Perspective Matters: A Mini-Post

Check out this sign for a minute. What would you think if you saw it? Would you be surprised? Confused?

We actually came across this sign one day as we rounded a corner. At first, we could only see the one portion of it (the part shown above). We were both caught a little off guard and thought it was really strange. We kind of said “What?!?” We had to go back and have a second look. Then we laughed and realized that this is an example of how seeing the whole picture really makes a big difference! You’ll be able to see the whole sign at the bottom of this post, but first we want to share a few thoughts.

We all have moments in life where we have a tendency to hyper-focus on one aspect of a situation, but looking at the bigger picture can change everything. What does this have to do with reclaiming life from pain? A lot, actually. In the pain course we were at in October we all had to describe pain. One group described it as looking through a paper towel roll at life. Pain demands attention. It can be like losing your peripheral vision, or in other words, the ability to fully engage in other aspects of life.

This can happen whether you’re the person in pain, the supporter, or the health care provider.

• As the person in pain, the other aspects of your life can get overshadowed by the pain.
• As a supporter, you may find it difficult at times to keep your perspective on who the person really is. This is especially true when they are not acting like the person you know and love, and it can be difficult to understand what they are experiencing.
• As a health care provider, it is easy to get ahead of your clients and give them an amazing plan with all the tools to succeed, then get frustrated that they aren’t following through. But if this happens, you may need to take a step back and look at the bigger picture. Keeping a holistic view leads to appropriate goals, which lead to recommendations that can effectively address the client’s needs.

If your situation makes about as much sense as the “free gun” sign, then maybe it’s time to shift your focus. We’re not trying to tell you to put on rose-coloured glasses, ignore reality, or expect a perspective change to be a magic cure. Basically, what we’re suggesting is: sometimes it’s worth re-examining your perspective and assumptions.

Back Pain: A Tale of Two ER Visits

Imagine this:

You are 25 years old. Your back has been hurting lately and it's been getting worse. You haven't seen your doctor about it yet. You've been pushing through it, popping over the counter painkillers, and hoping it'll get better. Then one day at work it suddenly gets a lot worse. The pain extends down your leg, and your leg gives out under you. You can't ignore this anymore. Your over the counter drugs aren't even touching the pain and you feel like you can't take it anymore. You call your partner, who drives you to the hospital. 

Now imagine you get into the emergency room and the nurse says "oh man, you must have a herniated disc" with a look of absolute pity. You wait a few hours to be seen by a resident doctor, who does an exam that you can only describe as excruciating. He says you need an MRI and tells the nurse to give you narcotics. The narcotics kick in and you finally fall asleep, leaving your partner to sit there wide awake wondering what's going on. A while later, another doctor comes in and does the same excruciating exam. Even with narcotics this one hurts. You try to tell them that the resident already did this, so please don't do it again, but the doctor proceeds anyway. You wait another few hours and get your MRI. Another doctor comes in and again examines you in the same, horribly painful way. This doctor says "it's definitely a severe herniated disc. This pain is never going to go away unless you have surgery. But the reality is there's way too many people with painful herniated discs. If a surgeon will even take you, it'll be at least a two year wait. If you had neurological symptoms, then you could get surgery right away. But since it's “only” pain, good luck. Here's a prescription for two days worth of narcotics. I can't give you any more because I don't know you, so I can't be sure you won't abuse or sell them. Follow up with your family doctor.” Later you call the family doctor, only to find out she's on vacation for three weeks, and the covering doctor does not prescribe narcotics. 

Can you imagine the feeling of absolute helplessness and frustration that you would feel? The key message you receive seems to be “your pain is here to stay, and we don't care.” 

Now imagine this version of the story:

When you get to the emergency room, the nurse reassures you. She tells you they have very good doctors here, and they'll be able to figure out a plan for how to deal with this. You wait a few hours to be seen by a resident doctor, who explains that he needs to do an exam to figure out whether there are any neurological symptoms accompanying your pain. The exam is painful for you, but he’s compassionate about it. After the exam, he tells you that the good news is he isn’t seeing any neurological deficits, and because of this he doesn't recommend advanced imaging, like an MRI. He explains that you could have a herniated disc. He also explains that research is now showing that a lot of people who have herniated discs don’t actually have any symptoms, and doing surgery on the people who are having pain is not necessarily helping them. Sometimes it even makes their pain worse. He does prescribe appropriate pain medication to help you get through this current bout of pain, but he also tells you that there are many strategies that can be used to better manage the pain, and medication is only a part of the answer. He tells you that the emergency room is great for dealing with medical emergencies, and it’s good you came here to rule out any neurological symptoms. But at this point, there are better places to further assess the cause of your pain and help you learn how to deal with it. He refers you to a pain specialist who can help you along the way and also advises you to follow up with your family doctor. He tells you to come back to the ER if you do develop neurological symptoms.

What do you think you might feel in this scenario, and what overall message would you receive this time?

Click to enlarge.

What are the differences?

In the first example the whole situation is the opposite of how we would like to see pain treated. There is no empathy or reassurance. The wording used only increases the threat value of the symptoms. (“Oh no, this is really bad!”) This can take a nervous system that’s already on high alert because of the sudden worsening pain and escalate the system’s response. It also does not provide any hope that things can change. (Which could be argued to add a whole new threat: this will NEVER go away!)

In our ideal situation the client is treated with caring, respect and compassion. Decisions are discussed with the client and education is provided. The overall approach hopefully made the client feel supported in a scary situation. 

