of the conference that was most practicing evolving for me was the idea of the pain-buffer. As a new graduate, I still feel uncomfortable when a patient tells me they are experiencing high levels of pain. My mind does a great job of running wild with catastrophic and sinister thoughts. It is reassuring to understand that even while in the presence of high pain, the patient is still a great distance away from the ledge of tissue threat.
I believe Moseley made this argument for the chronic pain individual. What does everyone think about a patient who is experiencing acute pain? What about a patient who is post-op?
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Great points everyone!
After reading your reflections, I feel that you each understand the deeper science of it more which makes you less sure of what you were doing before.
This will be the case the entire year.
As you become more knowledgeable, you will begin to be less confident and second guess your concepts from the past.
Keep this up! -
One concept that I found very interesting was the idea of progressing the patients “load” in every aspect of the biopsychosocial model. He pointed out that we are very good as PTs about progressing mechanical load, but that we tend to neglect advancement of psychological load or biologic load when prescribing and progressing our interventions. The examples that he gave were having the patient do the exercise while they are thinking about being on an important conference call (psychologic load) or after they have eaten a large meal (biologic load). Has anyone tried intentionally altering these variables with their patients with chronic pain and if so, how did they respond?
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Brian: I liked the idea of loading different aspects of their contextual factors to further their gains, too, but I’ve had trouble figuring out the best way to go about that. I’d be interested if anyone has given that a go. I had a patient that may have benefited from this (her shoulder pain increases with stress and always on Sunday) but trying to find the “trigger” escaped us both, so I felt like I needed more info before trying.
Steven: I always think of the black knight off of Monty Python when I think of the problem with a pure pain science approach — most likely if your arms are chopped off, you won’t be doing so well (unless it is a hammer through the neck). So I usually consider if the person needs a little or a lot of PSE via their thoughts and beliefs about their acute or post-op surgery.
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Steven: I think we need to be careful to avoid “throwing out the baby with the bath water”, particularly in our patients with acute or post-op conditions. It is still necessary to query and examine for red flags and I think it is still appropriate to fall back on some of your basic biologic and hystologic knowledge regarding stages of healing and expected healing times for specific tissues (think about deep aching pain in a patient that is 4 weeks post fracture). It seems to me that the appropriate place for PNE in this situation is to begin educating the patient regarding the expected trajectory of their symptoms and to be equipped to recognize when a patient is beginning to experience pain that is not in proportion to their injury or is lasting longer than expected.
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Very true. Some people already have a view of pain that will not hinder their recovery. Some people are actually in the acute or acute on chronic phase of pain that may lend itself less to overactive neurotags and overblown buffers. These patients don’t need “the talk.” What these patients need is for us to not perpetuate harmful narratives and to employ soft language. Does that patient really need the visual of their RC getting pinched under their acromion? Or can we explain this symptom in a less threatening way?
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After all, nociception is AN input, just not the ONLY input. I like the idea of considering how much PSE they need.
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I agree that TNE isn’t necessarily something that needs to be addressed with every patient. In regards to the patient who is in the acute stage of post-op recovery, I believe that having an open communication and educating them on the realistic expectations of their recovery is one of the most important things that we can provide. I have noticed more and more that a lot of patients who have had surgery, have no idea what to expect as far as recovery goes. That includes pain expectations, movement restrictions, prognosis for return to PLOF/sport/work, and the amount of time and work that is required to return to their normal function.
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Great points all around.
I, too, enjoyed learning about the concept of grading and incorporating more than just the mechanical load and feel this has such value to making PNE a more all-encompassing treatment. Personally, I have not really found a great way to work in some of these concepts, but for sure need to start playing with adding these things in as I progress with patients.
Kind of going off what Eric said- I had an interesting discussion with Micheal the other day about various treatment routes to take with a difficult patient. It basically came back to the importance of clinical reasoning to help tailor your approach.
Some “highlights” of the conversation:
– reflective questioning is so important to get insight into the patients belief system
– differentiating between fear avoidance because of fear of damage, fear of increased pain, past experience, etc. & letting this guide your treatment and educationAdding in these concepts with the patient seemed to work well during the session, but I will be interested to see any carry over next visit. What are some of the ways from session to session y’all get the patient to reflect? Any suggestions on methods of the test-treat-reassess model in this context to gauge understanding, effectiveness, progress, etc.?
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