I’m sitting in a café, trying to mark exams (and stop procrastinating) and the ladies opposite me are having a fairly public and loud “nutrition consult”. One is paying the other for her advice and is listening intently. I promise I am trying hard not to listen… but it is so loud… and so….. interesting:
Client: So that is why my knees are giving me so much trouble? Because of my diet?
“Nutrition” lady: Absolutely – your diet is so inflammatory, it is 100% causing your knees to get sore and probably also causing all sorts of other problems – heart problems, digestive problems…..
Client: ooooooooooohhhhhh. Woooooooooow!
“Nutrition” lady: you need to eat more Kale, melon, spinach, beans. But NEVER eat raw broccoli and avoid pumpkin and cooked cauliflower – you can eat it raw but never cooked. Eat blueberries and raspberries but NEVER strawberries – those babies are so bad for you……………… And it all must be organic…..
On and on it went. The client left a little bewildered with a strange and random list, heading home via the organic shop to infuriate her family, friends and facebook friends with her new nonsense diet that was going to cure her knee pain and toxic liver.
Now can you see why I couldn’t concentrate?
The “why” behind our pain can tend to drive us to do some strange things – it is a big component of “the search” for the quick and easy answer to our pain. If we can just find out the why, then we can do something about it and there is our answer. Hooray!!!!! If only it was that easy.
Looking for answers seems to be part of our culture – we are quick to blame, rather than attend to the problem in front of us. My own example of this is my tension headaches – they come on occasionally, perhaps a couple of times a year, usually when I am burning the candle at both ends. They tend to last a week or so and they suck! They are a good empathy check for me to help deal with patients in pain. My natural tendency is to go looking for a specific reason as to why they might have popped up this time – is it lack of sleep, stress, too much work on etc. Sometimes, I just can’t pin down a reason at all and I find this situation the most distressing – if I can’t even figure out what I have done to bring them on, how do I stop it from coming on again? The desire to be in control in all aspects of my life is obviously a dominant one! I have begun to reason with myself that perhaps I can’t be in control of these things – and that is OK! I can generally keep doing what I need to do WITH a headache and I know it will go away in the near future.
Disengaging the patient away from looking for the “why” is a massive part of pain education. Its also often the hardest part to shift – people have usually latched onto a “why” that may be incorrect but has meaning or makes sense to them. They will often have fitted it into a rule type situation that looks like this:
When I _____________________________, ____________________________ happens.
When I eat cooked cauliflower, my knees get really sore
These are often incorrect and unhelpful understandings about a person’s individual situation. Myth busting in these cases is an important part of pain education. How we go about that is probably going to be the key to success or failure. For example, laughing until you fall on the floor about the cauliflower probably isn’t going to work well as a rapport building exercise. We need to remember that the desire to know why can be a powerful driver and disentangling that needs to be done delicately. We also need to recognise that if we take away someone’s long held assumptions, we need to replace it with something that is accurate, tangible, reassuring and helps them to look forward towards function, rather than keep looking for answers. This is the essence of good pain education.
Is it just me or is there a growing sense in the community that health care delivery is not meeting the perceived needs of its consumers – patients and their families? “Google doctor” situations, horror stories of friends and relatives, less than perfect outcomes….. Bad experiences become folklore and bad news travels way faster than good stories. I see it sometimes creating an “Us Vs Them” scenario in hospital and healthcare settings and I think it can tell us a lot about consumer expectations – they largely don’t seem to intersect with the realities of our health care systems.
So with this in mind, is what we are doing in delivering health care falling short of the mark, or is it just that our patient’s expectations are not realistic? The answer is: probably a touch of both.
Qualitative research by Slade et al in 2009, paints a picture that by and large, patients want to be heard and understood. They desired a therapeutic partnership that was neither clinician dominant nor patient driven – an equal working relationship. We also know that for patients with back pain, one of the most common complaints they have about practitioners is that they don’t listen ( Allegretti, Andrew, Borkan et al, 2010; Stenberg, Fjellman-Wiklund, & Ahlgren, 2012) and that when practitioners are trained in empathy techniques, patients tend to report that those practitioners are more caring. (Bonvicini, Perlin, Bylund….et al, 2009). So it would seem that if we were to do a customer service overhaul to improve patient satisfaction (and likely clinical outcomes), a great place to start would be to allow more time for each patient so that they have the chance to feel heard and understood.
