Midwives are amazing creatures.  Long before the advent of pain scientists, midwives have known a thing or two about pain:

• Fear about childbirth will increase the pain experienced
• A lack of knowledge will enhance fear
• Fear and anxiety can interfere with our body’s ability to function at its best
• People’s experience of the same painful stimulus varies incredibly across a population and is influenced by many factors

Similarly, long before the Moseley’s, Louw and  Butlers  of the pain world starting banging on about pain education, midwives knew that if a pregnant woman had a good understanding of the physiological processes that were going on in her body during pregnancy and labour, she was less likely to be distressed and anxious about these processes (aka-bringing a baby into the world!).    Like in chronic musculoskeletal pain¹, education and reassurance prior to childbirth has been shown to deliver significantly better clinical outcomes, in terms of reductions in interventions and mental health outcomes^2,3 .

In some pockets of the community internet (and Northcote), there is a sense that natural, drug free childbirth is a reflection of a mother’s mother-liness (is there such a word?) and that if she had to have a caesarian section, she just wasn’t trying hard enough/allowed those wretched doctors to violate her/  didn’t read the right books or do the right course.  They can also convey the idea that not achieving (or aiming for) natural birth will mean a lack of bonding between mother and child or blah blah blah bollocks.   There probably exists an argument on the other side of the fence that our caesarian rates are too high compared to the WHO recommended 10% and that we could be putting more attention on reducing the rates to a level that balances safety for mum and bub against the cost and complications that potentially accompany a surgical birth.

So, in honour of my beautiful sister-in-law who is about to give birth to my niece or nephew, I have penned a few thoughts about childbirth ….. and pain:

• Be careful whose advice you take… including mine! Childbirth is one of the most emotional experiences you will ever go through.  It is rare for a woman to experience it and for it not to leave some kind of mark (not talking about stretch marks or episiotomy scars!)  The emotional toll following childbirth, even in the “best” ones, can feel a little like PTSD (or a lot like PTSD in some cases).  People will want to tell you their story, which is a natural reaction to such a big emotional event, and is an often an important debrief for them.  They might want you to do things the way they did…. Or not do things the way they did.  Then next woman might give you the complete opposite advice.  Keep that in mind whilst politely listening to their stories.  Remember that the horror stories will perpetuate much more so than the cruisy birth stories      (Bad news sells much better than good news – ask any journalist!). Hearing these horror stories can contribute to your fear levels, even if only subconsciously.

• A little bit of knowledge goes a long way. Take your advice from someone you trust and who hopefully will be caring for you during the birth process.  As I mentioned above, having a good understanding of the process is helpful to normalise the sensations  that you will experience.  The idea is hopefully that during the labour you can experience a level of acceptance of the process, rather than fighting the sensations and this will allow the labour to progress.  As in other elements of healthcare, the rapport you have with your caregivers has an important effect on the clinical outcomes.

• Have realistic expectations. They call it labour for a reason – it is unlikely to be a walk in the park.  On the other hand, if things go pear shaped, and interventions are needed, don’t get yourself in a twist worrying that things didn’t go to plan.  Be grateful that we live in a country that offers safe and clean hospitals and well trained medical staff that can help you if you need it.  A healthy and safe mum and bub have to be the first priority.

• Breathing is powerful. As in any other event where pain might be present, deep breathing and other relaxation techniques can be an effective tool with no risks or side effects.  The evidence, although not particularly comprehensive on the subject, suggests that relaxation techniques can help reduce the incidence of instrumental delivery⁴. Deep breathing helps to engage the parasympathetic nervous system, which can help initiate the body’s own pain modulation.  Most protocols suggest practising the techniques in the weeks leading up to delivery.

• Set up your support team well.  Let them know your thoughts and values around delivering your baby and trust that during the process they can advocate for you well, so you can focus on…. other things… probably breathing.  Arm your supporters with the same reassuring education material – they can help normalise things for you, when things feel anything but normal.  This will help keep the fear out of the process.

• Try a TENS machine and heat packs, especially in early labour. It’s pain science in action!  You can often hire the TENS units so that you don’t have to buy them.  For the heat packs, it can be helpful to have a few on the go so that you can rotate them for re-heating.

