Reality checking expectations and setting appropriate goals

 

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.

  1. 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.
  2. Michael Nicholas, Allan Molloy, Lois Tonks & Lee Beeston, “Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain”, 3rd (2012), Harper Collins
  3. Dennis Turk, “Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain”  Clinical Journal of Pain, 18, (2002), 355-365.
  4. 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.