Switching a patient from a predominantly passive approach to an active approach can be a tricky proposition. Generally, if someone is used to coming in for manual treatment and has not been using active approaches to address their pain, there is always going to be an element of “handing over their health” to the practitioner – that is, that there is an undertone in that consultation, that to a certain degree, the practitioner is responsible for the outcomes of the treatment and the progression of the pain state. When things go wrong (flare ups) or improvement in pain scores aren’t being seen, it is easy for the patient to think that the fault lies with the practitioner – are they withholding treatments that were previously effective in the earlier days of treatment, are they doing the techniques wrong – too hard, too soft, in the wrong place and so on? Unfortunately, this is the nature of passive approaches – the patient is relying on something or someone to take the pain away from them. Not only is this disempowering for the patient, but it puts a lot of pressure on the practitioner.
With a little knowledge about pain science and the changes that occur in central sensitisation, we know that we can’t make the chronic pain sufferer’s pain go away by massaging, stretching or manipulating the tissues that were initially causing the symptoms. In the chronic pain patient, the tissue causing the symptoms (in this case –perpetuating the pain) is the central nervous system. Its plastic nature means that the changes that have occurred to create the persisting pain state, can potentially be changed back. To effectively tackle this though, we know we need to take a broader approach and include education, stress reduction, movement rehabilitation and thought based approaches as well as manual therapy in the right context.
How do we make this switch, when the therapeutic relationship has been established with a passive basis for some time? This is tough situation and one that doesn’t always have good outcomes. If we suddenly want to introduce exercise, pacing, thought challenging and other self management strategies into our management of a chronic pain situation, where the patient has long been relying on the practitioner to do the work for them, it can upset the status quo. Frequently patients can feel that the practitioner is no longer “there for them” or can even feel that they no longer care about the person’s pain – because ultimately, making that switch from passive to active is removing the responsibility for the outcomes, from the practitioner to the patient – handing them back their health.
To give this process the best possible chance of happening effectively there are a few things to keep in mind:
- Sometimes it can be easier to refer to the patient to another practitioner within the clinic or to someone you know will work using a biopsychosocial approach. This has the advantage that you can separate your approach from the next practitioner’s approach and the patient can start afresh. It is really helpful if you can set up their expectations for the new approach, mainly with the idea that there will be exercise involved and a lot more talking about the understanding of their condition and less hands on therapy. This sets up for movement rehab approaches, education and cognitive behavioural therapy (CBT) approaches. If the patient goes along expecting these approaches, the subsequent practitioner is more likely to be able to successfully integrate them.
- If you can’t refer on due to a lack of appropriate practitioners or because the patient is not keen to see anyone else, then start with good pain education. Set aside up to an hour and let the patient know that most of that time will be spent talking. Explain, using as many resources as you can, the basics of pain physiology and the changes that occur from acute situations to chronic situations. This will help to explain why passive approaches haven’t been effective at resolving the situation and can help underpin why you feel active approaches will give better outcomes. You might be surprised at the level of information they can take on board. You can back up this session by loaning a book with similar information such as Explain Pain 1 or Manage Your Pain 2 and asking them to read it as homework. This video by the Hunter Integrated Pain Services team can also be helpful : https://www.youtube.com/watch?v=4b8oB757DKc
- You can then take a gently – gently approach and begin to add active approaches. You could start by switching manual therapy sessions to exercise or stretching based sessions within your rooms. You could add homework exercises and work up to a level of supported external exercises such as personal training, pilates or yoga. Add some mindfulness training to their homework and you are well on your way.
- You can still use manual therapy as part of the process. We know that it makes people feel better, and even if those effects are only temporary we can take advantage of them – The feel-good factor following manual therapy can boost morale and make people feel a bit more positive about their situation. Additionally if you improve the function of a joint or region by increasing it’s range of motion or decreasing the pain associated with movement you can hopefully get better engagement with movement based approaches. You just need to make sure that the patient understands the purpose of the treatment is for those reasons and is not aiming to be curative.
- Butler, D & Moseley, L. (2003) Explain Pain. NOI Group Publishing, Adelaide
- Nicholas, M., Siddal, P., Tonkin, L., & Beeston L. (2002) Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain, 3rd Harper Collins.
For the person who has had pain for a long time, particularly when they have been on “the search” – for the right practitioner, therapy or intervention that holds the magic bullet to cure their pain, setting goals that are reasonable can be the first hurdle to overcome.
Recently I treated a young girl who has had various longstanding painful conditions. She worked in a manual job that she enjoyed and two of these conditions had begun following incidents at work. She left one job after feeling that her bosses and work colleagues were turning on her. It was a traumatic experience and one that she felt both angry and sad about. In her subsequent job she also had a minor injury and was starting to recognise some of the same patterns that had occurred at her last job –she felt like she was being excluded by co-workers and that there was a general lack of support offered to her regarding working around her injuries and concerns by management. She was no longer really enjoying going to work, despite still really loving the actual manual work and the satisfaction that came with completing a job well.
