Pain Theory Applied

This post will be a little different from our typical chronic pain post. This is a real-life story about a woman who was able to use strategies based on pain theories to minimize disability from her pain. This post will bring together points that have been made throughout our previous posts.

This woman, let’s call her Abigail, had a knee injury a couple of years ago. At that time, the knee pain got pretty bad. It definitely interfered with her function. She wanted to go jogging, but that caused the pain to flare up, so she stopped doing it. Sometimes she even had trouble walking. She had a really hard time getting up and down off the floor with her young children, and it interfered with her enjoyment of spending time with them. She went to her doctor, who diagnosed it and referred her to a physiotherapist (PT). The PT taught her how to strengthen her quadriceps to put less strain on her knee. She had custom shoe inserts made to support her flat feet (which can cause her knees to go inward, and was thought to be contributing to the pain). She iced her knee and took anti-inflammatories only when the pain got really bad, thinking that she should avoid taking too many meds. She wore a knee brace for a while, because she felt scared to do things without it on. All these things seemed to help, and she felt good that she had a few strategies, but it took months until the pain gradually went away.

Now fast forward a couple of years. Abigail is in better shape overall, and her knee hasn’t been bothering her, unless she does too many squats. She likes to go to a zumba class a couple of times per month. She wants to be able to go jogging, because she has enjoyed that in the past. She’s a little worried that her knee might bother her, but she wants to try it. She starts a running routine with some co-workers, taking it easy at first and gradually building up, with a goal of reaching 30 minutes. She registers for a 5km fun run, hoping she’ll actually be able to run it. The first few weeks of training, her knee feels fine. She’s pleasantly surprised, but still careful.

When she gets to a point where she’s running 20 minute intervals, the knee pain is suddenly back. It’s relatively mild at this point, but it’s got her attention. She knows she doesn’t want to go back to the moderate/severe pain that affected her so much two years ago.  

This time, she sees an occupational therapist and a physiotherapist who both specialize in pain.  Her health care team explains some theories and science around pain.

1. The “Pain Alarm” (see this post)

• The pain alarm can be useful, so it is probably telling her something.
• Since the pain clearly started when she began to run 20 minutes at a time, she thinks it’s probably telling her she’s pushing herself too hard, too fast.
• But if she blindly listens to that alarm, or misinterprets what it’s telling her, and she stops moving completely, it will likely get worse.

2. Pain related fear and avoidance (see the diagram on this post)

• If she stops doing activities that can hurt (like running, zumba, or playing with her kids), the decreased activity could actually make things more difficult and painful. This in turn could increase her avoidance of these tasks, creating a cycle that results in decreased functioning.  
• If she completely ignores what her body is saying, and continues trying to increase her running endurance by trying harder and harder to push through the pain, well, that could potentially cause serious pain. Which would lead to avoiding activities because her knee truly can’t tolerate them. This in turn could lead to more fear, and more avoidance, and more pain.

3. “Safety in Me” vs “Danger in me” (see this website)

• There is value in anything that helps build her confidence in her body’s ability to move without causing her pain to get worse.

So basically, Abigail knows she has to pay attention to the acute pain “alarm.” She needs to find the balance where she continues to do activities, but doesn’t overdo it. Understanding these concepts, she works with her health care team to explore how her new knowledge applies to her situation, and develops some strategies:

• She knows that she needs to keep moving, but aims to “fly under the radar” (see last post) of pain, meaning that she will do movements that bring her just to the point of discomfort, but not past it into pain. Basically, she wants to stay in the pushing-herself-but-safe zone.
• With that in mind, she scales back on running, but doesn’t stop. She knows that when she was running for 16 minutes, her knee pain didn’t flare up. So she decides to go back down from 20 minutes to 16, and stay there for a couple of weeks. She plans to increase her time only if she feels the pain is well under control.
• She decides to replace Zumba classes with water aerobics for a while, to give her the chance to focus on running. She realizes that both running and Zumba involve impact on her joints, and decides she needs to choose one to focus on. She wants to increase her running endurance, so that's the one she chooses.
• She learns different exercises from her physiotherapist. This time the exercises are more personalized to the specific reason for her knee pain.
• She ices her knee and takes anti-inflammatories any time she feels the pain and swelling coming, instead of trying to be “tough” and taking meds only when she can’t take the pain anymore. She knows she wants to keep the inflammation at bay so she can keep moving.

