Monthly Archives: October 2014

Failure is not an option

Exercise is an essential part of any rehabilitation approach to chronic pain.  Our clinical experience as well as the literature tells us that it works 1,2. Further to this, there doesn’t seem to be much evidence to tell us which exercise works best – whether we choose motor control type exercises, graded strength based approaches or even aerobic exercises. Regardless of what exercise you choose, you are likely to see improvement in pain and function 3.

When we are setting someone up with an exercise program as part of a management program, it is incredibly important that we put a lot of effort into making sure that the program is going to be ongoing.  In the event that they don’t stick with the exercise program and stop doing it before it can start to have the anticipated positive effects, the take home message for the patient is “exercise doesn’t work for my pain”.   It becomes for them yet another failed treatment and can feed into the cycle of hopelessness that many chronic pain suffers experience.  By having a half-hearted go at exercise and failing, it may have inadvertently done more harm than good.

Research tells us that adherence to home exercise programs on the whole is an uphill battle, with up to 70% of patient not engaging in prescribed home exercises 4. Efforts to increase compliance such as involving the patient in the planning and goal setting process, formally establishing motivation and compliance, exploring the patient’s beliefs about exercise and pain, planning for and troubleshooting obstacles and setbacks and regular follow ups to check compliance have been shown to dramatically improve adherence to exercise programs 4.

For people who haven’t got a strong exercise history, starting out with a high level of support is going to mean better adherence in both the short and long term.  Telling someone to start exercising, without much guidance or support is likely to last about two weeks – until the rain, cold, dark, sickness, increased pain or countless other obstacles rear their ugly head.  Specifically, to increase your chances of getting an exercise program to stick the following can be helpful:

  • Establish motivation – why are you here? What do you want to get out of this?
  • What do you enjoy doing? What fits in with your lifestyle? What are you likely to stick with?
  • What do you understand about your pain and how exercise effects it and vice versa?
  • Try to make sure the exercise is scheduled, especially for the first few months. This might mean that the person attends a class, personal training session, clinical pilates, small group training, bootcamp, crossfit etc. When it is scheduled into their diary and they are expected to attend, the chances of them turning up are greater.  This is often even further evident when there is a financial commitment attached to that session (ie. they still pay for the session in the event they don’t turn up!). If the sessions are not as individualised as something like a personal training session, getting them to create a diary entry for something like a gym class is the next best thing.
  • Having a high level of supervision, particularly in the early phases can be really helpful in building confidence. This is particularly important when there is a level of fear avoidance.  If there is someone qualified who can confidently say to the client that the exercise they are doing is safe and won’t be causing damage, they are more likely to engage in the exercise even if there is some pain associated.   There is also greater chance that the exercises will be appropriately progressed and therefore you will see better results.
  • For people who are struggling to see the value in, or are unable to afford these types of highly supervised sessions on an ongoing basis, I often suggest that they start with a period of 8-12 weeks on such a program and then review it. More often than not, when the review time comes around, they have seen the value in the sessions and the results that are happening. They will often be happy to continue because they are enjoying the progress they are making.  If they choose not to keep going, you have at least got a level of habit, some confidence and success, to keep going on a slightly less supervised program.
  • Making a fairly direct referral to the exercise practitioner also helps with the uptake of your suggestion. If you are referring to someone that you know and trust, and can help the person to facilitate contact with that person, you can help smooth the way to the start of their journey.  When they are aware that you trust the practitioner, they will have a greater level of confidence in them too.  This works particularly well when you have your rehab options “in-house” but can also work  with some well established local networks.

 

 

  1. Van Middelkoop, M., Rubinstein, S., Verhagen, A., Ostelo, R., Koes, B., & van Tulder, M. (2010). Exercise therapy for chronic nonspecific low back pain. Best Practice and Research Clinical Rheumatology, 24, 193-204
  2. Hayden, J., van Tulder, M., Malmivaara, A., et al. (2005) Exercise therapy for treatment of non-specific low back pain.  Cochrane Database Syst Rev, (3). CD000335
  3. Gazzi Macedo, L., Latimer, J., Maher, C., et al.(2012). Effect of motor control exercises versus graded activity in patients with nonspecific low back pain: A randomized controlled trial.  Physical Therapy, 92 (3), 363-377.
  4. Beinart, N., Goodchild, C., Weinman, J., Ayis, S., & Godfrey, (2013). Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review.  The Spine Journal, 13, 1940-1950.

