As physical therapists we know the scenario quite well. The new patient intake forms come across our desk right before an evaluation and the body chart is completely covered in “X” marks indicating areas of pain. There is no clear nerve root pattern, no dermal pattern, no pattern at all – just X’s spanning across the body. Perhaps there was an initial trauma several years prior, though many times the onset is insidious.
Often times the medication list is extensive and includes opiates or narcotics. During the history taking portion of the evaluation the patients often recounts a long tail of failed medical remedies. Perhaps they have seen countless health care professionals of various types in various locations. Perhaps they express disdain that their physician has sent them to you because in the past physical therapy has done nothing for them. And perhaps a little voice inside our head gives a deep sigh and says “oh dear.”
There is growing concern over distribution and overuse of opioids by chronic pain patients. Medical practitioners are under pressure by third party payers and the medical boards to prescribe in a safe and conservative manner, though due to the addictive nature of the opioids and narcotics, when denied continuous access to medications some patients may seek a string of new physicians.1 While there is evidence to suggest that opioids can provide analgesic effects to a chronic pain patient for up to eight weeks, they have not been seen to provide pain relief for the same dose after 2 months. 1
Further conversation with our chronic pain patient may reveal how horrified the patient truly is at how their pain has been managed. We know that most of them are not drug seekers for the sake of drug seeking. Chronic and excruciating pain has lead them to seek whatever may get them through their day and many times the pain medications offer a window of relief.
We as physical therapists are the most equipped health care professionals to treat patients with chronic pain. So why then have we found ourselves beating our heads against our desk when we fail to make them better?
Lorimer Mosely, David Butler, Paul Hodges, and Adriaan Louw suggest that we explain pain to them to get them better. These physical therapists come from various research groups using MRI, Ultrasound imaging, mirrors, and various other techniques to develop a profound understanding of what pain is, how it behaves, and what we can do to treat patients suffering from it.
Books such as Explain Pain by Mosely and Butler (of the Neuro Orthopaedic Institute) use beautiful art and laymen’s terms to explain these concepts to patients and healthcare providers alike.2 Mosely’s book Painful Yarns uses a collection of relatable stories to explain how pain behaves (the Australian term Yarns means stories)3. The gift that Mosely gives to patients and healthcare providers alike is humor. The reader gains a sense of neuroscience through anecdotes and analogies in a empathetic and lighthearted manner.
It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain.
The importance of this concept is that the ability to correctly and succinctly explain pain to patients is producing results. Anecdotally, it has changed the way I practice. The concept lies in explaining the concept of neuroplasticity, the brain homunculus, and physiological adaptations that take place as a result of the this process. Adriaan Louw of the Spine and Pain Institute explains that the role the sympathetic and parasympathetic nervous system in his series of books Why I Hurt.4 This series of books covers topics including general pain, back surgery, whiplash, as well as pelvic pain.
Louw demonstrates his conversations with patients in several continuing education formats. At the end of the day we as therapists are generally good at reviewing evidence based literature regarding pain, neuroscience, and therapeutic management, though conveying this subject matter to patients with a variety of educational and psychosocial backgrounds can be a challenge. The following dialogue is one that I commonly use during evaluations and treatment sessions with patients. I find that this has enhanced my ability to gain trust and build rapport with chronic pain patients.
I begin by stating that their case is one that I am familiar with. Many patients feel that their symptoms may be baffling since no single health care professional has been able to explain to them why or how their symptoms persist. Often times I hold this conversation during manual therapy when the patient is lying still and is in a relaxed and comfortable position. I assure them that their symptoms are not in their head, though the brain plays an important role in the experience of pain.
I state the following “It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain. For example, if you fall and sprain your ankle, your brain will tell you that it hurts, so that you will stop walking on it and allow the tendons to rest.
However if you were to step off a curb and sprain your ankle, and a bus was coming at you full speed, your brain would not inform you of pain, but to get out of the way of the bus. It is in this manner that the brain decides what the greatest threat to you is.
If there was an initial injury to the patient that resulted in a chronic pain cycle I would recount the following: Your brain acts like a security system to your body, similar to how a security system would protect a house. If someone threw a brick into the front window of your home and robbed it, you would buy a very loud, noisy security system, and perhaps get a guard dog.
This security system may be so sensitive that it went off when anyone came to the door – not just a criminal. Under a high security threat some alarms go off whenever someone approaches the door. Your brain acts in the same manner to protect your body- it will become weary of normal, non-threatening movements, positions, and activities because it wants to protect you. In this way it can become so sensitive that it does not know the difference between a real threat and a perceived threat. I then explain to the patient that the goal of physical therapy is to address the true mechanical threats and to reteach them safe movements.
This dialogue has opened the doors to communication with my patients. My perception of my practice is that I am earning earlier trust and rapport which merits quicker results with evidence based physical therapy treatment of manual therapy, therapeutic activity, and exercise.
- Fields H. The Doctor’s Dilemma. Neuron. 2011 Feb 24; 69(4): 591–594.
- Butler D. Mosely L. Explain Pain 2nd Edition. Noigroup Publications; 2013.
- Mosely L. Painful Yarns. Dancing Giraffe Press; 2007.
- Louw A. Why I Hurt. International Spine and Pain Institute; 1 editiob; 2013.