• Those in science and healthcare have a solid understanding of the “shit happens principle”. It can be helpful to get on board with this one.  It says that sometimes, despite doing all the right things, they don’t always go as intended.  So whilst the stats might say that doing your relaxation and breathing, staying active during labor and educating yourself will improve your chances of a vaginal delivery, they don’t speak for the individual….. and hence, shit happens.  Sometimes we just can’t be in control of everything and it is best to go with the flow.  Trust that your caregivers are making the decisions in yours and your baby’s best interests.

I could go on….. but instead, let me tell you about the birth of MY first child………….

1. Mosely, L., Nicholas, M., & Hodges, P. (2004).  A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clincal Journal of Pain.  20( 5),324-332
2. Johnson R, Slade P. (2002). Does fear of childbirth during pregnancy predict emergency caesarean section?  British Journal of Obstetrics and Gynaecology, 109(11):1213– 1221.
3. Toohil, J., Fenwick, J., Gamble, J., Creedy, D., Buist, A., Turkstra, E., & Ryding, E. (2014). A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women. Birth, 41(12), 384- 395.
4. Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., Jordan, S., Lavender, T., & Neilson, J. (2012). Cochrane Database Systematic Review, Mar 14;3:CD009234. doi: 10.1002/14651858.CD009234.pub2. Review.

Hands up who has stuck their nose into pain science, or just science in general, adopted some new ways of approaching patient care and got better outcomes?  Hands up, who has then poked their nose back into their profession’s water cooler discussions, be it at a conference, internet discussion forums or the actual water cooler itself, and found themselves despairing, pulling their hair out and declaring I CAN’T DO THIS ANYMORE – I NEED A CAREER CHANGE!!! ??

Over this last week I have had discussions with three colleagues who have approached me about wanting to make a career change out of their respective manual therapy industry.  They have approached me seeking some guidance into what might be possible, affordable, fulfilling career options to take sidesteps from their current careers. The recurrent undertones of discontent seem to follow these broad themes:

• People in my profession aren’t keeping up with what is going on, in fact there seems to be pushback against any movement forward – It’ s like they WANT to keep us in the dark ages/on the fringe
• The way that the practice that I work in is structured is designed to keep people sick/broken/in pain/fearful/coming back and I can’t seem to fight against these commercially driven factors to change things
• My colleagues talk about change or keeping up to date but the other day I overheard him/her telling a patient that “once we get the MRI (for their non specific low back pain) then we can make a plan”.
• I practice using a current understanding of pain, yet these “gurus” spouting reductionist nonsense often represent our profession to the public and the medical profession. They end up representing me and its not fair!
• I am stuck in a rut and can’t seem to get my longer term patients to move to a more active management approach – it drives me crazy

I feel like I have been having these conversations almost weekly for a year – and I am no closer to coming up with answers for people regarding a tidy solution.  So, despite admitting to not having the answers, these are some of the suggestions that I have made to various people along the way.

• Remember that the grass is always greener on the other side. Many people in the other careers that you might aspire to switch over to, have very similar issues and frustrations, sometimes they are exactly the same, sometimes slightly different.

• Is switching to a different profession (within allied health/manual therapy) going to allow you to practice in such a different way as to dramatically improve your personal job satisfaction? Is the loss of income, costs of retraining and setting up going to be worth it?  If it is, then go for it…. But make sure you have thought it through really carefully. Remember that education is a massive industry these days, and it is buyer beware in terms of whether you will get a job at the end of a masters degree or other course.  Universities are more than happy to take your money and enroll you in a program with little or no reference to whether the industry can support all the extra grads.

• Instead of focusing on what other people in your industry are doing or saying – just do your job really, really well. Focus on each patient as an individual and try to apply the best approach that you think will help that person, with reference to what the science tells you, but also with reference to your experience. Remember that the changes you can help a person to make in their life can be phenomenal.  The reality of improvements on functional testing or a pain catastrophising scale that we might judge our clinical success by, play out for the patient as things like getting back to work, playing with kids, getting back to the sport or gardening that they love.  That is a massive impact!  It is easy to get wrapped up in prestige, hierarchies and reputations of a profession, (especially in the presence of gurus) and forget that within each of those industries, there are great practitioners and crap practitioners.  Is the label that important? Does it change how you can deliver your service?  Can you slightly change your model of delivery and still stay well within your scope of practice?