Getting the listening bits right seems like an easy start – to me it is a bit like the low hanging fruit. But what happens when we have done all the listening and education that “best practice” tells us is the way forward, and the patient still wants “something to be done” – an MRI to rule out the disc bulge like Aunty Mary had, or the antibiotics for their viral URTI? Do our efforts need to be turned towards educating the doctor?
Well, maybe, but probably not …….. This study by French et al, published in 2013, looked to educate general practitioners in best practice guidelines in the management of acute low back pain. Largely, what they were looking for was: would educating doctors on this topic change their clinical behaviour in terms of reducing the use of imaging, keeping patients active, reassuring them and promoting self management? The answer: a big fat no! The doctor’s clinical behaviour did not change, despite their assurances after the training session that it would – months down the track their referral rates for imaging were just the same as prior to the training. Speak to doctors at the coal face and the answer as to why this is becomes clear very quickly – patients demand action! Doctors are not stupid – they know the deal with management of low back – but the realities of their practice is that sometimes the patient is so insistent that even the best educational tools and reassurance don’t cut it. They are on a tight schedule and are aware that the patient will go elsewhere anyway.
Soooooo…… Do we need to direct our attention to changing society’s understanding of conditions like back pain? How easy is it to do this? Do public education campaigns work? A Cochrane review done in 2009 by Grilli, Ramsey and Minozzi tells us that although the body of evidence is not particularly large or of a very high quality, there is evidence that using mass media campaigns can change population attitudes and behaviour on topics such as HIV education, immunization rates and back surgery rates. The study acknowledges a couple of important points. Firstly, that it is hard to tell if the effects of the campaigns are coming about because of exposure of the material to the general population or because health practitioners are also exposed to the campaign and adjust their behaviour. Also, it recognises that while mass media can be a powerful tool in reaching people with education material, it may also play a role in shaping the damaging views people hold, such as those quick fix, miracle stories on the news or the sad (and often extreme) stories of people going down a path of pain and disability.
In the case of back pain public health campaigns, the ‘Back Pain: Don’t take it lying down’ campaign, run by Victorian Workcover Authority (Australia) in 1997-1999 was hailed as being a small but successful public intervention. Over the three year period that the campaign was run, it was found that there were significant improvements in back pain beliefs in both the nearly 5000 people surveyed in the general public and 2500 general practitioners (Buchbinder, 2008). The flow on effects from these positive outcomes are hard to measure – but the campaign was prompted by high absenteeism in the workplace. It wouldn’t be hard to account for the dollars spent if the subsequent clinical outcomes included reduced absenteeism and reductions in healthcare visits.
In addressing “risk” in public healthcare settings, there is said to be what is called a “prevention paradox” – this is the idea that there is a more substantial public health benefit from a small shift in risk across a large population, than from a large shift in risk for a small subgroup (perhaps even a high risk group). This fits with the idea that the shift needs to be population wide, and that even a small shift is a good start.
So, if I won 10 million dollars, would I spend it on a public health campaign to reduce the burden of low back pain on society? Maybe….. as long as I could manage the campaign from here:
Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683.
Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10.
Buchbinder, R. (2008). Self-management education en masse: effectiveness of the Back Pain: Don’t Take it Lying Down mass media campaign. Medical Journal of Australia, 17;189(10 Suppl), S29-32.
French, S., MckKenzie, J., O’Connor, D., Grimshaw, J., Mortimer, D……..et al. (2013). Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomized trial. Plos One, 13;8(6):e65471. doi: 10.1371/journal.pone.0065471.
Slade, S., Molloy, E., & Keating, J. (2009). ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23(3), 270-80.
Grilli, R., Ramsay, C., Minozzi, S. (2002). Mass media interventions: effects on health services utilization. Cochrane Database Systematic Reviews. CD000389
Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. Journal of Rehabilitation Medicine , 44(2), 163-171
The second San Diego Pain Summit at times, felt more like the most fun school or friend re-union you could imagine, than an educational event! Some of the people I was most excited to “catch-up” with, I had never actually met before in the flesh. Pushing aside the fantastic social opportunities, the wonderful connections made and the beautiful setting, the program provided an exciting array of speakers who kept the audience engaged for the full two days.
Kicking things off was a session run by Paul Lagerman (Aka The Naked Physio) about Clinicians Getting Creative. He presented a series of creative and sometimes artistic images and tools that might be used to help practitioners to help patients come to a deeper understanding about their pain. Many of them served as a great springboard for discussion and others were sure to be shared by clinicians for use in the clinic on Monday.
