Manual therapy is not effective in the long term in treating chronic pain^1,2.  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 (3^rd ed., pp2069-2080).  Philadelphia:Lippincott.  Bonica’s Management of Pain.       Williams and  Wilkins.

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 pain.  Places will be limited.  To register your interest email [email protected]

 

 

 

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.

 

 

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.

 

1. Butler, D & Moseley, L. (2003) Explain Pain. NOI Group Publishing, Adelaide
2. Nicholas, M., Siddal, P., Tonkin, L., & Beeston L. (2002) Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain, 3^rd 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.

A Common Clinical Tale

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.

A Common Clinical Challenge

With a long history of relying on manual therapy (weekly treatments for many years covered by 3^rd party insurance), and a strongly held belief that she was entitled 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!

Setting Goals to Move Forward

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 (2 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.

A Successful Outcome?

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 practice setting. 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 off 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 was helpful for her and enabled her to bounce back from the minor setbacks.

Upcoming Seminars

Check out our upcoming events for details on future seminars and workshops that cover topics like goal setting and pain education.

References

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”, 3^rd (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.

 

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:

1. 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.
2. Include in your education the concept of flare ups and expectations that they might occur
3. 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.

 

1. 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 even be produced by the brain even in the absence of nociception.

We also know that in many instances, our thoughts play an important role in maintaining pain states. These “yellow flags” will often give us an idea of which patients are more likely to have dysfunctional thoughts around their condition. 

Not every chronic pain patient is the same.

You probably have seen patients with persisting pain who seem to have minimal catastrophising thoughts around their condition. There are also those who 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 at a high intensity in a program that included functional weight-bearing 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 over-activation 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.

Upcoming Seminars

Be sure to check out our upcoming events for details on future seminars and workshops that cover how to implement the biopyschosocial approach to understanding and managing pain.

Mindfulness is a powerful tool that you can incorporate into your pain education or general discussion  with clients about having an impact on their pain, anxiety and stress levels.  It can take as little as five minutes of your consult time and can be as simple as getting people started with the smiling mind app or website (see below for links).  In my experience if you “prescribe” some mindfulness training, in the same way that you would exercises, stretches or other health advice, the uptake of this advice can be surprisingly successful.

Additionally there was a fantastic documentary on SBS recently called “Don’t worry, Be Happy” by Michael Mosley – the UK doctor who did the excellent 5:2 diet documentaries and others on interval based exercise training.  It is a fantastic evidence based look at how mindfulness training effects the brain and also a practical look at how doing some regular mindfulness training, along with other simple techniques reduced Dr Mosley’s own anxiety levels and gave him a more positive outlook.

http://www.sbs.com.au/ondemand/video/310415939727/Michael-Mosley-Don-t-Worry-Be-Happy

(if the link no longer exists, I suggest you google Michael Mosley – don’t worry be happy)

These are simple, cheap and incredible effective techniques that can have a massive impact on your own clients, but potentially also on our greater health care infrastructure by improving outcomes and therefore  reducing costs.  Get on board!

Smiling mind

http://smilingmind.com.au/

The app for this program is available free  for iphone and ipad.  Android users might have more luck using the website to access the meditations.

 

Another fantastic free resource:

Frantic World

http://franticworld.com/