Since my job change about a year ago, I've started seeing more patients with chronic pain - some diagnosed with conditions such as chronic regional pain syndrome (CRPS) or fibromyalgia - others coming in having had unsuccessful rehabilitation or where symptoms have progressed from something small into a loss of function. While it seems that I'm working with more of these patients, the alternative perspective is that I've been spending a lot of time learning about pain, so perhaps I'm just recognizing things differently than before. I can easily recall patients earlier in my PT career who likely would have benefited from pain education, but I didn't know it at the time.
Regardless of diagnosis or level of function - emotionally, I am sad for these patients, particularly when it's a kid. A child who has had pain for months and has started to lose function or interest in activities because of their pain starts feeling hopeless about their future. This can be pain that has debilitated kids so that they cannot attend school or play their favorite sports or adults who can't tolerate their work day, ultimately losing income. Having recently learned about the positive benefits of teaching people about how pain works, I feel an obligation to guide these patients down the road of pain science. This is a world that I am new to and have spent a lot of time learning about - only to discover that I have a lot more learning to go. For example, I'm learning about the impact of the words I use to describe to a patient why they are hurting - and changing how you explain things is a big challenge. What I quickly learned was that physical therapy is the right place for people experiencing chronic pain, helping them find their way back to function even if it isn't their optimal level or their prior level of function. One of my favorite things about being a physical therapist compared to most other healthcare professions is the regularity at which we interact with our patients and, because of this, the relationships we develop.
In my search to learn more about working with patients experiencing chronic pain, some of the themes I've come across are simple but vital:
1) These patients need to like their clinicians. If we can't relate or connect, we'll have no impact on guiding them through their pain journey. Fortunately, most of the kids find me funny... or at least funny looking... so they get comfortable working with me. On my neurological rehabilitation rotation in PT School, my clinical instructor sat me down and said "What you lack in knowledge, you overwhelmingly make up for with your personality." She basically told me I was dumb, but that patients will like me because I can connect to them. I like to think I've gotten smarter - but that my personality hasn't changed.
2) Listen to the patient! They often tell you a lot of hints to help understand their pain experience so you can break it down. Also, many times, patients who have had pain for a long period of time have seen multiple healthcare providers and already know certain techniques that have not been successful for them in the past. Why would you repeat that approach if it has already failed?
3) Based on the biopsychosocial model, pain is far more complicated than solely focusing on body healing processes, and if we don't give enough attention to the psychological components of pain, we're neglecting a major piece of the puzzle.
I've previously written about my interest in learning about chronic pain in relationship to the hip hinge course as well as the chronic pain presentation I attended at Seattle Children's Hospital. I'm just touching the surface of my chronic pain learning. Today I'm focused on this paper: A pain neuromatrix approach to patients with chronic pain - G.L. Moseley 2003 as well as his book with David Butler, Explain Pain.
In the journal article, Moseley describes assessment and treatment recommendations for patients with chronic pain. He starts by defining "pain is produced by the brain when it perceives that danger to the body tissue exists and that action is required." Studies have shown that there are multiple regions of the brain that release a pain signal, collectively referred to as the "pain matrix" but that these regions vary from person to person. The brain holds an image of the body known as the "virtual body" which is constantly updated by interacting with the environment. When pain persists, the virtual body adapts, often becoming more sensitive, so that less danger inputs are needed for the body to recognize threat level.
What do you do when this occurs? The paper recommends treatment options with key focus on
"reduced input of threat," particularly pain education. The more a person understands how pain works, the smaller impact pain has on their function. If you have been experiencing pain, it may help you to learn more about how pain works. Check out this entertaining Ted Talk for an introduction to pain science. In the clinic, patient education using multiple forms such as pictures or metaphors or videos and not focused solely on anatomical considerations are necessary. It is helpful to ask a patient what they think is causing their pain, and if they focus on an anatomical cause, to help them understand alternative narratives to explain their condition.
In addition, treatments need to toe the line of challenging the patient without overstimulating their pain matrix. Body movement is beneficial, but the loading needs to be done in a progressive manner along with education. The paper suggests finding the baseline amount of activity that is tolerated without increasing symptoms and making numerous small progressions rather than overshooting the level of tolerance.
The article (and some friends) ultimately convinced me to read Explain Pain, by Lorimer Moseley and David Butler. Explain Pain is a book written to help the general population understand pain. It is reader friendly and has cute illustrations that are helpful in simplifying the complexities of pain science. Some key takeaways from the book:
1) The amount of pain you experience does not necessarily correlate with tissue damage. It is possible to have pain without any tissue damage at all. It is also possible to have extreme levels of tissue damage without having any pain. Phantom limb pain - pain where a limb has been amputated and no longer is attached to the body - illustrates that pain does not correlate with tissue damage, as there is no tissue present to elicit a pain response.
2) Pain depends on numerous factors and the brain decides whether or not something hurts, without exception. Pain relies on context. Signals go to the brain for processing and the brain weighs out these signals to determine if the body is in danger or not.
3) All pain is real. All pain is normal. It is a useful protector for your body. As such, it should be respected - not feared. It should be validated and considered in treatment programs. And it should be considered an individualized experience where each person needs separate treatment to recognize their own pain response.
Once I read these resources, it triggered reading others. More on them in an upcoming post. For now, I hope that someone who is experiencing pain reads this and learns one thing that may help them with their pain.
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