• Take stock of where you are at personally – have you had a holiday recently? Are you regularly engaging in conferences, seminars  or professional meeting to keep you motivated and in the zone? Are you working too many hours? Dealing with patients, especially ones in pain is draining in full time mode. Can you switch to part time or diversify your practice to break things up?  At a low ebb you will find yourself wanting to bail out much more readily. 

• Can you refer those long term, dependent patients who are still stuck in passive mode, and haven’t made the progression to an active approach in line with your own changes, to someone else? It’s really hard to change the nature of that relationship once it has been established.  The effect they have on your mood, and that fact that you are probably not helping them much might mean that the kindest thing you can do for them is suggest that they “start fresh”  with a colleague who can show them a new way forward.  (Make sure you know that whoever you are referring to has a good grasp of a biopsychosocial approach!)

• Pursue the stuff that you love outside of work. Remember that work is only part of your life and no career is going to give you complete and utter life satisfaction.

• Stay off the idiot forums!! If that is your exposure to the nonsense that upsets you, just don’t go there, at least for a while.  Stick to discussions with like minded people  and hang out with people who you think can balance things well.

Over a series of weeks I will be interviewing some smart pain people, to hear about how they approach a fictional patient with hip osteoarthritis, who is convinced she needs a hip replacement.  The interviews go for 20 minutes – perfect for the commute or a procrastination session.

Interview #1 Dr Samuel Whittle

Interview #2 Dr Drew Slimmon

I hang out with some pretty clever people.  I read a lot of blogs and articles  written by practitioners and therapists with an evidence based bias.  I teach and engage with people who affirm to me that things are changing, practitioners are paying attention and institutions are taking on board newer ways to teach and conceptualise our roles in manual and exercise therapy as being aligned with what the evidence tells us.

……. and then…. a work colleague of a close relative of mine, a lady that I know and have a great deal of respect for, hurt her neck a couple of weeks ago.  She slept funny on a different pillow and her neck was stiff for several days.  Following that she started to develop a headache – it was a busy time at work and there were some stressful things going on at home for her.  Sick of the pain and not sure where to turn, she mentioned it to her work colleagues at lunch and was directed to a practitioner up the road.  He took x-rays of her whole back (at her expense), told her that her neck curve was “almost backwards” it was so flat, she had a scoliosis and that she would need 10 weeks of manipulative treatment twice a week.

She went along with the whole treatment plan, including buying into the “my x-rays were so bad” and the “I have a scoliosis” thing.

This was happening in my neighborhood, to someone I knew and cared about.

…..and then….  another relative hurt their back and asked if I could see them.  I was in the middle of moving overseas and was flat out, so suggested that she see a practitioner she had previously seen and gotten on well with.  She is fit, healthy, young, employed and sensible.  This is the third episode of low back pain she has had in about a year and there was no radiation, leg pain  or other symptoms that might have pointed towards disc involvement.  The practitioner treated her with some manual therapy which gave good relief – she was able to get back to work, but then told her that if it didn’t get better after three treatments, she would need to get and MRI to “check out the discs”.

Groan and double groan.

It makes me so mad to hear this stuff, more potently when it happens to people that we know and love – we know that it goes on every day, and it is what drives those of us trying to bring about change to persist.  But sometimes it just seems so hard!! How do we connect with the x-ray practitioner to show him that he is potentially doing more harm than good before he has even touched the patient? How can we trust that there is not another generation of these practitioners being generated as we speak?   How do we get the MRI practitioner to understand that by handing that referral slip to my relative, she is setting her up for fear and unreasonable expectations and a likely poorer outcome?

Both of these practitioners are fairly young (I am 36, and am definitely young, if that helps to give you an idea of how I am making that call)  and both are bound by their national registration bodies to do CPD on a two year cycle.  The intention of this is obviously to try to keep practitioners up to date with changes in their field.   The problem seems to be, that the interpretation of what constitutes acceptable CPD is incredibly vague and some practitioners ride the waves of “woo courses”, business or marketing type courses and other nonsense that fills their quota, year after year – completely defeating the purpose.  Do we mandate what people need to cover in their CPD cycles, (more than the existing compulsory components which often tend to focus on safety, privacy and other compliance issues)? Do we tighten the rules on what we consider to be acceptable CPD with a reasonable evidence base?  I can’t see it happening in the near future – I can imagine the uproar!