Robert Sapolsky was engaging and witty. Having recently crammed his book “Why Zebras Don’t Get Ulcers”, much of the material was familiar, however I found his endearing stage presence did much to dissipate my stressful reaction to the material –which is largely about how stress is so damaging to many systems in the body! Immediately following him was Fabrizio Benedetti who spoke about how placebo works at a neural level, in situations of pain, Parkinsons Disease and physical exertion. Largely they tend to activate the exact same pathways that specific drugs do, to provide improvements – somewhat obvious when pondered more deeply, and yet something I hadn’t thought to think about! It brought up many thoughts and questions for me regarding the clinical benefits of this that aren’t currently being used and other questions about ethical issues in this area.
Kevin Vowles, who I have written previously about here, spoke of ACT and its use and efficacy in the treatment of persisting pain. He says that the literature tells us that for patients who have persistent pain, it is unlikely that any modality will be able to significantly reduce pain scores. With this in mind, he advocates helping the patient to take the focus off the struggle to reduce their pain and emphasizes trying to live a valued and meaningful life in the presence of pain. (I have written about ACT in the clinic here) It was a fantastic refresher and he is a charming and charismatic speaker. I can highly recommend his courses.
Other highlights of the summit were Bronnie Lennox Thompson, whose gentle dulcet tones could lull anyone into changing their behaviour, speaking about motivational interviewing techniques. The verbal sparring between Todd Hargrove and Greg Lehman provided much entertainment, but equally their presentations were both fantastic and endeared attendees to look further into their blogs and courses. Sandy Hilton gave great insight into how structuring not just your language and treatment can help a patient to relax to better engage with treatment, but even how arranging your furniture and clinic set up can help put patients at ease and create a relaxing environment.
The Summit provides an opportunity for clinicians to come together and strengthen ties that are desperately needed. In order for us to keep moving forward as a community to help the healthcare industry adopt a clinical approach to treating pain that fits with our modern understanding of pain science, we need to make sure that our “team” is as strong and focused as possible. Plus a bit of sunshine doesn’t hurt!
Be sure to keep an eye out for the podcast by Karen Litzy from Healthy, Wealthy and Smart which was recorded at the event.
Karen Litzy and I get our selfie on
Out to lunch with Joletta Belton from MyCuppaJo
Antipodeans represent! Bronnie Lennox Thompson and Paul Lagerman
I presented on Cognitive behavioural therapy and its use in the treatment of chronic pain
Painiacs, like myself, can feel at times like the process of getting practitioners to reduce reliance on reductionist approaches and adopt (even slightly) a more biopsychosocial approach when dealing with patients, is a massive uphill battle. The fact that you are reading this blog suggests that you are probably most of the way there – but how do we engage those practitioners who are most in need of the “paradigm shift” required for society to be able to approach pain with a better understanding of the evidence about pain?
Social media has become an incredibly powerful medium for information to be spread far and wide. So whilst things might appear to us to be slow, you can imagine how much harder and slower it would be without the internet. We are able to get our hands on far more content than ever before, share ideas, discuss approaches, debate opinions – put together these can help us to view different parameters of our practice in the light of an informed mind.
One of the problems with the internet is, our searching tends to confirm our own biases for the vast majority of the time. Which if you are hoping to expand the depth of your knowledge on a particular topic can be very helpful – forums can help with different resources, and others opinions can help guide your discoveries. But what happens if your initial inkilings about a subject lead you down a dangerous and ill informed path?
I am fascinated (and at the same time furiously frustrated) with Anti-vaxxers. What makes a person so convinced that Big Pharma are out to get us despite every bit of evidence telling us that vaccines are overwhelmingly safe? That the risk of exposing their child to a dangerous and preventable disease is a better option than vaccination? I ask this very genuinely – I have no doubt that they are looking out for their child’s health. My curiosity is surrounding how the situation comes about in the first place – because we know that once people strongly hold these views, getting them to change their mind is nearly impossible. In fact, using techniques such as delivering information that demonstrates the lack of a link between vaccines and autism, or about the dangers of vaccine preventable diseases, can actually make people dig their heals in even more! ( See the article here) (A subsequent study found that highlighting factual information about the dangers of diseases such as measles, particularly with the use of pictures and descriptions of children infected with the disease, had slightly better success).