Acknowledging the elephant in the room

Manual therapy is not effective in the long term in treating chronic pain1,2.  It’s the elephant in the room that is harder for some practitioners to acknowledge than others.  Is it the fear that this science might make manual practitioners obsolete in managing these patients, that makes it easier to ignore or dismiss than engage with?

 

Some manual practitioners might have difficulty engaging with pain science because they are quietly thinking “but what I do works – I make people feel better”.  And there is a reason that they think this – a lot of the time, patients will get a level of pain relief from manual therapy.  Practitioners will hear it day in and day out – “it feels a lot easier/more free/less painful” after a treatment.  It affirms that what we do is hitting the spot and having an effect…….. but the problem is, if we continue with this model of care in the chronic pain setting, we will be having this conversation over and over and over because the relief that people feel in this situation is overwhelmingly going to be temporary.

The temptation for manual practitioners delving into pain science might be to disengage with the material all together – “you can’t measure what we do,” “I am confident that I am making a difference,” “my patients tell me it helps them,” or “perhaps what you do doesn’t work, but I practice this particular stream of manual therapy techniques and I fix people with chronic pain.

 

In order for us to get good acceptance of pain science in manual therapies, we need to make sure that our approaches don’t throw the baby out with the bath water – manual therapy can still have a place in the chronic pain setting, it just has to be used in a very defined context that is understood by both the practitioner and the patient.  We also need to offer manual therapists some really good options for how to incorporate an understanding of pain physiology into their practice.  There are plenty of “non hands on” evidence based approaches that demonstrate good clinical outcomes,  that can be used in private practices such as osteopathic, physiotherapy, myotherapy or massage practices. These might include exercise, mindfulness, pain education and cognitive behavioural therapy (CBT) approaches.  Up-skilling manual therapists in these approaches makes a lot of sense – who else has good palpation and assessment skills, an opportunity to create good rapport with patients due to the nature of our longer consultations and a solid health sciences background?

 

I firmly believe that active approaches are the way forward in both the acute and chronic setting.  However I still use my hands on skills every day in practice.

 

  • Being able to reproduce a patient’s pain in an initial consultation during the examination process demonstrates to the patient that you have listened to their story and that you believe that their pain is real.  This is very important if you are including, or the patient has been exposed to pain education material that tells a story of central sensitisation.  One of goals of pain education is to help the patient to separate out the sensation of pain and the idea that the pain is representative of tissue damage.  We teach that the mechanisms perpetuating the pain are located not so much in the original tissue, but in the central nervous system, and if we are not careful, we can convey the idea that the pain is not real.

 

  • Having a good idea of where and how the pain can be reproduced gives us a “yard stick”.  We can get the patient to engage in active approaches and demonstrate to them how these can improve the level of pain provoked on palpation or with other examination techniques, thereby reinforcing that these approaches are effective.

 

  • When you are starting movement based approaches or starting a chronic pain management program that removes or reduces some of the “crutches” that people have been using, (including the reduction of opioids), patients are likely to experience times of increased pain, often for several weeks before the introduced approaches start to have an effect.  This can reduce the patient’s acceptance of the outlined management and they can potentially fall off the wagon.  If manual therapy had worked for them in the past in temporarily reducing their pain, then using it in the short term as the program is getting started is probably justified, as long as both practitioner and patient know that that is the context it is being used in and that the expectation is that over a period of time it will be reduced or stopped.

 

  • No matter how well we try to educate our patients, reframe our management approaches and attempt to get the patient to embrace active approaches, there are some that are going to be resentful in coming to see a manual therapist without receiving manual therapy.  This is particularly prominent in patients who have attended other practitioners of  your particular profession or even other practitioners in the clinic and long held that  expectation. There is probably a case to be argued that refusing to treat these patients with any manual therapy will result in them leaving the clinic and searching for the next practitioner/therapy/intervention that is going “cure” their pain.  In these cases perhaps a softly softly approach might work better- a combination of gradually introducing pain concepts and active approaches  whilst gradually reducing their reliance on manual therapy.  We know that these patients are particularly vulnerable to anyone who offers them a quick fix – it could be argued that even though it doesn’t fall strictly within the bounds of an evidence based approach at the outset, if you are moving them in the right direction, it is a better outcome than losing them to the expensive miracle healer around the corner.