Times are certainly changing and there is movement and momentum.  The most obvious place to be focusing our efforts are at an undergraduate level, and within my profession there are some affirming and exciting changes occurring in our teaching institutions that lead me to feel a lot more optimistic.  In the meantime, for the sake of my sanity, I am going to stick with reading my sensible folk blogs and stay off the stupidity forums – that way I can maintain my own momentum!

The idea that what is going on in a person’s life can have an influence on their pain, can be a difficult sell to a patient with pain.  Sometimes even for ‘painiacs’ like myself, it is hard to see the wood for the trees and stop yourself from separating out the bio from biopsychosocial.  Being mindful about our own experiences with pain as a practitioner can teach us many things that we can use  in our clinical practice.

Years ago I had low back pain.  It had been around for about 6 years, but didn’t have any real functional impact on my life.  It was there, I was distressed about it to a degree but it didn’t stop me doing anything.  I had some funny concurrent symptoms which prompted me to present for a medical review.  I had an MRI and nothing was found.  The other symptoms disappeared and the very sensible referring doctor simply told me: Just get strong.  Three simple words, combined with his confidence and the negative MRI were incredibly reassuring.  I did get strong and about 4 months later the back pain was no longer a daily problem.  Within 12 months it had almost completely gone.  Rarely, certain biomechanical stresses will tip it over into a flare up – sitting for prolonged periods and certain exercises at the gym, if I overdo it.  When this occurs, it tends to behave like chronic pain– it doesn’t have a reliable pattern, doesn’t respond well to pain medications and the pain can be a lot more intense than what you might expect for such simple stresses.

Earlier this year I was booked to go to a conference overseas.  In preparing for it, I had thought briefly about the fact that I rarely sat these days, and that the big flight, combined with 3 days at the conference was more sitting than I was used to.  I was aware that my back might get a bit sore.  Three days prior to the departure day, we discovered a large, mysterious lump on the side of  my 22 month old daughter’s head.  We took her to the childrens hospital and an appointment with a surgeon was made for the day that I was due to be leaving.    I was beside myself with worry.

We had a lot of discussion around whether I should go or not.  The tickets were non refundable and I had been looking forward to going for a long time.  It was unlikely that any scans or surgery were going to happen in the time I was away, owing to the weekend in the middle.  My husband and I decided that I should go, and could always come back early if it were warranted.

I was a nervous wreck.  I couldn’t find my passport the day before I was due to go, I wasn’t sleeping and my back was niggling – just what I needed.  Passport found, I boarded the plane for an uncomfortable 18 hour journey.  The first day of the conference I found bearable – lots of walking in between speakers, using the hotel gym and stretching out in the evening.  Day two I was miserable – jet lag had caught up, I wasn’t able to concentrate much with the presentations and the back pain was getting much worse.  That night I skyped home to hear more about the plan that the surgeon was putting in place.  There were neurosurgeons being consulted and an appointment at the childrens hospital, following a CT scan, which was to happen on the day I arrived home.  There was a suggestion that the lump was a meningocele – a protrusion of the dura, filled with cerebrospinal fluid, caused by a defect in the skull.  Things were looking serious, and my husband, a surgeon himself, who could usually talk me through my worries, was himself distressed and upset.

Day 3 was exceedingly uncomfortable. I stood at the back of the room for several of the speakers, wriggled like a 3 year old, and was distracted.  Skyping home again that night I heard that my very calm husband, who is usually very dismissive of our children’s ailments, had had a “moment” at work, shortly after receiving the referral appointment to the childrens hospital.  It was for the Childrens Cancer Centre with an oncologist, a detail he thoughtfully left out of our skype session.  Taking my cues from his level of distress, my journey home was a bit of a nightmare.  The pain was almost unbearable, sitting was really uncomfortable and with storms across the country, my flights were delayed.  I was lucky to score 3 seats on the plane and exhausted, slept through the flight.

