Therapeutic pain science educated has sky-rocketed in the past few years.  Even though the concepts have been around for quite some time, it seems to have found a place among on-line discussions, continuing education courses and a slew of YouTube videos since my graduate studies.

I have become quite fond of the information myself and continuing to mingle it into my treatment interventions.  Even though it has not become a primary intervention in my practice, it has a notch in patient education and helps me understand chronic pain—which should lead to patients understanding their condition more.

Just recently, a colleague of mine was educating a patient about central sensitization and how it can be a reason for his chronic pain.  Read the following letter that was written by this PT to a patient’s physician.  From reading, you will know why the physical therapist performed this intervention and even why this note was written:

Dr. ****:

Mr *** was recently referred to In Touch Therapy for treatment of low back pain. Upon examination, it was observed that this patient demonstrated intense pain of the low back, upper back, neck, and right upper extremity. He exhibited high fear avoidance to movement and exercises. Pt stated that he has significant issues and damage to his back that will not respond to physical therapy interventions. Mr *** was unable to tolerate even low intensity exercises and manual therapy interventions during the initial evaluation despite utilization of therapeutic modalities to lower irritability of symptoms. Application of electrical stimulation pads was reported to be significantly painful. While seated receiving moist heat and electrical stimulation, pt reported increased pain in the back due to the floor vibrating as therapists and other patients walked past him.

Second and third treatment sessions were focused on improving joint mobility in a pain free range to manage symptoms and decrease fear of movement. Again, all activities that were expected to be pain relieving were reported as painful. Due to allodynia, inability to complete low intensity exercises, and lack of improvement; pt was educated on central sensitization phenomenon and plan of care was discussed. Pt appeared disinterested and stated that this concept makes sense but does not apply to him due to severity of damage in his back. Although he did not agree with explanation, he appeared willing to continue with PT POC to improve mobility and decrease central nervous system hypersensitivity.

Pt returned to the clinic this morning (10/6/2014) agitated. He states that he will no longer come to this clinic to receive treatment due to physical therapist’s belief that the pain is in the patient’s head (not what we were suggesting or educating him about). Communication was attempted with the patient to explain this misconception of what was discussed at the prior visit, but he declined. Pt stated that he is going back to the VA to tell them what he thinks of this clinic and he would not return.

Based on these findings and the patient’s reaction to treatment, it is my belief that Mr ***will not benefit from physical therapy interventions at this time.

If you have any questions or comments, please feel free to contact me at ***-***-****

Sincerely,

Dr. ****

Professionally, I feel my colleague made the right call to educate about central sensitization based on the negative patient response thus far to manual therapy, therapeutic exercise and even modalities.  The patient’s presentation is also classical of central sensitization as backed by recognition factors from Nijs et al 2010.

This type of reaction hopefully will not happen to anyone but is a good learning experience for us all.  I will say, this is an extreme reaction from a patient. We have to tread down this type of education path with care and caution as we do not know how patients will perceive it though. This is especially important in chronic pain patients, who could have some other psychological condition and in this case, a diagnosis of PTSD.

Even though I do NOT recommend disregarding the “bio “in biopsychosocial aspect of pain; in this particular case, the “bio” was EXTREMELY difficult to address secondary to allodynic response, therefore, a psychosocial aspect was implemented and unfortunately, back-fired.

What are your thoughts on this case? Has this ever happened to you? 

Should WE, as physical therapist, be educating about a biopsychosocial approach or leave this to psychologists?

With information provided, what would YOU do differently in this case?

Do you think this patient was going to get better ANYWAY?  Could we have just pushed aerobic exercise, non-specific movements and bullshit modalities for 8 week…or even placed him with a tech to complete core exercises, strengthening and motor control?

 

 

 

 

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20 comments

  1. You need the buy in. Without that, any intervention will be rendered useless. I’ve been using Pain Science Education since one of Butler’s first US courses in 2002. This reaction has happened a handful of times and most recently just a few weeks ago, where someone had such a negative reaction, he yelled at me on the phone for about 10 minutes before I hung up on him. Some people need a mechanical explanation. Our colleagues in psychology and psychiatry will absolutely would easily tell us the mind does not adapt to major changes in belief easily. No one wants to be labelled as all in their head, but that is the negative connotation that happens. I even make it a point to say, “I’m not saying this is all in your head.” The emphasis is on the output as a result of inputs that are considered threatening.