With a long history of relying on manual therapy (weekly treatments for many years covered by 3rd party insurance) and a strongly held belief that she was entitb led to a cure because the initial injury was not her fault, we started our pain education sessions with a lot of discussion around reasonable expectations and goals. She had several “ah –ha” moments following pain physiology explanations and was engaged with the material, remarking that it both fitted with her situation and that it made a lot of sense. Her level of insight into her condition was very high and she was quite open to digging into her understanding of her condition in subsequent cognitive behavioural therapy sessions, coming up with the ideas that her anger at both workplaces had been contributing to creating the conflict. She also felt that once she had thought things through, the bosses weren’t really responsible for her recovery or happiness at work. She challenged the idea that she held that they didn’t care about her, by reflecting on the fact that they were very busy and didn’t tend to have a great deal of contact with the workers. Therefore the lack of care that she perceived probably wasn’t deliberate on their part. This lead to a realization on her part that punishing the bosses and the company by taking days off work probably wasn’t going to achieve the outcome she wanted!
We know these are really important factors in the success of return to work following an injury – if workers feel well supported they will tend to do better1. It would be great if we could encourage all workplaces to embrace this understanding – but failing that, it can be helpful to work with the patient about their understanding of the situation. After two sessions (Two x 1 hour sessions on pain education, goal setting, flare up management and thought challenging) we had come up with some more reasonable goals that were based more around function rather that curing her pain. Some of these included goals around work – like getting her to challenge her thoughts at the time of deciding to take a day off work. Other goals included reading the book: Manage your Pain2 to reinforce some of the pain principles that we had discussed. She was feeling a lot better about her situation and this was reflected in a fairly dramatic improvement in her Pain Catastrophizing Scale(PCS) scores. She was also taking less days off work and going to the gym more often. Her pain levels were still up and down but overall she was reporting feeling a bit better.
Evaluating success in cases like this are not as black and white as they might be in acute cases. Complete relief from pain does occur sometimes but this is not really backed up by the literature, which tells us that while good functional outcomes can be achieved and distress and medication usage can all be reduced, significant reductions in pain scores are not always easy to come by3. Having said that, these figures are mostly coming from Interdisciplinary pain clinics, whose patients have been in pain an average of 7 years prior to presentation4 and are likely to be more disabled and unemployed than patients that we might see in a private setting such as a private physiotherapy or osteopathy practice. Therefore we would hope to be seeing some good reductions in pain scores at least some of the time. In the case of this young girl, my benchmarks for success were based around keeping her in paid employment and managing the falls of the wagon, which have so far occurred twice since our initial goal setting sessions. These temporary backward steps were always likely to occur as she had some big yellow flags from the outset and breaking those long held beliefs was going to be tough at times. For her, knowing that her GP, psychologist and myself were all on the same page about the situation, were helpful in bouncing back from the minor setbacks.
- W Shaw, C Main & V Johnston, “Addressing occupational factors in the management of low back pain: implications for physical therapist practice. [Review]” Physical Therapy, 91(5) (2011), 777-89.
- Michael Nicholas, Allan Molloy, Lois Tonks & Lee Beeston, “Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain”, 3rd (2012), Harper Collins
- Dennis Turk, “Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain” Clinical Journal of Pain, 18, (2002), 355-365.
- H Davies, T Crombie, J Brown & C Martin, “Diminishing returns or appropriate treatment strategy? An analysis of short term outcomes after pain clinic treatment”, Pain, 70 (1997), 203-208.
When a person who has had persisting pain for a period of time commences any form of exercise as part of a rehabilitation program, it is likely that they will experience periods of increased pain or acute flare ups. This is because they are likely to have some level of central sensitisation that will tend to lower their threshold for pain signals to be sent to, and interpreted by the brain as a pain experience. Additionally their descending modulatory systems (such as the GABA, serotonin and a-adrenergic systems), that would normally suppress information of a less threatening nature are likely to be severely inhibited, therefore allowing the brain to be bombarded with pain signals that ordinarily wouldn’t make it through. However, even when a healthy person starts a movement program that they haven’t previously done, they are likely to experience some level of discomfort or even temporary pain as their body adjusts to the new movement and loading patterns being asked of it.
When starting someone on a movement program who has chronic pain, it is important to explain this concept to them. In the process of educating them and forewarning them of the possibility of increased pain in the initial phases, we are helping to set their expectations and therefore reduce their levels of distress in the event that they do have a flare up. It helps to normalise the situation and “normal” reduces fear.
Movement is an essential part of any program help people with chronic pain move to a better functional state. Combined with other active modalities such as stretching, modulation of activities, thought management (such as cognitive behavioural therapy) and returning to work, we are likely to see much better outcomes than those we would expect when patients continue with passive modalities such as manual therapy or medication 1.