In a blur of jetlag and anxiety bordering on panic, we took our daughter for scans and appointments, and finally to theatre for a biopsy of this mysterious and as yet undiagnosed mass.  In the happiest of happy circumstances, the mass turned out to be a haematoma that had failed to resolve, causing some reactive bony changes around it, which made it appear nasty.  The surgeon stuck a needle in it and drained it.  She was completely fine and the bony changes disappeared over the following weeks.  My back pain went away, unnoticed.

A month later I attended a three day seminar and then flew the next day to a conference.  It was a thoroughly enjoyable four days and as I sat at breakfast the next day, I reflected on the fact that I hadn’t had even a niggle of back pain. ……  I HADN’T HAD EVEN A NIGGLE OF BACK PAIN!!!!!!   Same biomechanical stress, completely different environmental setting.

I liken this experience to concept of DIMS and SIMs that David Butler and Lorimer Moseley have created for their new pain workbook “The Protectometer”, a great resource that I have already used with a few patients.  It takes what can sometimes be seen as an esoteric concept – the idea that our thoughts, environment, worries and fears can have a massive impact on our pain, and gives it a level of structure and tangibility. In short, the things that represent danger to our brain (danger in me or DIMs) will elevate our pain levels, the things that represent safety to our brains (safety in me SIMs) will reduce our pain levels.  The exercise becomes one of recognising the presence of DIMS and SIMs, reducing the DIMs where possible and increasing the SIMs.  Sometimes, even recognising that DIMs are at play, even if you can’t change them, can reduce distress about pain……. If you can see the wood for the trees!

I treated a fun and bubbly lady, who worked in a law firm, as a  patient about 5 months ago.  She had  chronic neck and arm pain and had been on the “search” merry-go-round for 6 years.  She came to see me because her manual therapy practitioner, who she had been seeing roughly 2-3 times a month for 4 years, had moved away.  She was highly distressed about her pain and fixated on the idea that there was a “cure” out there for her – that she only had to look hard enough for it.  She was very knowledgeable on the various combinations of over the counter medications she could combine with her prescription drugs to get a variable level of pain relief, and consequently was taking a lot of opioids.

Functionally, she was still employed at work but was starting to take more and more sick days off work, was cancelling social events on bad days and had stopped doing some of the things that she loved like yoga and classes at the gym.  Whilst she still regularly went to the  gym and had a personal trainer, there were dozens of “rules” about what she couldn’t do – based on cause and effect assumptions she had made about flare ups following a session at the gym.  She also had a lot of pain behaviours at both work and home – talk and avoidances that painted a picture of her being “sick” or “broken”.   As with most of these cases, there was nothing on her imaging that provided a definitive answer as to why her pain was hanging around.

Despite all of this, she was a cheery and happy person, was very motivated to get better and had a lot of insight into her thinking and understanding of her condition – I knew that she was going to do really well with a bigger picture approach.

After spending the initial consult having a really good listen to her story, including her disappointment with all the failed treatments, I introduced the idea of taking a bigger picture (or biopsychosocial) approach, as it was known to get better outcomes for achieving her goals – to get back to the gym fully, to return to yoga and for pain not to dominate her life as much as it was.  She was keen to try a different approach as she acknowledged that her journey up until now had not provided the answers she had been looking for – if anything she felt like pain was becoming a bigger part of her life.

We booked in some long consults for the following three weeks and over that time, did some pain education, reviewed her thoughts and understanding of her condition, introduced some mindfulness meditation and began to create a team around her.  We enlisted the help of an exercise physiologist to review her exercise program and challenge some of the “rules” she had around exercise, especially regarding her fear of load bearing through her arms and doing anything with her arms above her shoulders.  Together with her personal trainer they started using a graded approach to re-introduce some of the exercises she had been avoiding.  We also got her GP involved for a medication review and fortunately he recognised and agreed with our intentions, and suggested that she reduce her use of opioids.

My main goal in those longer sessions was to use a level of understanding of pain neurophysiology to separate the connection between pain and tissue damage.  With this established, we were then able to take our emphasis off chasing the pain and put it onto her functional goals – we spent a lot of time talking about what was important to her, what her pain represented to her and how it was having an impact on her life.    I then began to introduce the concept that if the pain didn’t represent damage and was unlikely to get worse, she could begin to take part in some of the things that she had been missing out on in the presence of pain.  We talked at length about the concept that the complete removal of the pain wasn’t necessary, for her to live her life the way that she wanted.

