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great article to refute the need for surgery.
I feel that this is the direct we are going in the medical world. Trying to understand that we may be doing what we think we are doing, but the effect on the patient is not because of that. It is because of the central and peripheral processes going on in the patient.Some huge names on the paper and they did that for a reason.
I wonder why they could not get this into another journal -
I agree this is a great article to help educate patients that surgery may not be the best option in every case. I think the power of perception is huge, but I would have never thought it was this powerful. This study definitely hits home the importance of patient expectations and our role as healthcare providers to help change those expectations in a positive way. It will be interesting to see the response to this article from different fields of medicine.
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Besides being an overall unique article and interesting read, I think this article just continues to highlight what Louw and Puentedura talked about in their viewpoint for JOSPT in March. Patient expectation of improvement or expectation of reinjury/tissue damage, in addition to the other psychosocial factors possibly present, can be large mediators of pain, disability, and fear avoidance. We know these things in terms of research and pain science but we do not necessarily communicate them in an effective way to our patients. All of us are familiar with data on the presence of common conditions (OA, disc bulge) in asymptomatic individuals that are listed at the start of the article, but merely just listing them off to our patients might not change perception at all. I know I have been guilty of not always providing clear and thorough pain education to some of my patients, and I have been around plenty of students and clinicians alike who have done the same. As much as we would like better collaboration with other healthcare professionals about pain science patient education, I think the onus rests firmly on us to become better at educating on pain science and measuring the possible effects of that education.
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I would like hear what your strategies are for educating patients about this and what you feel has been successful – does the same strategy work for all? There are posters and visuals available (Victim of Medical Imaging Terminology – VOMIT) for example. I made a poster for our clinic but have yet to use it, etc. Obviously all individuals are different and have different beliefs, so what other tools have you used or seen used to push your point?
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Aaron, I actually hadn’t seen that VOMIT poster before and it brings up several body areas such as the ankle and T spine that I didn’t already have good examples for. I know that APTA has been pushing a graphic that demonstrates the number of disc bulges in asymptomatic individuals that if anyone hasn’t seen yet should definitely check out. My typical strategy for arthritic conditions is to discuss the disparity between when their pain started and their beliefs about when the arthritis actually began developing. Most patients readily admit that they think the arthritis has been developing over a long period of time, and by pointing out that they may have had findings on imaging well before pain started, they can start to see that they are not always equivalent. I would love to hear other strategies people use though, because this is something that I have a hard time with when working with patients who don’t respond well to a short and simple education like above. A quick search of youtube videos that provide similar education to the VOMIT poster turned up nothing.
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I have tried using a similar strategy with that August mentioned when pertaining to OA, primarily the hip and knee. Another strategy that I use mainly for those LBP patients that are fixated on their bulged disc or stenosis that showed on on their MRI is: asking them if their pain is different throughout the day. The vast majority, with questioning, respond that their pain varies throughout the day. Whether that be better in the morning, mid day or evening…their pain varies. Let’s just say they say that their pain is better in the evening. I’ll ask them if they think their “stenosis” looks better or different when their pain is higher during the day. Then progress with some statement about how their variation in pain is based on the brain’s perceived threat throughout the day. If they question about the brain’s perceived threat, I’ll give a quick explanation of Adriaan Louw’s metaphor, the home security alarm.
Sometimes when you point out that their pain is variable throughout the day and their “radiographic diagnosis” does not very within the same 24 hours, they understand that their pain may not be directly be related to their said diagnosis.
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I participate in a local journal club with a few orthopedic surgeons in town. One of the older MD’s is in his mid 70’s and still practicing and performing surgery. He remarked at a recent meeting that they used to perform surgical lavage “Wash out” procedure for knee arthritis in the 1970’s and 1980’s, and they got reimbursed for the surgery. He said those patients usually did very well. It fits with what we see in this study.
Justin and August – great tips that I will use with my patient regarding pain education. If I start down the road of pain science with a patient, I will usually start with the “explain pain in 5 minutes” video, then move to the alarm system metaphor Justin mentioned.
I also like to use this analogy, not sure where I picked it up. I ask the patient what their favorite sport is, or what they used to play as a kid. Let’s say it’s tennis. If they have had knee/back/whatever pain for 5 years, I will say ” What do you think would happen if you practiced tennis for several hours every single day for 5 years. You would probably get pretty good, right? In fact, the part of your brain that controls the movements of your arm and racket, the part that deals with hand eye coordination, etc, these areas would get physically bigger. Your brain would be able to produce these movements with little to no thought. Well, your pain has been practicing too! You have been activating the area of your brain that produces pain for 8+ hours per day every day, and now your brain is really good at it.”
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