Abigail finds great success in this plan. She’s absolutely thrilled that she was able to do it, and is so glad that she didn’t stop running when the pain first started. She’s also glad she took the pain seriously and came up with a plan. She’s grateful for all of the pain theory that she was able to build into her plan. The best part - in another month, she’s able to run the 5 km fun run without experiencing knee pain! 

Acknowledgments:

Diagram by Reclaiming Life. Graphics from freepik.com

How Can Pain be Changed? Brain Based Treatment Ideas

"If we’re in pain, it's changes in our total body that have lead to chronic pain, but it is changeable." - David Butler (2015)

At the end of our last post we talked about how pain treatment is evolving and growing as knowledge of pain increases. We described some neurophysiology concepts in that post, and how they relate to pain. Now let’s go one step deeper and look at an overall approach and some specific treatments that apply these concepts to clinical practice.

The neuromatrix approach described by Moseley (2003) leads to a clinical framework that involves using this knowledge of brain mechanisms to change the experience of pain.  Research into neuroplasticity has opened the door to the idea that our brains can, and do, change throughout our entire lives. The great thing about this is it creates new possibilities in the treatment of pain.

All of these ideas are based on some common themes:

• Many areas of our brain work together as part of the pain response. The network that makes up this response is unique to each individual.
• Pain is an alarm telling us that something is wrong - but the alarm can malfunction. It can respond to the wrong type of information, or require less activation of the network to produce a pain response.“Smaller and seemingly less relevant inputs are sufficient to...produce pain” (Moseley, 2003, p. 4).
• If we can decrease the threat value of the signals our brain receives, or allow more of the network to be activated before the pain response is triggered, we can decrease the pain (Moseley, 2003).

Moseley (2003)  explained three steps to treatment based on these concepts. Today, we’ll examine each step and how a variety of treatment ideas could be incorporated into the process he described.

1. An initial step in treatment involves reducing the threatening input and/or the threat value the brain assigns to these signals. The idea is that if the signals coming from the body are decreased or  interpreted as less of a threat, then the alarm doesn’t need to sound as loud. There are several ways to achieve this. One way is by fixing physical issues in order to reduce the actual input. This can be done through manual therapy, exercises, heat/ice as appropriate, pain medications, etc. Another approach is to reduce the threat value of the inputs. This can be done by things like education about pain, and techniques that calm your nervous system like relaxation, deep breathing, and even laughter yoga.

2. The next step is to figure out how to activate components of the “neuromatrix” without triggering pain. Like we talked about last time, the neuromatrix is a network comprised of different areas and processes within the brain. When enough of the network is activated the pain response is triggered. The goal with this step is to activate some components of this network without activating the pain response.   Some examples of ways to do this include:

• visualization (imagining pain free movement)
• breaking activities down into simple movements
• reducing the physical demand of a task
• changing the way tasks are done
• changing the context surrounding tasks
• changing the language we use to decrease  the  “threat” associated with a particular movement

3. Then, the next step is to gradually increase how much of the neuromatrix is activated, so that more and more of it can be activated without resulting in pain.  The key to achieving this without causing flare ups is to be aware of the threshold (how much of the neuromatrix can be activated without pain), and very gradually increase that threshold. One way to conceptualize this is the idea of  flying under the radar, as described in the graphic below. The idea is to avoid triggering enough of the neuromatrix to cause a flare-up, and gradually push the limits. This will increase how much of the neuromatrix can be activated before a flare up is triggered.

