The ‘why does it persist?’ series looks at the reasons why painful problems often continue despite treatment and the healing process. With 1 in 5 people experiencing on-going aches and pains, it is vital that we think widely about the causes of persisting pain and how we can tackle them more effectively.
Here’s the first maintaining factor—the early message given to the acute back pain patient, “don’t bend your back”. What’s the problem with this message?
Frequently the acute pain starts on bending over, usually whilst doing something innocuous such as picking up a pen or leaning slightly to clean your teeth at the basin. In this case, the pain is immediately associated with the position or the movement, this being laid down as a new rule: ‘bending is dangerous’. If, as often happens, the initial advice given is to avoid bending, this confirms the original thought, “Ah yes, I knew that bending was dangerous and now he/she has told me that as well, so it’s definite”. This belief becomes ingrained quickly and has consequences for behaviours, or rather, how we then move. The guarding that can be useful at the start of a problem persists as you continue to avoid normal movements beyond a time that is adaptive, i.e./ are you still bending from the knees weeks later?
When we don’t move our body it becomes stiff and often painful. Think about getting out of a car after a long journey or even pulling your thumb back for a few minutes and letting go. The blood flow slows and the tissues creep, there is less oxygen and more acid, all ingredients for aches and pains. But this is normal and the pain a prompt to move and resume normal service.
When we have acute pain we often immobilise the affected area to reduce the range of motion that we use for the purposes of protecting the damaged tissue. The ‘unused’ range becomes stiff and painful and as we reach it sooner with normal movements, it is easy to evoke sensitivity. Again, this is normal in the early stages of an injury and useful for healing, but as time goes on, continuing to use strategies that are appropriate for acute pain will create barriers for recovery. And importantly, these strategies are based upon beliefs about pain, hence taking us back to the point that early messages are key players in what happens next.
At the first meeting with a patient there are a few basic ingredients to ensure that the first steps to recovery are in the right direction:
1. The welcome; to make sure that the patient feels as comfortable as possible.
2. The narrative; allow the patient to tell their story in their own words, with a few pointers so that all the relevant information can be gathered. This is the Sherlock Holmes section.
3. The meaning; explanations create a sense of meaning; “Why has this happened? All I did was bend over to pick up a pencil!”. Explaining that pain is not an accurate indicator of tissue damage, how pain is created, what can influence pain, how these problems typically evolve over time and of course what can be done.
4. Validate the narrative and any investigations that may have been undertaken; make sense of the language and put it into perspective remembering that many people have changes in their spine with little or no pain; and a structure is not pain anyhow, one is objective and one is subjective.
The patient must feel better in terms of knowing the nature of the pain and the problem, what you can do about it, what they must do about it and how long it is likely to take. Knowledge is power and gives a sense of control, and we all like to be in control. Conversely, cultivating fear with strong and inaccurate visual metaphors triggers further protection in terms of sensitivity and the way in which the patient approaches the problem is usually passive rather than proactive. The latter is the more effective way to recovery.
Anatole Broyard’s brilliant essay on the doctor-patient relationship highlights the fact that as a healthcare professional one can believe that you are in the driving seat, but actually, the patient is assessing you as much as you are assessing them!