In some ways it is understandable – there have been times in the past where government bodies have got it wrong in making recommendations for the public, and plenty of examples of where commercial interests play a big role in influencing public policy and recommendations even in the face of significant evidence that flies in the face of such recommendations – (see this fantastic podcast by Dr Norman Swan on the ABC Health Report reviewing both commercial and pharmaceutical influences in the calcium and vitamin D public recommendations). Perhaps hearing about these situations, the potential anti-vaxxer starts to see conspiracies everywhere and feels the need to seek “the hidden truth”. Dr Patrick Stokes, a senior lecturer in Philosophy at Deakin University eloquently laid out how this can be taken one step further:
“Antivax belief may play on the basic human fears of hesitant parents but the specific contents of those beliefs don’t come out of nowhere. Much of it emerges from what sociologists have called the “cultic milieu” – a cultural space that trades in “forbidden” or “suppressed” knowledge. This milieu is held together by a common rejection of orthodoxy for the sake of rejecting orthodoxy. Believe whatever you want – so long as it’s not what the “mainstream” believes.
This sort of epistemic contrarianism might make you feel superior to the “sheeple”, the unawake masses too gullible, thick or corrupted to see what’s really going on. It might also introduce you to a network of like-minded people who can act as a buffer from criticism. But it’s also a betrayal of the social basis of knowledge – our radical epistemic interdependency” ( You can find whole article here)
So, I guess that goes some way to explain how educated (yes, sometimes even very educated), middle class people in affluent suburbs (as that is the most accurate demographic picture of the “conscientious objector”) come around to thinking that not vaccinating their children is the correct choice. There is probably an element of the entitlement culture creeping into the issue too – “Why should I do something to help out everybody else?”. Throw in the odd distressing Chinese whispered story about the kid whose autism kicked in right after the MMR needle and I can begin to see how it comes about. It doesn’t make the situation any better though! (For those of you who don’t know, Australia has just introduced a ‘No Jab, No Play’ legislation change which is likely to vastly drop the number of conscientious objectors via financial disincentives. You can read more about this topic on this blog.
So what is the link to pain science? It’s the digging in of the heels situation – knowing that once people have settled on an opinion that suits their understanding, fits with their biases and pays their bills, getting them to change their mind about their approach can be difficult. Pushing too hard in the “wrong” direction can have the opposite effect to what we are hoping to achieve. When formulating a message, it probably needs to be carefully worded so that it doesn’t throw the baby out with the bath water – you can keep your trigger points, dry needling, manipulation, ouchy tool massage, strict order based therapy protocols, pilates……. whatever single modality floats your boat and pays the bills – you probably just need to frame that intervention accurately to the patient and use it as part of bigger picture approach that places a great deal of emphasis on working towards self efficacy.
If person expects that a treatment is going to have a positive effect, it greatly increases the chance of that occurring – isn’t that an amazingly wonderful and slightly mysterious phenomenon? Studies that look at these interactions in clinical situations are plentiful and it is such a well documented phenomenon that it almost seems not worth mentioning. But it is amazing isn’t it?
When we are talking about interventions that are directed at pain conditions, particularly chronic pain conditions, it is relatively easy to understand why a proportion of a group of people in pain, will have a positive response to even placebo conditions. A kind researcher or clinician may have taken the time to ask a lot of questions about them and their pain, giving them the impression that they care about their story. They may have had to review their symptoms and function over a period of time with increased scrutiny and may find that they aren’t as disabled or in as much pain as they rated themselves as being at baseline. They may decide that “this is the one” on their pain merry-go round of interventions, and choose to get a bit more active and take a slightly more positive approach to life at the same time as the trial. Who knows? Fascinating stuff!
What is even more fascinating is when we see our expectations having distinctly measurable physiological consequences. I was prompted recently to re-read this fantastic article by Alia Crumb et al from 2011, called “Mind over Milkshakes”. In the study they took 46 subjects and got them to consume a milkshake on two separate occasions. On one of the occasions the milkshake was presented to them as an “Indulgent” shake, and was labelled as being high fat and high calorie. On the other occasion, it was presented as a “Sensible” shake and labelled as being healthy, low fat and low calorie. In actuality, the shakes were identical. They took before and after blood measurements, as well as asking participants to rate how full they felt after each shake. After consuming the indulgent shake, steep decreases in ghrelin, a hormone responsible for regulating hunger, were seen in the blood measurements and the participants rated themselves as being very satisfied or full. However, after consuming the healthy shake, a far smaller decline in ghrelin levels was seen and subjects rated themselves as far less full. How amazing is that? Not only do our expectations change our perceptions of body sensations such as hunger, thirst or pain, but they also change our hormonal response.