Modern science and knowledge about the brain and nervous system has opened up a variety of treatment options. Treatment can be done in several different ways, depending on the individual’s needs, and the approach can change over time as needed. Note, we have to be careful attributing everything to the brain. The brain clearly plays a huge role in pain, but human beings are vastly complex, and so is pain. In order to understand pain, clinicians need to understand “several domains...neuroscience, immunology, endocrinology, psychology, sociology, and philosophy”. (First-person neuroscience and the understanding of pain. Thacker and Moseley. 2012). We would like to suggest that because so many factors contribute to pain, there is hope that all of these factors can be used to change pain.  Even though we don’t have a cure for chronic pain yet, we do have solutions; methods to reduce and manage it, and learn to function better.

Acknowledgement:

Diagrams by Ashley and Colleen. Graphics are from freepik.com

References:

Butler, D. via  Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016.

Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Thacker, M.A., & Moseley, G.L. (2012). First-person neuroscience and the understanding of pain. The Medical Journal of Australia, 196(6), 410-411.

Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378-1382.

The Brain and Pain: Is Chronic Pain Changeable?

A while ago, I (Colleen) was having a discussion about pain with a friend who has fibromyalgia. One of her comments was that she believes it’s “all in her head.” (I cringed as she said that, but then listened to her reasoning.) She feels like there isn’t anything wrong with her tissue and body. It seems like her brain is hypersensitive to “pain signals,” just like it is to many other things (stress, sound, etc). I stopped cringing, and commented how cool it is that our brain’s perception of those signals can be changed.

Her reply was “Do you really think that can change?”

I responded: “Absolutely”

Why that answer? Back when we were in OT school we didn’t learn a lot about chronic pain other than, it was chronic. But since then, we’ve learned enough to convince us that it isn’t as static as we once thought. Yes, it is persistent, and yes, it is real. And no, there aren’t any magic wands to make it completely go away. But the research suggests that it is definitely possible to change our nervous system and our experience of pain.

So let’s take a peek at this idea. How did it become a part of the pain picture? And what is the evidence?

Some (Very) Basic Neurophysiology 

This idea of looking at the brain’s connection to pain is relatively new. A lot of it has come into play in the last few decades as new technologies have become available. We are now able to see what is going on in the brain during different activities (fMRI). Researchers and clinicians have begun to understand just how much the brain can, and does, play a role in pain. For the sake of this post, we are only touching on a few ideas. 

• Neuroplasticity: One of the key points that has come out of this research is the idea of neuroplasticity - that is, our brains are changing every day and will continue to change for our entire lives (Butler, 2014).
• Neurotags: Our brain is made up of tons of neurons that are interconnected in a complex way. A neurotag is a network of neurons from different areas of the brain. When this network is activated, it “generates a particular experience” (Cundiff & Schellinck, 2015; Moseley, Butler, Beames, & Giles, 2012). We have all kinds of neurotags, for a variety of different experiences, and the components that make up these neurotags are individual. For example, if you have experienced food poisoning after consuming a chicken burger, you could have a “food poisoning neurotag.” This neurotag would include neurons that are related to the smell of chicken, the appearance of a burger, the type of bun used, the restaurant you were at, etc. When enough of these neurons are activated, the whole neurotag gets activated, and you experience nausea (Cundiff & Schellinck, 2015). 
• Activation threshold: The activation threshold is the amount of input that is needed to cause a nerve cell to fire. Just like nerve cells have an activation threshold, neurotags need a certain amount of stimulation to be triggered. The activation threshold is the amount of the neurotag that has to be activated before it produces an output (Moseley, Butler, Beames, & Giles, 2012). In the above example, maybe just seeing a similar burger wouldn’t be enough to activate that whole network, but seeing the burger at the same food truck in the summer would activate the nauseous sensation.  

So How Does This all Relate to Pain? 

There is a prominent approach called the neuromatrix theory of pain that takes all the concepts we explained above, and turns them into a way to explain and address pain.

Back in an earlier post we talked about how pain is not simply a representation of what is happening in our tissues, but rather a judgement about the signals from our body. Our brain makes decisions about what these signals mean. Basically, “pain is produced whenever the brain concludes that body tissue is in danger and action is required” (Moseley, 2003). 