Here are a few steps to help set up expectations for a movement program:
- Start with solid pain education including pathophysiological changes that occur in peripheral nerve tissues, the spinal cord and brain in persisting pain states. This helps to underpin your management which is going to involve normal movement to hopefully reverse some of these changes. It helps with the uptake of the exercise and other components.
- Include in your education the concept of flare ups and expectations that they might occur
- Further diffuse the fear associated with the potential for flare ups by arming the patient with a series of pain breaks. These are techniques and tools that they can use to temporarily reduce pain levels. Pain breaks may reduce pain scores enough to make the person feel more positive, move better and reduce some of the accompanying muscular tension that tends to go hand in hand with higher levels of pain. In some cases the pain break allows the nervous system to take a moment of rest and can break or reduce the pain cycle. Pain breaks might include:
- Very hot shower over the affected area for a period of time (make sure to warn the person not to burn themselves)
- TENs machine for 20-30 minutes
- Series of exercises or stretches
- Medication that has been prescribed for breakthrough pain
- Cognitive Behavioural Therapy worksheets
- Mindfulness meditation
- Manual therapy
As some of the above pain breaks could be considered passive interventions, it is important that you explain the context that they will be used in – that is that they are short term interventions used to break the pain cycle – not something that is aiming to be curative or used in the long term. They help to improve function in the short term so that progress can continue through to the longer term.
- Lynn Snow-Turek, Margaret Norris & Gabriel Tan, “Active and passive coping strategies in chronic pain patients” Pain, 64 (1996): 455-462.
We know that in chronic pain situations, changes occur in the nervous system that render the system more likely to create and send nociceptive signals. Changes occur in the brain whereby nociceptive signals are given more attention and pain can be produced by the brain even in the absence of nociception. We also know that our thoughts play an important role in maintaining pain states in many instances, and that those “yellow flags” will often give us an idea of which patients are more likely to have dysfunctional thoughts around their condition. However, you probably have seen patients in persisting pain who seem to have minimal catastrophising thoughts around their condition and who also seem to be exercising often, sometimes even at an elite level. In these cases, you will often find that mechanical or tissue factors are playing a larger role than you might have otherwise expected, given the chronic nature of the issue.
The best example I have to demonstrate this scenario is that of my aunt, who is an extremely fit and active lady in her late 50s. She had a disc bulge in her lumbar spine around 17 years ago which was very painful and disabling at the time, but healed within the time frame that was expected. She returned to her exercise routine within months and regained her fitness. However she continued to have frequent acute flare ups of back pain in the ensuing years. These were often catastrophic and disabling, occasionally requiring an ambulance, but never with any nerve root involvement. They were what we would call mechanical back pain. Over the years the acute episodes became more frequent and about a year ago she called me to chat about it, extremely frustrated. I was initially a bit perplexed as to why this kept happening as her pragmatic, no nonsense approach to life did not put her into a yellow flag category. I was also aware that she was exercising regularly and to a high intensity in a program that included functional weightbearing exercises, cardio, swimming and walking. On further questioning I found out that she was opting out of many of the exercises that were prescribed for the class – anything that involved flexion or core activation. She also mentioned that she never ever bent (flexed) her back in any activities, always preferring to bend her knees and keep her back straight. As it turned out, following her initial injury she had been told never to use lumbar flexion for any movement – that she needed to bend from the knees at all times, use a lumbar roll for the car etc. She was also taught to brace her abdominal muscles when doing any activities such as rolling over or lifting objects. The advice to avoid flexion in that acute healing phase was probably helpful, and the bracing or core engagement advice was fast becoming popular for low back pain at the time. However…….. when it healed, she never went back to the initial therapist and therefore continued to think that flexion was taboo. She was still even using a long armed brush and shovel when cleaning up so that she didn’t have to bend to the floor! Therefore on examination, 17 years later, her range of motion of lumbar flexion was incredibly restricted and she had some serious overactivation of her abdominal muscles. It was no wonder she often set off these acute episodes by getting into the car or putting on her socks!
We spent some time on education about the spine and reassuring her that her disc injury had well and truly healed and that flexion was a normal movement for the spine. I suggested that she start doing some gentle flexion stretches for the lumbar spine and lower limbs and she was diligent with these, often doing 20 minutes of stretching, five times a week. I also suggested that she start trying some of the exercises she had been avoiding by starting within a smaller range, beginning with small numbers and working up from there. We went through this process about a year ago and she hasn’t had an acute episode since. When we recently chatted about it she said “when you told me it was healed, you gave me permission to do stuff again. It completely change my thinking about myself and I was suddenly confident about trying things again”.
The patient’s understanding of their condition plays a massive role in the progression of that condition. Getting it right from the start is so important, but it is never too late to dig deeper into their understanding and make some improvements. Then, you will find things will fall into place much easier.