Another article that has tickled my fancy in recent times is that by Ben Darlow et al, published this year in Spine, entitled “Easy to harm, hard to heal”. A qualitative study, they interviewed 12 subjects with acute low back pain and 11 with chronic low back pain, about their understanding of their condition. Overwhelmingly the themes that came across were those that indicated that the subjects viewed their back as being fragile, vulnerable, unlikely to heal and at risk of further injury. The flow on from these misconceptions meant that people believed that they needed to rest, avoid activities that they considered dangerous such as lifting, and be vigilant about their posture. The desire for a diagnosis or label for their pain was a common theme for both acute and chronic low back pain patients, as they felt it was important for management or preventing recurrence. People strongly believed that the pain was representing damage in their back and that avoiding bringing on that pain was therefore important – a slippery slope to loss of function, disability and misery.
It is a fantastic paper and is well worth a read. For clinicians, these themes are not surprising – we hear these thoughts expressed about back pain on a daily basis. We tackle these misunderstandings with reassurance and education and pave a way out of the pain spiral with active rehabilitation approaches. It is fairly obviously that these extremely commonly held beliefs are at least partly to blame for the transition from acute to chronic pain in many patients. It begs the question, how do we stop this before it starts? Medical and allied health professionals are gaining greater awareness and understanding of these themes and are altering their treatment approaches. The push to reduce reliance on passive modalities, improve our communication skills to deliver education and reassurance, and reduce the use of imaging for cases of simple low back pain is well on its way to becoming established across professional boundaries. Yet vast numbers of patients will demand that something be “done” for their back pain, and clinicians who are well aware of these principles are often pushed into referring for imaging, owing to demanding patients with unreasonable expectations. And so begins the pain merry-go round for those patients.
The push to create awareness of these issues among healthcare professionals is an obvious place to start and needs to continue for changes to be effectively made. This study further tells us that a great deal of the patient’s misunderstandings about their condition may have come from influences from health professionals. However, at some point we probably need to be addressing the beliefs held by society about this common, debilitating and costly health problem, which ultimately doesn’t need to be such a burden on our healthcare and welfare systems. Public education campaigns in other areas of healthcare where misconceptions exist, such as those associated with the over-prescription of antibiotics, or reducing higher than average back surgery rates, have had some, albeit small, effects on changing outcomes of the patient/clinician interaction and improving desired outcomes. Perhaps it’s time we turned the conversation around from focusing on the next big cure, breakthrough or development in chronic pain treatments, and started focusing on normalising the experience of back pain.
By Carey Wheeler
A couple of years ago I was on a holiday with my family in Bali. On one of the days we went for a trip to the Bali Zoo and we asked our taxi driver if we could take the long way there by seeing some of the surrounding sights and sounds. Religion plays a very large role in daily life for the Balinese, and being the inquisitive type that I am, I was interested in learning about the different rituals and beliefs of this vibrant culture.
One thing of particular interest was how so many religions all got along so well in such a small part of the country. The metaphor that the driver used was perhaps the most succinct and intelligent answer I could ever imagine. Conveniently, it can also be used as a metaphor for physical therapy and pain science.
As we navigated the narrow streets of the outskirts of Seminyak, his story went something like this: “The Balinese people are very welcoming. We are very humble and understanding. For us, God is like this van. If you look at the van from that side (motioning to the left), all you can see is what you see from that side. If you look from the front, that’s all you see. Look from the top and the van looks different again. But you are always looking at the same van. The Balinese people understand this. We understand that even though we may be looking at religion from different angles, we are all celebrating God in our own way.” Wow!
This is not the first time that physical therapy has been likened to religion. The secular, isolated and reductionist models that pervade and divide the manual and exercise therapy worlds see us bickering between manipulative and non-manipulative therapies, between hands-off exercise based therapies and hands-on therapies. There is constant back and forth between the fascia fanatics and trigger pointers, the craniosacral pulsers and lymphatic drainers. The question has been asked before and needs to be asked again: How can they all be right?
When we are faced with a question like this, Occam’s Razor usually cuts to the point pretty well; “the simplest answer is usually correct”. The only way that all of these approaches can be correct is if the mechanisms by which they propose to have their effect are the same. Therefore the posturing, postulating and bickering is unnecessary and frivolous. The specifics and the details of each branch of physical and manual therapy are no longer contentious. We are all looking at the same van from a slightly different angle. Like the Balinese, we can actually all get along in this small world of ours. So rather than argue about what we can see from where we stand, we need to discuss what it is that we are actually looking at.