Now combine this definition of pain with the neurophysiology described above. All the concepts like neurotags and neuroplasticity can be applied to pain. The brain is always receiving signals, or messages, from the body. These signals have the potential to trigger a “danger” or “pain” response in the brain (neurotag). If enough of the neurotag is triggered (activation threshold), then the whole network is triggered. Many areas of the brain become activated at the same time and they work together to produce pain as a way to bring your attention to the threat. Because of neuroplasticity, this whole process can change over time (Moseley, 2003; Moseley, Butler, Beames, & Giles, 2012). These concepts can guide treatment planning.

The idea that pain involves many areas of the brain interacting with each other can also be helpful when considering treatment options. It means there are many more mechanisms involved in pain than previously thought. As David Butler (2015) said, this is exciting because it “underpins the ENORMOUS power of context. Say 500 areas of the brain are in action when we’re in pain - it means that there is kind of a formula for your pain.  We’re all different, and it can be changeable.” 

So back to our initial question “is chronic pain changeable?”  As our knowledge of the brain changes, so does our view on pain. Chronic pain is not as static as once thought. Current research on the brain’s role in pain has led to new ideas and theories about treatment. This post has been all about the idea that pain can change, and why we believe this is important. In future posts, we will discuss techniques and strategies that are built on these concepts.

Acknowledgement

Diagrams by Ashley and Colleen. Graphics are from freepik.com. 

References

Butler, D. (2014). noijam blog: Explain Brain. Retrived from https://noijam.com/2014/12/09/explain-brain/ on April 16, 2016. 
Butler, D. via  Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016. 
Cundiff, L. & Schellinck, S. (2015). The Physiology of Pain. In Occupational Therapy Best Practice: Chronic Pain Management [Course Manual]. 
Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140. 
Moseley, G.L., Butler, D., Beames, T.B., & Giles, T, J. (2012). The Graded Motor Imagery Handbook. Adelaide, Australia: Noigroup Publications.

Neuroscience and Pain

Acknowledgement:

Diagram by Ashley and Colleen. Graphics from freepik.com with the exception of the mosquito and the tent. They are by Julia Makotinsky from JMDesigns.

References:  

Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016.

Moseley, G.L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, Volume 12, 169-178.

Moseley, G.L., Butler, D., Beames, T.B., & Giles, T, J,. (2012). The Graded Motor Imagery Handbook. Adelaide, Australia: Noigroup Publications.

Strategize: A Mini-Post

Strategize: “to make a plan for achieving a goal” (Merriam Webster, 2016).

Goal-setting is essential in providing effective health care (and most other areas of life where you want to achieve something), but it needs to go beyond having a vague idea of what you want to achieve. Goal-setting needs to go a bit deeper, into how you will achieve it.

Imagine this: There was a woman who wanted to start ice skating again. She happened to mention this to a health care provider one day. This health care provider, trying to help her regain some of the activities she lost, told her that her homework for the week was to go skating. However, the client just didn't feel comfortable or safe going skating - so she didn't. Every week the health care provider asked if she had gone yet, and expressed disappointment that she hadn’t. This left the woman feeling disappointed in herself, and never led to her going skating.

Fast forward a bit. The client had moved on to a new health care provider This one listened and acknowledged her concerns about balance and the risk of falling while skating. He also recognized that she was worried that a fall on the ice could lead to being in pain for a long time. The woman and her health care provider discussed which movements were likely safe (even if they hurt), and which movements were still best to avoid. He gave her simple strategies for improving balance, activities where she could succeed and see improvement. Though time, experience,and support, she learned skills that could help her achieve her goal. She also became more confident that she could deal with the effects of a potential fall. And finally, the health care provider shared in the excitement when the client did go skating on her own...and didn't fall!

There are a few different ideas that could be pulled out of these examples. Perhaps the biggest lesson in this story is the value of health care providers who listen to their client’s concerns. In the second example, the provider created plans with his client, rather than for her. He helped the woman achieve her goal by strategizing. The process of strategizing involved finding out what the woman’s goal was, digging deeper to find out what factors were interfering with that goal, and addressing those factors. In this way, the health care provider was able to make a true difference in the woman’s life.

