Remember when you first began practice? Patients came to you for help. You were the solution to their pain..or were you?? Admittedly, you might have been a little scared…not entirely sure of how to deal with your first complex patient of the day. He had chronic LBP for the past 8 years…heck maybe for the past 15 years! All you knew was he could sense your new-ness and he didn’t like it.
Over the months you began to gain confidence in your abilities. You took some continuing education courses and learned some manual skills. Chronic pain patients became easy. You’d work with that very same patient and his pain would reduce for a time…maybe the duration of his course of treatment, then you’d send him off. Successful. Done. Period…?
Eventually he’d come back. “Oh it’s flared up! It’s killin’ me. 12/10! What can you do??” As luck would have it, you had taken a new course. You had new answers, and believe it or not, those answers applied to your same old patient. “Well I want to assess the strength of certain muscles in the core and find the relationship between those and your posture. Also we’ll need to have you avoid doing these certain things and bending in the trunk. They all cause damage.”
There it is. You’ve done your pain education. That was about all there was to say…because pain was simple. A patient comes in with pain in X area…well treat X area and solve your problem. Again, just simple.
…Now, if you read this blog regularly, you might think you know what I’m getting into. “Oh..duh! This is the classic PT (or pretty much any health care professional) attaching mechanics to pain…and he’s doing it in the chronic pain state!! Barf!” If that’s you…just contain yourself (and your fluids) for the moment. I’m going somewhere with this. Back to the story…
Fast-forward a year, maybe two: “Hey Doc..” he says with a half-smile, “..its acting up again. Same old spot.” It’s him. That same patient, and he’s back…with the same pain…what the #*%#? This doesn’t make sense. I fixed his alignment, balanced out his muscles, and I corrected his posture. I even stuck a needle in there for good measure! WHY IS HE BACK?!?
Being a good therapist, you clue in this time. You decide to work your “magic,” BUT this time…you take closer note. You’re more seasoned now. And after treating many patients you’ve come to the conclusion that there’s something else to this chronic pain thing, but you can’t quite put your finger on it. Now, however, you’ve got an ace up your sleeve: Social media.
You’ve learned about tons of new techniques and treatment philosophies since the last time you treated this guy; all thanks to your new, professional network on Twitter and Facebook. You decide to reach out to your internet friends for some answers; but not for any specific treatment techniques this time — you’re past that. You realize the answer must be deeper than that. This is something you’ve seen in many, many patients. It doesn’t seem so simple anymore.
Connecting with the social network, your calls for truth and a better understanding are answered! The biopsychosocial model for pain! The neuromatrix pain theory! It’s a revelation! You see the world with new eyes and you’re eager to start your pain education with this same patient. You see hope. You see a future of aiding this patient into the course of ridding himself from the chronic pain he’s suffered from for so many years.
It’s Day 2 of treating this patient, this being his third course of physical therapy in as many years (at your hands, nonetheless). Normally, that fact would be a drag, but today is different. You’re optimistic. You’ve seen the light!
“Pain is a perception! Don’t you get it? The nerves in your arm send danger signals to your brain and your brain makes sense of them and gives you pain in that area, but it’s not really in that area. It’s in this map in your brain…” You go on; and he probably looks slightly entertained and perhaps a little concerned at your manic behavior. But all of that is of small significance to you. You’ve finally found the answer and now you’ve given that answer to the one person (you know) who needs it the most. Victory is afoot!
…But it’s not. Not really. Because he still leaves your clinic in pain. In fact, he comes back for several more treatments with pain. Sure, it might be blunted a little. Maybe dropped one or two points on a scale, but it’s still there. Still affecting his day to day. Still significant. He now knows his pain is pain is cerebral, but his experience is anything but that. His experience screams and shouts at him that his back is messed up, fragile, and in danger.
So what gives? Why isn’t this the solution? Why wasn’t he cured? Pain education was performed. You did it right this time. What’s the hold up? Where’s his pain education revelation? Why is there such a disconnect between what he now knows and what his brain is doing? Shouldn’t they be the same thing?
That, my friends, is a good question.
Check back in a few days for Part 2 where I attempt to answer some of these questions…or at least make sense of them.
PS – This excellent reflection about the rollercoaster of professional practice by David Butler at NOI Jam and Group is recommended similar reading. And I’m going a different direction with Part 2, so don’t think you can skip out by reading David’s stuff.