Points to ponder:

We’ve packed a lot of concepts into these two short examples. These topics could be posts in themselves, but we just wanted to introduce the ideas here. We would love to hear your thoughts on them.

1.) Respecting the client - In the first example we saw three different doctors do the same painful exam three different times. We totally understand each doctor wanting to an assessment before they make decisions. But if a colleague just did the very same thing, you trust their judgement, and the assessment is very painful for the client...is it necessary? At this point what are you looking for with your assessment and is it a good reason/justification to put the client through the assessment? If it is necessary, explaining the benefits to to the client might put them at ease. 

2.) Language - As we mentioned above, the language clinicians use to describe the pain can either reassure or terrify the person in pain. Clinicians are often rushed, trying to see many people in a short time frame. However, in our example above, it really wouldn’t take any longer to communicate in the encouraging manner used in the second scenario.

3.) Imaging - Imaging for pain is a topic that is currently being researched and discussed. As Bronnie Thompson so succinctly stated “We know that most people with back pain are not going to benefit from having X-ray, CT or MRI because these images either don’t show anything useful (no image shows pain) or show something irrelevant that might look interesting but is actually unrelated to back pain. We know this, and there have been numerous treatment guidelines and algorithms and education indicating not to give imaging for low back pain without neurological changes” (Thompson, 2016).

4.) Surgery - Again this is a topic that is currently being researched and discussed. There are many articles on this topic, and some suggest that surgery has been “overprescribed” (Senelick, 2014).

5.) Pain Education -  Educating the client on their own condition can begin at any stage and with any health care provider. While there may not be time to address it in detail in the emergency room, it can be further explored with healthcare providers who specialize in pain. These could be physicians, occupational therapists, physical therapists, psychologists, physiatrists, pharmacists, or a team of providers working together.

And a parting thought:

The first scenario is based on a real story. We don’t share it as a criticism, but as a starting place for a discussion on how pain is approached in assessment and treatment. For health care providers, we hope to draw attention to the impact your information and language can have on clients and their outcomes. If you’ve happened to be the client or family in an ER visit that resembles the first one, please don’t give up. There are health care providers out there who are treating people with compassion, kindness, and care.  And there IS hope that your pain and your life can get better.


Acknowledgement: 
Diagram by Ashley and Colleen at Reclaiming Life. Graphics from Freepik.com.

References:

Senelick, 2 (2014). MRI Back Scans Do Not Predict if you Need Surgery. Retrieved from http://www.huffingtonpost.com/richard-c-senelick-md/sciatica-_b_4098475.html on January 16, 2016

Thompson, B. (2015). HealthSkills: How to Spend Money You Don’t Need To. Retrieved from https://healthskills.wordpress.com/2015/02/02/how-to-spend-money-you-dont-need-to/ on January 16, 2016

A Year in Review

It seems like everywhere in blog-land reviews of 2015 and goals for 2016 are abundant. As 2015 is the first (half) year of our blog, we thought it would be fun to look back on our beginning.

Back in July we decided to start a blog, sat down, came up with a name and wrote our first post. Neither of us knew what to expect or where it would go, but we definitely had a lot to say on the topic - our list of ideas just kept growing and growing. 

For us the blog has been a journey. Writing some of these posts has brought tears. Others have challenged us both personally and professionally. We’ve learned a lot and read journal articles for “fun.” We’ve tried out some of the things we’re learning in our own lives. We’ve met some really great people, both online and in person. We get excited as we see our number of readers and our e-mail list grow. One of our first e-mails to each other went like this:

C: We’ve had 118 views on our blog. Do you think that was all us dealing with our formatting?

A: Well, I have a confession to make. I looked at it 118 times yesterday. (Totally joking)

But the cool news is it isn’t just us who is reading our blog. We’re excited to see all the locations our blog is reaching, and so grateful for the beautiful comments and questions we have received along the way. 

So, like any good blog review post, here’s a look back at some of the key points we’ve learned in 2015:

1.) It’s all about the nervous system. Well, we’ll admit, there are some other pieces in there. But we’ve come to realize that any helpful approach to pain management needs to take the nervous system into consideration. We’ve also realized just how much this is NOT discussed in conventional pain management. 

2.) Pain asks to be respected. There will be more on this topic in the future. Pain is, at the very basic level, an alarm. Ignoring it can lead to your body sounding the alarm louder. 

3.) There is lots of amazing information out there. And lots of people who are super excited about pain management and doing really cool research and clinical work.

4.) There are many tools that can help individuals take back some control of their lives. These tools can include: energy conservation, pacing, and planning. We’ve both had some very cool “reclaiming” moments in our own lives this past year. 

5.) There are people who are “pain superstars” and we can all learn from each other. In fact, everyone has their own superstar moments. 

6.) Sometimes pain doesn’t need to be viewed as the enemy or something that needs to be overcome or beaten. Sometimes a gentler approach is what is needed. We love Bronnie Thompson’s use of the term “flexible persistence.” 

So what’s next for our blog? Well, that picture is still forming. We have lots of ideas and topics we want to explore. This includes things that we’ve discussed lately but also questions that we’ve been asked by our readers. Please feel free to continue sharing your thoughts, experiences, insights, and questions. We love receiving your e-mails and comments! The ideas around pain management are expanding and changing at the moment. We really want to learn all we can and share this information with you in the coming year. While we don’t know exactly what 2016 will look like for our blog, we’re excited to see where it goes. We hope it’s full of lots of interesting, useful posts and over time becomes a place of encouragement, information and celebration of successes.