Acknowledgements:

Skates from freepik.com (Modified by Colleen and Ashley.)

References:  

Strategize. 2016. In Merriam-Webster.com.

Retrieved March 14, 2016, from http://www.merriam-webster.com/dictionary/strategize

The Pain Management Prism

Let’s take a look at the goal of pain management. It’s a pretty good goal. We’re betting that this goal would resonate with a lot of readers, either for yourself, for a loved one or for a client. But how is it achieved? The more we learn, the more we see that pain management really can be divided into a few inter-wound, but different paths.

Let’s use the image of a prism to explain how the different aspects of pain management work together. As you see in the image above, when a beam of light hits a prism, the light is separated into a rainbow of colours. For the purposes of this post, let’s think of pain management as that beam of light. Then we can divide it into several components to examine how they connect with each other to achieve one cohesive goal. 

To begin with, let’s take a brief look at what components go into our experience of pain and how we can impact those components. To greatly oversimplify the process, first your body senses something (pressure, temperature, etc) and creates a message about it. Your nerves then transmit this message up to your brain. Your brain then combines this message with other information to come up with an interpretation of what is happening in the body. If your brain decides this is something you need to be aware of immediately, it lets you know through pain.

How This Relates to Pain Management

The message creation: One aspect of pain management is to look at what is happening in the tissue. That is, focus on what is causing the sensory neurons to fire. For example, is there a broken bone, too much pressure, or damaged cartilage? Are the muscles tense or stiff? This may be the most common approach to pain management and is particularly beneficial in acute pain situations where there is an immediate problem in the tissue. Treatment involves techniques such as stretching, strengthening, realigning, using ice or heat, massage, and electrical stimulation.

The message transmission: Another aspect of pain management is to look at quieting or blocking the signals that your brain receives from the nerve cells in your body. The theory behind this is that if you can quiet the message, you can reduce or eliminate the pain. The nervous system is more complex than a simple messaging system. It modifies the messages sent to the brain, sometimes amplifying the message. This is problematic for us when it results in chronic pain, so some treatments try to dampen the message or cut it off completely. These treatment methods include nerve blocks and some pharmaceuticals.

When most people think of pain management, they focus on treatments that address these two mechanisms. However, there is a third mechanism that is also essential in addressing the complexity of chronic pain.

The message interpretation: The final aspect of pain management we’ll discuss in this post is how the brain interprets these signals. When your brain gets a signal that something is going on in the body it gathers all the information it can to make a decision about this signal. It looks at past experiences, what you know about that area, and other sensory information. Things like mood, fatigue, and a multitude of other factors impact how these sensations are interpreted.  The brain then makes a decision about the significance of the information. It decides whether an alarm is needed, and how loud the alarm will sound. We then experience this “alarm” as pain. 

Researchers have turned this concept around and speculated that if the threat value of these incoming signals could be lowered, then the volume on the alarm could be decreased. Therefore the pain could also be reduced (Moseley, 2007).  Some examples of treatments based on this concept include relaxation techniques (telling the brain that things are okay), visualization (telling your brain that you can complete the movement pain free), and graded exposure (learning that awful pain doesn’t happen with every movement). This is the aspect of pain management that we’ve focused on the most in our blog so far, because it’s an area that we find really exciting. It’s an area that’s relatively new and full of possibilities.

The entire spectrum works together

Just like white light is made up of a spectrum of colours, we believe that effective pain management is made up of a combination of treatment techniques. There is benefit to looking at tissue based mechanisms as well as brain based mechanisms, and everything in-between. All three components discussed in this post (creation, transmission, and interpretation) have an impact on the pain message and open up possibilities for intervention. This generates a whole range of tools that can be explored and new ways to potentially change and reduce pain. But more than simply reducing pain, this opens the door to improving functioning and quality of life for individuals with chronic pain. For us, this means there is always hope.

Acknowledgements:

Diagrams by Ashley and Colleen. Nervous system graphic and brain drawing from freepik.com

References:

Moseley, G.L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, Volume 12, 169-178.

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