In physical therapies, the engine, chassis and interior of our van are built from the non-specific effects of what we do. Formerly known as the placebo effect, the non-specific effects of physical therapies include aspects such as expectation, conditioning, descending inhibition and, in some cases, diffuse noxious inhibitory control (1). All of these very real and very interactive mechanisms of physical therapy are at play with everything that we do. The likelihood of us finding more and more relevant non-specific effects is far greater than us chancing upon the elusive specific effects we have been searching so long for. Rather than debate which modality provides the strongest specific effect to a certain tissue we should discuss how we can maximise the role that the non-specific effects play in our interaction with our patients and clients.
The caveat here is that when we have enough evidence to show that a modality or an approach holds no clinical benefit beyond the non-specific effects, we need to seriously consider the ethics of continuing to use that modality (i.e stop looking at the van from that angle). The retort, and one that I acknowledge is very valid, is that when interacting with patients it is the magnitude to which we can influence the non-specific effects of an intervention that will ultimately determine the effectiveness of that intervention (2). This means that we have to acknowledge the role of the patient’s beliefs and expectations in their outcomes, but to not let patient beliefs dictate an implausible or non-evidence based approach.
However, if we can all agree that the immediate and short term outcomes that our patient’s see are based largely on the non-specific effects of our interventions then we can also agree that it is what happens outside of the clinic that is most important to long term outcomes. Long term structural, psychological and social or behavioural change doesn’t occur in a single session or with two sessions per week for six weeks. We need to stop the bickering over beliefs, shake hands, and acknowledge that we all have the potential to have an effect on pain in the short term. Then we can sit down together and help each other to ask better questions.
What biopsychosocial factors have led this person to be here today? What can I do to give this patient the power they need to make the changes that are necessary for long term change? How can I best communicate this information to this patient to make sure they understand what it is we are actually trying to change? Who else in their circle of influence needs to understand this so they can be the best support for this patient? The questions go on and on but they are infinitely more meaningful than asking from what angle does the van look the best!
1) Bialosky.JE, Bishop.MD, George.SZ, Robinson.ME, 2011, Journal of Manual and Manipulative Therapy, ‘Placebo response to manual therapy: something out of nothing?’, Vol.19, Iss.1, pp.11-19
2) Kalauokalani. D, Cherkin. DC, Sherman. KJ, Koepsell.TD, Deyo.RA, 2001, Spine, ‘Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects’, Vol.26, Iss.13, pp.1418-1424
Carey Wheeler is a Clinical Myotherapist (BHSc) and has been in private practice for 5 years. He lives and works in Geelong, Australia. Carey’s clinical approach has always been movement based with a strong focus towards active therapy which developed from a background in strength and conditioning as a personal trainer. One of his main practice goals is to help patients bridge the gap between rehab and training. www.baycityspinalsports.com.au
Here we go again – yet another article about how parents are doing things wrong! Everywhere a parent chooses to look, someone is telling them that they are doing things wrong – too much gluten, screen time, sugar, sun, not enough sun, outdoor play,….. Mention breastfeeding, co-sleeping or sleep training and social media has a meltdown! So, in an effort to stay away from parent bashing, I am going to stick fairly close to the science and have a look at the literature around pain in kids, and how their parents play a role in reducing or enhancing that pain experience for their offspring.
It is fairly well understood in the pain community that there is an association between catastrophising (essentially, dwelling on the worst case scenario) and pain related disability (Linton & Vlaeyen, 2012). The theory goes that worrying excessively about our pain or condition makes us less likely to attempt to do things that might make that pain any worse, and subsequently we avoid things. These means that over time we lose function and become less able to do the things that are important to us. The literature also paints us a fairly clear picture about the idea that this tendency to dwell on the worst possible outcomes is a trait that can be passed down to our children. Families can tend to adopt specific ways of thinking about pain, which can ultimately be very unhelpful (Kralkevic, Banozic, Maric, Cosic, Sapunar et al, 2012; Wilson, Moss, Palermo, 2014). Following on from this, it can also be shown that children who have a parent with chronic pain, are far more likely to develop chronic pain themselves, sometimes even pain that is similar to their parent (Umberger, 2013).