ACT and mindfulness approaches in pain are both blissfully simple when you strip them down to basics.  Provided you stick to the scope of pain and refer to a psychologist or GP if you feel that there are other psychological co-morbidities, these approaches will fall nicely under the umbrella of pain education and as a manual or exercise therapist, can fall well within your scope of practice. It makes sense for practitioners who are working with people in pain to look into some of these tools and start integrating some of the approaches in their clinical approaches.  Some great resource to start are:

• The Happiness Trap, by Russ Harris (perfect to hand over to a patient as well)
• Fordyces Behavioural Methods for Chronic Pain and Illness (2014, Main, Keefe, Jensen, Vlaeyen & Vowles)
• Acceptance and Commitment Therapy for Chronic Pain (2005, Dahl, Wilson, Luciano &Hayes)

After a brief break in sessions, my patient returned, more bubbly than normal, with a list of all the ways she had been working towards her goals.  Most importantly she reported that she had a better outlook on what her pain meant to her.  This included dropping a lot of her pain behaviours which had been defining to both her, and the people around her that she was “broken”. Ultimately this meant that she was far less distressed.  Her pain scores had dropped considerably – she still had pain, but it wasn’t interfering with her life as much as it had been.  This was reflected by a big improvement in her Pain Catastrophising Scale scores as well.

I chose not to use manual therapy on this patient because she had been so fixated and reliant on treatment prior to coming to see me, that I felt that if I used it, any gains that we made using a more biopsychosocial approach, might have been attributed to the hands on treatment, and taken away from the emphasis I was trying to create on self-management and active approaches.  Subsequently, and for a brief flare up episode we have used some manual therapy – but in a different context than what she had been previously – she now sees its as one of many tools that she could access to help her stay on track.

One of my favourite quotes that sums up a lot about these approaches is this:

“People who have something better to do don’t suffer as much.”  (Wilbert Fordyce, 1988)

You can also read this blog by Joletta Belton, who has suffered with chronic pain, but using these approaches has managed to gain a level of control of her pain and of her life.  It is very inspiring and great to forward on to patients who might be starting to gain an understanding of the concepts.

Over the weekend I was involved in a discussion on a forum site about active versus passive approaches in manual therapy.  It was posted by some very sensible people, well versed in pain science and with further training in exercise approaches.  My comment to them suggested that their understanding of  active approaches was going to be different to a lot of other practitioners, still stuck in passive mode.  I suggested that because these guys were well advanced on their integration of pain science into clinical practice, that it is easy to forget that there are large numbers of practitioners who have no understanding of these concepts and how they work in the real world – that things weren’t changing as fast as we might think they are.   Someone replied to my comment that this was not the case, as in their experience, most practitioners were on board with prescribing a stretch or two as part of treatment or occasionally recommending someone do pilates.  Job done.

It was a Saturday afternoon, I was wrangling 3 kids solo and trying to bake a cake for a four year old birthday the following day.  PLUS, I am a massive chicken on the internet.

I hate the conflict, tend to take it all very personally and it seems to be rare that a good outcome results from these often heated discussions.  Everyone thinks they are right and the lack of tone, body language and other social norms that would ordinarily govern such a discussion are lost – things tend to get said that ordinarily wouldn’t, if the discussion was face to face.  Therefore I didn’t get back on and say what was burning and bouncing around in my head as I beat butter and sugar together –       THAT IS NOT AN ACTIVE APPROACH!

All was not lost though!  Through the therapeutic mechanisms of smashing eggs and more beating, I tried hard to define what actually IS an active approach.  I believe that if we summed up the things that pain science teaches us, active approaches over passive approaches would have to be my  number one take home point – simply because it underpins everything else.  It puts the ball back in the patient’s court, gives them a sense of control and reduces helplessness. Together with education, it paves a lifelong pathway for patients to manage their own condition, instead of having to rely on someone else to take their pain away or help them out.

Further narrowing things down, I pondered that language is the most important thing when setting up active approaches.