 

What do you think?  Should we interpret evidence in a black and white manner or is there room to read between the lines?  Is any form of manual therapy in the chronic setting to be avoided altogether because it sends the wrong message to the patient?   Are there other aspects of using manual therapy in chronic settings that might be considered helpful?  Discussion and comments welcome.

 

 

  1. Rubinstein, S., van Middelkoop, M., Assendelft, W., de Boer, M.,& van Tulder, M. 2011. Spinal Manipulative Therapy for Chronic Low-Back Pain: An Update of a Cochrane Review. Spine 36,13
  1. Loeser, J. & Turk, D. (2001). Multidiciplinary pain management.  In Loeser J (3rd ed., pp2069-2080).  Philadelphia:Lippincott.  Bonica’s Management of Pain.       Williams and  Wilkins.

Embracing what works – Cognitive Behavioural Therapy approaches

A young regular client comes in to see you with knee pain that has come on after she started riding her bike more often and began an exercise class that included a bit of running.  You examine her and decide that she has a mild patella tracking issue that is causing a touch of patello-femoral pain.  It should respond to your management plan – some strengthening, a bit of stretching and some manual therapy.  No problems!  She does well on the plan and returns a week later reporting a 50% decrease in her symptoms and seems happy.  The following week however, she offers to fill in for a friend’s futsal team and plays not one but two games in the middle of the week.  Her knee pain returns as does the swelling.  Your reassure her and explain that you are confident that the backward step is explained by the excessive overloading of the tissues and that once this flare up settles she will continue to improve on the course of treatment you had initially outlined.

However……  she seems to be having a minor meltdown about the knee situation.  She is crying and doesn’t seem to believe what you have to say.  She is anxious to get the manual therapy started.  While she is on the table you ask her what it is about the situation that she is most worried about.  She gathers her thoughts and tells you:

  • I have had such an awful time with my back pain (that you have treated her for over the years) and it has dominated my life. I am worried that my knee will not get better and I will need to constantly be stopping doing what I enjoy doing and will need to be spending money on treatment all the time
  • I am angry that I can’t do the things that I want to do. I should be able to play game of soccer with my mates.
  • My cousin has been diagnosed with rheumatoid arthritis. She was really fit and healthy and now she can’t run or do much.  I am worried that I am going to end up like her.

She also tells you that she has been under a lot of stress with a deadline at work and hasn’t slept well for about a week.  She is exhausted.  You decide to address her concerns and help her to identify how real the thoughts around her knee are, and if they are unhelpful and likely to be hindering her recovery.  Using open ended questions you begin to tease out a more balanced view of the situation:

  • How has your back been lately? I thought you felt that you were getting on top of it a bit more?
    • She replies “That is true. I haven’t really felt it much in the past few months and it has been even better since I started bootcamp” 
  • If your back got better with our plan of attack, what do you think is likely to happen with the knee?
    • “It would probably keep getting better like it had been doing. I guess I just got a bit carried away and was having too much fun with the soccer and I overdid it” 
  • You had been building up your running and exercise tolerance beautifully in the last few months. You probably would have been fine to start back at soccer once the knee had settled a bit more, but a gradual approach might have been a bit better.  Do you think your expectations weren’t matching up to the actual picture of your current fitness and injury level?
    • “I guess so. I have always been pretty competitive and been tempted to push through. I probably shouldn’t feel angry about it because it was a bit of a silly thing to do”
  • You mentioned your cousin a few weeks ago. It obviously a really stressful thing to watch her going through.  What makes you think you will end up like her?
    • “It’s genetic isn’t it? I am worried that it might be the cause of my knee pain.  But I googled it doesn’t really sound like what I have got going on.  I think I am just really upset about seeing it stop her.”
  • In this case “google doctor” is probably right. You don’t have any other signs or symptoms that might indicate that you have rheumatoid arthritis.   Also, based on what I have observed with your knee and what you have told me, I am confident that our initial diagnosis still fits.  Does that make you feel a little easier about those fears?
    • “Yes, I think I knew that but it is nice to hear it. I am just so tired I feel like I can’t think straight!”
  • Yes, a lack of sleep certainly can cloud our ability to see the issues clearly