These are pretty important findings and ones that we should be paying attention to as a society. Chronic pain is costly, and prevention is always going to be the best way to go. Government bodies are starting to pay attention to this interaction between parents, children and pain and are taking action. Knowing that early exposure to painful procedures and the subsequent distress, tends to “prime” a child’s nervous system and make them more sensitive to painful procedures in the future, (Taddio, Katz, Ilersich, & Koren, 1997), and also armed with a growing body of research to suggest that distraction during procedures such as vaccination and venipuncture are effective measures to reduce pain and distress in the infant (Chambers, Taddio, Uman, McMurtry, HELPinKIDS Team, 2009), initiatives such as the “It Doesn’t Have to Hurt” campaign https://www.painbc.ca/news/it-doesnt-have-hurt-campaign are popping up, and will hopefully draw increasing public attention.
So how does the research help us when dealing with pain in our kids? Firstly, modelling is incredibly important. A study done by Goodman and McGrath in 2002 showed that kids exposed to their mum undergoing a painful experience (cold pressor task), where the mums were asked to either maximize or minimise their pain response, were compared to a control group given no instructions. They found that kids who had seen their mum “carrying on” about the experience tended to demonstrate a significantly lower pain threshold, when they were subsequently given the cold pressor test. Conversely, kids who had watched their mum minimise her pain, were found to display much lower expressions of pain during their testing. Kids are like sponges and the things that we do and say about pain experiences directly shape their own understanding about pain.
Parental protectiveness and parental pain catastrophising also can have a big impact on how children function. For kids, one of the best ways to measure function is school attendance. A study by Logan et al in 2012 showed that parental pain catastrophising and parental protective responses to child pain, both independently predicted child school absences. This tells us again, that kids take their cues from parents, and that in making the decision to take the day off school, parental anxiety plays a big role.
So can we put it all together to provide some evidence based guidance about dealing with pain in kids? Hell no! I wouldn’t dare start telling you how to parent your kids! However, I can tell you how I try to use these ideas in dealing with my own kid’s ouchies.
- Validation – recognise the situation, demonstrate some empathy. “Ouch – that hurt, are you ok?”
- Reassurance – if you are Ok with the situation, they are likely to be Ok with it. “Let me have a look – Oh, yes that would have hurt. It looks Ok though and I’m pretty sure you will be fine”
- Apply placebo procedures as required (if ever placebo has an important role, here is your chance!) “Here let me kiss it better”* and if the big interventions are required “do you think a dinosaur bandaid would help?”
- Distraction – change the subject as quickly as is practical “Look, the kids are waiting for you on the tyre swing, do you want me to take you over there?”
As clinicians we need to be aware when assessing children in pain, that parental anxiety and family traits will play heavily into the situation. As in any pain situation, reassurance is extremely important and in some instances, your time and attention may need to be more on the parent, than the child in pain. Equally, being aware of these factors, you may decide that parental anxiety is playing such a large role in a child’s pain experience that it needs to be addressed in order for the child to get better functional outcomes. This is a delicate situation and how you address it as a clinician is probably best navigated according to the specifics of the circumstances. A referral to a psychologist might ultimately be needed, however you may be able to address some of the issues with the parents using an educational approach.
* Placebo kisses are not routinely applied in our household for any bottom or tongue related injuries
Chambers, C., Taddio, A., Uman, L., McMurtry, C., HELPinKDS Team. (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clinical Therapy, 31, Suppl 2, S77-S103.
Goodman, J., & McGrath, P. (2003). Mother’s modeling influences children’s pain during a cold pressor task. Pain, 104(3), 559-565.
Kraljevic, S., Banozic, A., Maric, A., Cosic, A., Sapunar, D., & Puljak, L. (2012). Parents’ pain catastrophizing is related to pain catastrophizing of their adult children. International Journal of Behavioural Medicine, 19(1), 115-119.
Linton, S., & Vlaeyen, J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.
Logan, D., Simons, L., & Carpino, E. (2012). Too sick for school? Parent influences on school functioning among children with chronic pain. Pain, 153(2), 437-443.
Taddio, A., Katz, J., Illersich, A., & Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349(9052):599-603.
Umberger, W. (2013). Children of parents with chronic noncancer pain: A comprehensive review of the literature. Journal of Child Adolescent Psychiatric Nursing, Oct 14, doi: 10.1111/jcap.12055. [Epub ahead of print]
Wilson, A., Moss, A., Palermo, T., & Fales, J. (2014). Parent pain and catastrophizing are associated with pain, somatic symptoms and pain-related disability among early adolescents. Journal of Pediatric Psychology, 39(4), 418-426
A recently graduated manual therapist feels a little frustrated after a busy week seeing patients – some of them aren’t getting better like she had hoped. Or, they do really well initially, boost her day with praise and adoration, and then the following two weeks they haven’t maintained the initial changes, and are disappointed, hinting that she has done something different in the second two treatments that haven’t worked as well as that magical first treatment. She beats herself up, worrying that her techniques are not up to scratch.