Language helps us:

• Convey to the patient with acute pain that everything is likely to get better, that they should stay active and remain positive that things will settle in time.
• Educate the patient with chronic pain about the changes that occur within the nervous system that perpetuate a pain experience and hence separate out tissue damage from pain, empowering them to move more and be fearful less

Language hinders us when:

• Our diagnosis and subsequent explanation to the patient implies that something is wrong, broken, impaired, switched off, weak…… Eg. Your pelvis is rotated, your leg is longer, your core is weak, your cranial rhythm is imbalanced, your feet are flat, your gluts are switched off and even your neck is out (yes, it still happens)
• Our management approach implies that in order overcome these diagnosed problems, the patient NEEDS to see the practitioner in order to get resolution of their symptoms. In other words – you can’t do this on your own.

Using an active approach in manual therapy really has very little to do with what actual techniques, exercises or stretches you use.  It is about the tone of the consult from the second the patient walks in the door – creating an empowered patient who is in control of their own health.  It is a bigger picture approach and understanding of our role in helping this person on their journey.  An understanding that what we do with our hands plays a very small role in that process and respecting that the power we have with our language is MASSIVE.  This doesn’t minimise or reduce the importance of our role as manual therapists –it just changes the emphasis.

I have spent the last four days in a row sitting on my bum.  I don’t usually sit for such long times and normally my back would be in all sorts of trouble with such an unaccustomed biomechanical stress.  However, I haven’t had even a niggle of discomfort.  I am pretty sure it is because I am doing what love and pursuing the things that matter to me.  Sorry – too much psycho -babble?  I  will give it some context later.

I have had the good fortune to have been at a 3 day pain seminar in Melbourne, finishing with a final day in beautiful Adelaide for Pain Adelaide – “probably the best little pain meeting in the world” – is how they describe it, and I would have to say I agree.  In a one day, multidimensional and multidisciplinary pain bonanza, 19 presenters spoke about pain – from cultural aspects of body pain versus “self” pain, to how new technology in G coupled protein receptors might lead to breakthroughs in targeted drug therapies, and everything in between.   Here is the range of my responses to the different speakers:

• Wow! That sounds amazing.  I really have very little idea of what you are talking about, but it sounds very complicated, you are obviously very passionate about it, and I can see that some very exciting things might come out of that research. (some of the PhD presentations and receptor pharmacology information)
• You are unreal! If only we could bottle you and distribute your sensibleness to practitioners around the globe. (Peter O’Sullivan and Kevin Vowles)
• Are things really that bad? I guess they are…… Lucky we have you on the team and there is so much momentum.  Standing ovation deserved.  (David Butler) 
• Are you sure you are a Rheumatologist? That presentation was awesome (Sam Whittle on Fibromyalgia)
• Whoa – I had never thought about pain in that context. I think it is breaking my brain. Fantastic!   (Jim Hearn on Pain and the Human Condition)
• You mean you think that the data is telling us that the only things that have any effect on a patient’s pain are talking to the patient and reassuring them? Mindblowing, but at the same time not that surprising. (James McAuley, Neuroscience Research Australia)

The thing that has most floated my boat in the last few days has been Kevin Vowles’ material on ACT and its use in treating chronic pain.  The crux of the idea of ACT for pain,  is that in pursuing a meaningful life – one that taps into your values and recognises the things that are important to you, pain doesn’t have to play such a big and central  role in defining our behaviour.  It ties in beautifully with mindfulness approaches.     I will write about it in more detail in the coming weeks. For now, I am off to explore Adelaide!

Find out more about some of the speakers here:

Peter O’Sullivan : Website and this fantastic podcast

David Bulter and Co : NOI goup

Lorimer Moseley and Co: Body in Mind

Dr Sam Whittle: @samwhittle

Pain Adelaide – Keep an eye out for it for next year and save the date!  A fantastic day.