 

If you enjoy spending time chatting with clients during consultations, it is likely that you have had many conversations like this in your work.  You are probably using some principles from a cognitive behavioural therapy model (CBT) in situations like this nearly every day.

Following the treatment, it is really likely that this person will stand up and feel an awful lot better and it is unlikely that your magic hands are the prime cause of the improvement.  Addressing the  emotional distress components of a pain experience is a really powerful clinical tool.  It is even better if you can encourage the person to challenge their unhelpful thoughts themselves in their everyday lives as it means that when the same thoughts pop up again later and causes them to feel those uncomfortable emotions (anger, fear, panic) they can negate or rationalise the thoughts that are underpinning those emotions.  This approach is in line with CBT models of treatment, often employed by psychologists.

CBT works with people to recognise the connections between the emotions, behaviours, thoughts and physical reactions that all occur in response to a situation.  It aims to give a person the skills to be able to solve their own problems and to manage their own psychological responses to situations.  It is accessible, easy to understand and it works for many conditions including anxiety, depression, sleep disturbance to mention a few.  With regards to chronic pain, it has been shown to help increase functional activity, reduce medication use, and improve mood 1.   Used on its own it is unlikely to have a lasting impact for the patient in chronic pain2,  however in combination with exercise approaches it produces superior outcomes 3.   Which makes sense – if you can address the unhelpful thoughts that are preventing someone from engaging in movement or rehabilitation approaches and reduce distress about their condition, they will often do better.

Some of the CBT principles don’t have to be done as formally as a structured therapeutic program psychologists are likely to employ – you can (and probably already do) use the approach more informally by helping patients to challenge unhelpful thoughts about their conditions.  In fact, as a practitioner who knows a lot about musculoskeletal problems, you are well placed to help them gain a better understanding and perspective of their condition.  Having said that, formal instruction around skills that  patients can practice in their everyday lives is an empowering tool for them and satisfying for clinician’s who can make a real difference to their patient’s quality of life.     Studies have also shown that with appropriate training in CBT techniques, other allied health professionals, besides psychologists, can get good results when using this approach with chronic pain patients 4.  As always, it is important to know the boundaries of your scope of practice and refer on to a clinical psychologist if your patient is presenting with wider ranging psychological problems then a specific chronic pain issue.  However if your goal is to help a patient to address unhelpful thoughts around their pain or musculoskeletal condition specifically, with  training, mentoring/supervision and wide reading on the topic, you can easily start to incorporate some of these skills into your practice.

Beyond Mechanical Pain will be running workshops in 2015, which will teach health practitioners practical CBT skills.  Our Clinical Neuropsychologist Dr Joanne Sherry will be teaching these components of the workshops.  The day long workshop will also teach skills around how to deliver pain education to clients and  mindfulness based approaches for painPlaces will be limited.  To register your interest email painsolutionsvictoria@gmail.com

 

 

 

  1. William, A., Eccleston, C. & Morley, S. (2012). Psychological therapies for management of chronic pain (excluding headache) in adults. Cochrane Database Systems Review, Nov14.
  2. Ostelo, R., Van Tulder, M., Vlaeyen, J., Linton, S., Moreley, S., & Assendelft, W. (2005). Behavioural treatment for chronic low back pain, Cochrane Database Systems Review, CDOO2014
  3. Vibe Fersum, K., O’Sullivan, P., Skouen, J., Smith, A., & Kvale, A. (2013). Efficacy of classification-based  cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial.  European Journal of Pain. 17,6, 916-928.
  4. Woby, S., Roach, N., Urmston, M., &  Watson,P. (2008). Outcome following a  physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes. Physiotherapy, 94, 115-124.