A professional development course run by a fellow manual therapist comes to town, scheduled for the following week. It promises a new and fantastic approach to treating a classically recalcitrant condition – one that doesn’t respond well to manual therapy in either the literature or the clinic. Despite it being drilled into her at university – “don’t believe any claims without asking for the evidence”, she thinks this could part of the solution for her current slump – perhaps I just need to learn how to do it right.
She rocks up to the course, excited to see what magical wonders are going to be taught. The Guru rises and speaks of the many, many patients he (lets be honest, they are mostly blokes!) has cured with his patented technique.
Case study after case study, miracle after miracle. He shows his eager audience the magic – be careful, you need to do it exactly this way, or it just doesn’t work. Not feeling it? Do less. You need to do it in the correct order or………, your hands need to be exactly here not there, you must do it x number of times or hold for exactly x number of seconds……..
Inspired and excited, she goes back to work, and lo and behold on the Monday, in walks a patient with exactly that condition. Brilliant, she thinks and gets to work, her workshop notes hiding in the top drawer of the desk. Technique delivered as per the recipe – job done. Unfortunately for everyone involved though, the patient does not get better, even with repeated treatments following the exact described protocol. The patient is devastated – this is their fourth failed treatment and they had really felt positive this time – after all, the practitioner was so confident and enthused that she could make a difference. As for the practitioner, disillusionment is settling in hard and fast. Underpinning it all is a thought that keeps rearing its ugly head – “I am just not good at the techniques”.
What this poor disillusioned young lass has missed as she plummets head first into her first career crisis are a few key issues:
- If it sounds too good to be true, it probably is!
- If the literature has repeatedly demonstrated than manual therapy is not an answer for this condition – run very fast in the opposite direction
- While he may have helped many patients to get a good outcome, he failed to present all the cases where things didn’t go so well.
- The ones that cancelled their appointment because the treatment wasn’t working and they couldn’t be bothered paying to go back and tell him that. He is unlikely to ever know that this is what happened because he doesn’t have the time or need to call the patient to follow up – he is busy enough in clinic so doesn’t need the patient to return, and the administrative tasks he needs to complete each night are a much higher priority. Even if he did get the chance to call the patient, it is possible that they may not tell him the truth – upsetting a charismatic practitioner by telling them that they haven’t helped feels a bit icky – better not to say anything
- The ones who weren’t getting better, but did come back in – and look at him with sad puppy dog eyes, confused as to why they aren’t getting better as he said they would. He is likely to refer them on to someone else if they are persistent enough and hang around – nobody likes to feel that uncomfortable!
- The ones who claim they feel better, swept up in the practitioner’s enthusiasm and repeated claims that things are feeling or looking better in their opinion, despite the fact that they have no functional improvement. Let not take any objective measurements in these cases – why spoil a good story?
- The ones that were spontaneously resolving or healing on their own anyway – who doesn’t want to take credit for that and who is definitively going to know?
Pain science is continuing to paint us a very clear picture about the management of chronic pain conditions – any single modality approach is unlikely to be the answer the patient is looking for, especially if that answer is a complete cure. Pain is complex – there are lots of factors that come together to cause the brain to create pain as an output. The tissue factors are just one of those factors and therefore solely directing our efforts towards “fixing” those tissues is going to be an exercise in futility more often than not, particularly in the chronic pain setting.
In an ideal world, the practitioner might have spent time with the patient validating their pain experience and previous failed treatments, gaining an understanding of what they believed was wrong with them, helping them to set expectations and educating them about the neurophysiology of pain. She could easily then have delivered the treatment protocol as part of her bigger picture approach – after all, there is plenty of evidence to say that therapeutic touch can be helpful…… just not on its own! She then might have spent time setting out some active management strategies and giving plenty of reassurance. If both practitioner and the patient have a better focus on how they define success, they are more likely to be happy with the progression of the therapy process – and our practitioner might last a few more years in practice!
Got a favourite guru story? Tell us in the comments on the facebook page. Might be best to keep identities out of it though…..
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 outcomes2,3 .
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………….
- 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
- 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.
- 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.
- 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.