Switching a patient from a predominantly passive approach to an active approach can be a tricky proposition. Generally, if someone is used to coming in for manual treatment and has not been using active approaches to address their pain, there is always going to be an element of “handing over their health” to the practitioner – that is, that there is an undertone in that consultation, that to a certain degree, the practitioner is responsible for the outcomes of the treatment and the progression of the pain state. When things go wrong (flare ups) or improvement in pain scores aren’t being seen, it is easy for the patient to think that the fault lies with the practitioner – are they withholding treatments that were previously effective in the earlier days of treatment, are they doing the techniques wrong – too hard, too soft, in the wrong place and so on? Unfortunately, this is the nature of passive approaches – the patient is relying on something or someone to take the pain away from them. Not only is this disempowering for the patient, but it puts a lot of pressure on the practitioner.
With a little knowledge about pain science and the changes that occur in central sensitisation, we know that we can’t make the chronic pain sufferer’s pain go away by massaging, stretching or manipulating the tissues that were initially causing the symptoms. In the chronic pain patient, the tissue causing the symptoms (in this case –perpetuating the pain) is the central nervous system. Its plastic nature means that the changes that have occurred to create the persisting pain state, can potentially be changed back. To effectively tackle this though, we know we need to take a broader approach and include education, stress reduction, movement rehabilitation and thought based approaches as well as manual therapy in the right context.
How do we make this switch, when the therapeutic relationship has been established with a passive basis for some time? This is tough situation and one that doesn’t always have good outcomes. If we suddenly want to introduce exercise, pacing, thought challenging and other self management strategies into our management of a chronic pain situation, where the patient has long been relying on the practitioner to do the work for them, it can upset the status quo. Frequently patients can feel that the practitioner is no longer “there for them” or can even feel that they no longer care about the person’s pain – because ultimately, making that switch from passive to active is removing the responsibility for the outcomes, from the practitioner to the patient – handing them back their health.
To give this process the best possible chance of happening effectively there are a few things to keep in mind:
- Sometimes it can be easier to refer to the patient to another practitioner within the clinic or to someone you know will work using a biopsychosocial approach. This has the advantage that you can separate your approach from the next practitioner’s approach and the patient can start afresh. It is really helpful if you can set up their expectations for the new approach, mainly with the idea that there will be exercise involved and a lot more talking about the understanding of their condition and less hands on therapy. This sets up for movement rehab approaches, education and cognitive behavioural therapy (CBT) approaches. If the patient goes along expecting these approaches, the subsequent practitioner is more likely to be able to successfully integrate them.
- If you can’t refer on due to a lack of appropriate practitioners or because the patient is not keen to see anyone else, then start with good pain education. Set aside up to an hour and let the patient know that most of that time will be spent talking. Explain, using as many resources as you can, the basics of pain physiology and the changes that occur from acute situations to chronic situations. This will help to explain why passive approaches haven’t been effective at resolving the situation and can help underpin why you feel active approaches will give better outcomes. You might be surprised at the level of information they can take on board. You can back up this session by loaning a book with similar information such as Explain Pain 1 or Manage Your Pain 2 and asking them to read it as homework. This video by the Hunter Integrated Pain Services team can also be helpful : https://www.youtube.com/watch?v=4b8oB757DKc
- You can then take a gently – gently approach and begin to add active approaches. You could start by switching manual therapy sessions to exercise or stretching based sessions within your rooms. You could add homework exercises and work up to a level of supported external exercises such as personal training, pilates or yoga. Add some mindfulness training to their homework and you are well on your way.
- You can still use manual therapy as part of the process. We know that it makes people feel better, and even if those effects are only temporary we can take advantage of them – The feel-good factor following manual therapy can boost morale and make people feel a bit more positive about their situation. Additionally if you improve the function of a joint or region by increasing it’s range of motion or decreasing the pain associated with movement you can hopefully get better engagement with movement based approaches. You just need to make sure that the patient understands the purpose of the treatment is for those reasons and is not aiming to be curative.
- Butler, D & Moseley, L. (2003) Explain Pain. NOI Group Publishing, Adelaide
- Nicholas, M., Siddal, P., Tonkin, L., & Beeston L. (2002) Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain, 3rd Harper Collins.