    1. Absolutely, the buy in is key! This is true for any treatment. IMO, That is why mechanical explanations have stayed mainstream and continue to give the best results. It is easy for patients to understand. Simplicity sells.

      You have been doing this type of education MUCH longer than me (not showing your age is it Dr. E?!); but I have come to the same conclusions as you mentioned above.

      This guy unfortunately did not buy in to any treatment that we offered…manual therapy, non-threatening exercise, aerobic exercise. A magic pill would have worked.
      H

  2. We have been taught in public health policy making that: without a change in beliefs, there can be no change in behavior. It is fascinating to me how this has not readily applied to our plan of care. I usually spend my first treatment explaining to my patients and asking them to ask me questions even as much as i ask them what they think is happening in their bodies. Pain education has to be a continuous approach. People will ask the same questions and we have to give consistent answers, not just as an individual PT, but as an entire profession. The patient might go through denial, anger, bargaining and depression before they learn to accept but we have to be consistent. We are as much responsible for their pain because we have been inconsistent in explaining to them WHY they have pain in the first place.

    1. Rheysonn,
      Excellent points and I agree with them all. Our profession is not necessary on the same page on many pages. Are we joint heads, muscle heads, nerve heads, fascial heads, etc. It comes to show you the complexity of the MSK system, but tough to be consistent when you get a different answer for LBP from each individual you see.

  3. Harrison,

    Tough break for your colleague. I have started to incorporate pain science as well so I am by no means a professional at it. However, in going with Adrian louw’s advice, the first thing we should do with these sensitized patients is apologize that we (as a medical community) have failed them up to that point. This brings empathy before the intellectual discourse. It’s also important that we preface our pain science education with something to the tune of “I am by no means saying that your pain Mr jones is in your head, you pain is real and please don’t misunderstand me. Your pain is real and don’t let anyone tell you different, but Mr. Jones I would like to simplify the science about pain so that you can better understand what you are feeling…” And then launch into it. The empathetic response helps us identify with the patient prior to delivering the education so that there is more buy in so to speak.
    I haven’t quite figured out how to address the patient that says “this makes sense but but but my pain this or my pain that..” I do feel like it’s worthwhile to use modalities (after education about pain science and what modalities can do) even though they have very little research to back them up. I also feel like simple spending a few sessions just educating us worthwhile prior to any interventions whether is manual, exercise etc. this buys us time to get their fear avoidance down and develop a relationship of trust. Why are we (and I say we because I am just as guilty) so caught up with doing “stuff”/treatments day 1 or even day 2. Our treatment can be education and I think that is very justifiable, especially in the presence of a chronic pain diagnosis. I don’t think this is psychology, I think this is physical therapy education. It’s the same passion we have toward spinal manipulation, chiropractors don’t own that just like we don’t. It’s a common treatment that both professions can provide, given they are trained to do so. It’s the same with pain science, we are trained and WELL equipped to take this head on. You should check out my own encounter on with pain as a perceived threat on my blog. It was a “a ha” moment for me..

  4. I find myself littering in pain science education throughout a course of treatment as opposed to having a highly direct conversation with the patient about it. Although sometimes I’m more direct about it. I feel like some patients will do well with the information and others not as well. I just use language of talking about how tissues heal and try to diminish the fear associated with certain words and diagnoses. I’ll often talk about how pain works without really directing it at them and how the brain can sensitize an area as a protective measure. Intelligent progression of movements and patient should hopefully gain more of a sense of confidence and robustness even if they never knew you were using an understanding of pain science with them.

    It’s really frustrating when a patient doesn’t give you a chance and I know we all tend to think we could have done something better. It’s always somewhat of an experiment. Ultimately, I’m not a psychologist and I don’t try to create that kind of a relationship with a patient.

