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.