We recently found ourselves with our nearly 2 year old daughter at The Royal Children’s Hospital late on a Sunday evening.  After being triaged we joined the busy waiting room, sitting next to a man who had brought his child in to be seen for a mild viral illness.  He huffed and fidgeted enough to let everyone know that he was not happy being made to wait as his son slept beside him.  After half an hour he loudly declared “our health system is just so stuffed….” . I thought about his statement, reflecting that we were sitting in one of the world’s best hospitals (that place is amazing!), waiting to see medical staff who we trust are going to be exceedingly well trained, for absolutely no cost.  I paused for a moment, before politely suggesting to him that, to be fair, if the nurses had thought that his son was very sick, he would have been seen without delay, and that I was sure that they would take good care of them when they did eventually get seen.  He conceded and quietened down, while I continued to ponder about our “entitlement culture”.  In our very clever western society, we have this expectation that medicine will have all the answers for us – got diabetes? Take medication.  Obesity?  Lap band surgery can help.  Break a bone? We can fix that.  Headache?  Take a pill.  We get so complacent about our advances that some people forget how and why they came about, and that years ago we didn’t have such a black and white mentality that things would work out Ok.  At the extreme end of this spectrum, people might feel so safe that they might choose not to vaccinate their children.  And what happens when it goes wrong and the surgery or treatment fails to fix the broken bone completely? “They stuffed it up”  is often the idea that the patient will take away from their experience, which I believe comes from this entitlement culture – we expect nothing less than perfection.

The problem with this black and white approach is that it can set people up with some very unrealistic expectations and a poor understanding of their condition, which might lead them on to develop chronic pain.  If you happen to be the clinician attempting to lead them out of their pain spiral, getting them to move through this blame, is going to be a key component for getting better functional outcomes.  Directing their understanding of their condition towards one that fits with our modern day understanding of pain physiology is going to be the best way to help reverse the spiral.

I recently treated a middle aged man, who had chronic pain following knee joint replacement surgery, who was very angry at his surgeon.  He was adamant that it was all the surgeon’s fault because he was worse following the surgery.  On further discussion though, he revealed that the surgeon had not been emphatic that the surgery was going to be the answer to this relatively young man’s problems, and had suggested that he wait a few years and continue trying more conservative treatments.  The patient, keen for the quick fix to fit in with his work commitments, had pushed for the surgery despite his recommendations and despite further informed consent discussions that detailed the possibilities of less than favourable outcomes.  We did some pain education sessions, where we discussed in detail the changes that occur within the nervous system in the chronic pain setting.  In this case, it was also very helpful to help this man to challenge his thoughts around “fault” and “blame”, with reference to these physiological changes,  because it enabled him to take back a level of control and responsibility for his condition, which helped with his commitment to the movement rehabilitation program we started him on.  After that shift in his thinking, he seemed to make gains a lot quicker.

Pain is a subjective experience.  It is vastly influenced by many social and emotional factors such as baseline anxiety and depression levels, the context of the pain and our understanding of the condition.  Consider the difference between the athlete with DOMs following a big training session, and a person with muscle pain following a traumatic assault.  Where the athlete believes that pain indicates a certain level of achievement as a means to their reaching their physical goal, it is likely that they will view that pain in positive light and have minimal associated distress.  Their previous experience tells them that it will be short lived and is not harmful and their coaches will re-enforce this concept.  For the person dealing with pain following an assault however, a whole different picture will be at play.  Firstly it is likely there will be fear and uncertainty around what underlying tissue damage has occurred and if there is going to be ongoing issues.  Additionally, the intense emotions attached to the initiating event will be difficult for that person to separate from their pain experience.  So whilst on a nociceptive level the two events might be similar, as a lived experience, the two scenarios will be poles apart.

Different cultures have various ways of expressing and accepting pain as part of life.  Generally this behaviour is modelled by older generations to younger generations.  Where stoic cultures will tend to complain little in the face of pain and make little fuss over small injuries in children, others will verbally and physically express their pain, and the slightest sniffle in the child can be labelled as an illness and treated with much attention.  It begs the question, does the tendency to magnify a pain experience in our expression of that pain, render us more likely to go on to develop chronic pain because of the catastrophising nature of the behaviour?  Or is the opposite scenario at play, whereby the effect of being heard and having our pain validated, has a comforting  and affirming effect which disarms the hold it might have on us?  Is a support group scenario where people discuss their chronic pain a help because of the group camaraderie, or a hindrance because of it’s tendency to encourage misery and magnification?  The answer, as with most things in the pain game, probably falls into the “it’s complex” box.