    1. Conrad,
      Yes, I agree and believe we may need to subgroup these individuals. Some need it and some do not. I would imagine this patient would have accepted it and it could have helped him, but struck out swinging. Better to strike out swinging than looking.

      Thanks for reading.
      Harrison

  5. I believe he did the right thing…The client clearly stated that what was being done wasn’t working and previous interventions had not worked.In this situation I may ask a client “Do you think you have the ability to get better?” and if not why not? See if you can get them thinking about taking ownership or find a path you can safely go down. I have sometimes had success when they say my back is too damaged, then going the route of saying I understand that, but I don’t have the ability to fix that part of your pain, but another part of your pain is central sensitization which we can try to address differently than they have previously. I have had one person thank me for admitting i couldnt “fix” their back, because everyone else told her they could and she had lots of treatment that went nowhere But some people are not ready to hear and will keep looking for someone who can “fix” it.

    It is a difficult line to tread. Consistent message through the system may need to happen to change this person’s mind. And if he shops he may find a clinic which will humor him for 6-8 weeks and make no progress, but reinforce that his back is a lost cause.

    In regards to us teaching pain science/biopsychosocial approach I also have learned from Adriann Louw’s work that if people aren’t moving because of joint, muscle or other orthopedic issues we would of course help them. If they are not moving because of central sensitization or other biopsychosocial issues who should help them? A psychologist may be able to help for sure, but they are not going to combine movement strategies in their treatment. We are well equipped to be educating on pain science, talking through things with patients, while we simultaneously guide them through movement.

    My last VA/PTSD patient a few weeks ago was the exact opposite response. He had multilevel fusions years ago..major narcotics/addiction issues very limited function, could hardly do an eval because you couldnt touch him or even get him comfortable on a table..I dipped my toe in on central sensitization and he responded tell me more…spent an hour talking with him about pain science…He left in tears wondering why no one had explained this in his 30 year history of back pain..came back the next visit saying he slept through the night for the 1st time in forever and the 3rd visit said he was feeling better and walked a mile…All with education and getting a plan he could buy into..he has still has pain and lots of dysfunction..but the education changed his whole outlook..so i think we definitely need to be doing this…even if it only helps some of the people we work with.

    1. Pain Science Education is the best we can do with true CS. With a handful of chronic pain patients with CS, I have worked on long term goals for function. Most of them got back to walking, working out and ADLs within limits of their own threshold, but pretty much every one of them still had pain. That’s th reality with CS, we can improve function in the long term, but many people would not want to hear that and it’s completely understandable.

    2. Keith,
      Wow, great story! I haven’t had a response as your case yet with education but it seemed you connected with him.

      Keep up the good work!
      H

    1. Michael,
      It seems he is headed that way. I think it was appropriate to give the CS education a shot, especially if you know it.
      I would like to sit in and watch how behav psych treats.
      H

  6. I have tried everything that everyone has mentioned above in the last 2 years of trying to explain pain to patients who ask me “why does this hurt?” I’ve had 3 verbal counseling’s with my supervisor from patients complaining that I said that “the pain is all in their head” despite my opening statements “I want to make sure that you DO NOT interpret this explanation of your complex pain as something that is all in your head.” On the other hand, I’ve also had patients return back to running, surfing, horse back riding, and scuba diving. The hospital I work for is terribly concerned that I may offend more in the future because they are patient centered and rely heavily on patient satisfaction (via NRC picker score results) for insurance reimbursement. Here is a short excerpt from an email I just wrote yesterday to a council chair:

    BTW, I completely agree with your point on the customer service approach all the way. That’s what the biopsychosocial model does, it treats the whole patient rather than the bioanatomic or specificity models that most old school physicians use when they tell their patients how they will be treated in PT. patients sometimes come to therapy expecting to receive massage and ultrasound only or pool only and are sometimes disappointed when our evidence based practice produces an alternate treatment approach that is less passive and promoting more self efficacy. This I think will pass in the future as more of the older referring physicians retire and the new physicians begin to populate healthcare who are more evidence based minded. Our current customer population that heals best from 80% of how the therapist made them feel and 20% from our technical skill is like this because they did not grow up in an “information age.” They grew up in an era where people looked each other in the eye during conversations and speaking to another human instead of into a mobile phone was what created that connection between them. Some of the therapists I have spoken with (not just at PIH, but therapists nationwide) find it insulting that they have to go through continuing education, advanced certification, fellowships, etc. so that they can have only a 20% impact on patient experience when using the PT specialty they have chosen. They are the ones who have a hard time buying into the customer service mindset. I think that this is already changing because there is a majority of therapists that keep sharing stories of how they provided exceptional service to their patients each day.

    Wishing you the very best,

    Sometimes there are things that go beyond our control. Such as things said to our patients in the past.

    1. Ken,
      Very good points overall. Sorry to hear about your trouble that you are experiencing in your facility.
      Keep progressing and always aim high.
      Harrison

  7. I am relatively new to incorporating pain science into treatment and have had both success and challenges with implementing it. Unfortunately I have had a similar experience to the one listed here, the patient was quite angry and accusatory that I was telling him the pain was all in his head. No amount of clarification or further instruction made any difference. He left quite upset. I found out a month later further medical testing revealed a rare form of an autoimmune disease. To my knowledge the medical management of this condition is helping. I learned from this case not to discredit the BIO in biopsychosocial.

    On the flipside I have seen other patients very positive gains in functional abilities. As for subgrouping patients I like the 4 Quadrant’s model, I find introducing pain science most succesful when the patient is ready to be “coached” and not when they are in a victim state looking for a hero.

  8. Hi Harrison. Just sharing a few thoughts. Central sensitization starts at the level of the spinal cord, not in the head. If you choose to talk to patients about the brain, what might help is to point out that how our brain projects pain to a bodypart is as real as any experience, so in this context “pain is in the tissues” is not wrong. Moreover, if we choose to utilize the biopsychosocial model, central sensitization is part of “bio” and not “psychosocial”.

    You ask “Do you think this patient was going to get better ANYWAY? ” We can speculate all we want, but sometimes it’s just impossible to predict the trajectory of one’s pain experience. I could be wrong, but this sounds like one of those cases.

    Evan Raftopoulos

    1. Hey Evan,
      Yes, not sure if the conversation started with pain science in the head for my colleague vs going at the dorsal horn like you said. It is a safer route IMO as to not get such a negative response such as this case.

      I wish I could have predicted if this person would get better too. I try to give it all I have to help everyone, but sometimes we fail. Aim high and go home knowing that you gave it all. Sometimes we just can’t help everyone.

      Thanks for reading,
      Harrison

  9. Thanks Harrison, I agree, if failing = the patient is not improved by some measure, then I’m failing every day. I try not to see it that way though and I think we (PTs) can benefit from letting go of that mentality. However and if we choose to accept that, we also have to let go of the idea that the patient always improves because of what we do. It’s not my intention to downplay our role, but I think it’s reasonable to say that most of the time the outcomes are influenced by many things out of our control. To me success is providing the best quality care that we are capable of providing. Sorry if I’m going a bit off topic here but I think this is something that many PTs struggle with.

    Evan

    1. Evan,
      You bring up good points. These are the non-specific effects and by far changes that are difficult to study, but part of human interaction.

      Even though some things may not be of what we do, we are still vital in our role as a professional, especially in MSK realm. Having our expert opinion, re-assurance and advice goes a long ways.

      Quick story. My wife and I just had a baby and I have been to a medical office more in the last 3 weeks than in my 30 yrs it seems! I am realizing that I get different answers for same questions and think to myself sometimes: I could figure this out and not have to see them. But…it is reassuring to go to someone to say they have seen the condition before…you should do this and that…but it should improve. That “normal” response makes a big difference and a major part of healthcare.

      H

    2. I completely agree Evan. Doing the right thing for our patients is sometimes difficult when outside influences are beyond our control and can cause us to fail or succeed in managing our patients with complex pain. But this should not stop us from continuing to do what we feel is the right treatment approach (in this case, it’s providing basic modern theories in pain science). I don’t feel bad when I “fail” because a patient is not accepting my plan of care because that’s beyond my control, as long as I know in my heart that I provided the best care and place effort on things that I can make a difference in.

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