Pot-Pourri

[Barrett Dorko]

Matt,

A good question.

Another: Why is it so dark in there? To me, pain is not just an aporia, its occurrence is a mystery. When it becomes solvable, it will retroactively become a puzzle solved.

To me, this highlights the question, "Can you alter the pain with position and/or use?"

Not substituting the word "eliminate" for "alter" and not "What makes you feel better?" Those are, nearly worthless questions and their typical answers won't guide care aside from some lucky method. Thus my line while teaching said with a Clint Eastwood impression: "Is it a good idea to go out to the waiting room and say to your next patient: 'Do you feel lucky today?'

[proud]

They, the patient in pain, will choose the outcome, not us.

Funny Mathew...I've recently taken to using that exact phrase with patients. (replacing "the patient" with "you" and "not us" with "me"

I've also taken to talling patients that the best I can offer is to determine with a fairly decent degree of sensitivity if something is ripped-torn-or broken.....or in danger of doing so.

After that...pain is more a thing people either cope with...or don't. Accept the risk....or don't.

I think we (providers of conservative NMSK) get the heck in the way more often than we help people.

Using myself as an example, I am 45 years old and go to the gym and lift what I consider to be reasonably heavy weights (60Lbs free weights for incline press etc etc).

I've been experiencing quite significant pain in my left shoulder when lifting weights for the past 6 months (worse with military press or incline press...but also bicep curls).

Anyway...I know there is no "magic treatment here". I know if I stop it would all be fine. I choose to proceed...

I cope.

I avoid seeing people like myself. For if I did...and did not know any better...I'd be weaker, more feable and starting my slow decent into nursing home aerobics!

[Johnny_Nada]

proud,

I'm assuming when you say "like yourself" you mean physical therapists?

I think about that quite frequently. Would I see anyone if I had a painful body part? Outside of having a red flag, probably not. I have in the past and looking back, it was one of the worst decisions I could have made. Given the evidence, the best thing I could do is "keep on, keeping on."

[Diane]

Even with no red flag, sometimes pain is bad enough that you just can't move without some help. You know, to get past the "pain" of it all.
I have no problem requisitioning help from people like us. As long as my groomer knows I'm in charge of them.

[nykinvic]

Using myself as an example, I am 45 years old and go to the gym and lift what I consider to be reasonably heavy weights (60Lbs free weights for incline press etc etc).

I've been experiencing quite significant pain in my left shoulder when lifting weights for the past 6 months (worse with military press or incline press...but also bicep curls).

Anyway...I know there is no "magic treatment here". I know if I stop it would all be fine. I choose to proceed...

I cope.

I avoid seeing people like myself. For if I did...and did not know any better...I'd be weaker, more feable and starting my slow decent into nursing home aerobics!

I'm confused by these statements. Why either proceed (as you are doing with pain felt in the L shoulder for the past 6 months while performing particular exercises in a particular way) or stop? Aren't there options between stay the course in pain or stop and head for the nursing home?

[Kyle Ridgeway]

A Year and a Day Later

I also wonder about the patients, the people who are challenging to engage. Those without social support and coping mechanisms. High symptom burden and remarkable distress. Pain. Lack of understanding. Unmet desires or requests. No resources. Learned helplessness. The patient room everyone dreads entering. Difficult, non-compliant, lost causes…or so some would say. How does the previous story end if they return for a hospital visit? I shudder at the potential. Post traumatic stress. Resentment. Acquisations. Confusion. Anger. Sadness. Loss. Depressive symptoms. What happens to those patients? Likely we see them again.

[proud]

I'm confused by these statements. Why either proceed (as you are doing with pain felt in the L shoulder for the past 6 months while performing particular exercises in a particular way) or stop? Aren't there options between stay the course in pain or stop and head for the nursing home?

Tongue a bit in cheek there Christine.

However, I have witnessed more cases of Physiotherapists practically assisting patients in a downward spiral.

One case in particular where an otherwise young robust soldier went from having difficulty running to barely being able to open a filing cabinet all based off the advice of his attending, biomechanically driven Physiotherapist. Every time the soldier did something that cause a bit of pain....the Physiotherapist wrote ever increasing restrictions until one day....the kid could not open a filing cabinet.

I'm a strong believer in the "suck it up buttercup" philosophy when it comes to managing my own pain complaints. And I have a feeling that if more people where to adopt this approach right off the bat at the initial hint of pain...people would have less problems in general.

Pain has become something that must be pathological, indicative of injury....and must never be experienced.

Physiotherapists (and of course others) profit in a big way creating this meme.

My argument is, if we want to survive as a profession, we should be doing the opposite. We should be culling our skills as expert diagnosticians and identifiers of red flags etc...and when there is no reasonable indication of imminent tissue trauma or tissue pathology...perhaps we guide patients back to whatever it is they have become unable to do...informing them that pain can be expected part of.....uhm....every day life.

More exercise, less smoking, improved sleep quality, less fear of pain....and less reliance on others to settle your non imminently dangerous painful problems.

In other words...stop medicalizing pain.

Ironically...I'm near certain there is a sustainable business model there for a forward thinking, science based, credible profession....

[proud]

"Your body will only give you what you demand from it...demand more"---anonymous

[proud]

I think a great deal can be done if every Physiotherapist invested a bit of time reading...got themselves the hell away from stabbing people with needles, thrusting away at joints or mashing away at people.....and then starting all sessions off by answering these four questions.

This is the way forward.

[Barrett Dorko]

proud,

Not speaking of pain that is non-pathologic doesn't mean it will disappear. You're acting as if the culture surrounding the person in pain has no role in this.

[mortene]

Pain is tricky, impossible to know for sure when it will emerge, when it will persist and when it will resolve. A "simple" case of everyday pain might become a long lasting disabling problem, and a case of intense pain with severe injury might resolve surprisingly quick.

I partly agree with you Proud, especially when it comes to "overprotection" of kids and learning people that pain is bad and that adventurous behaviour should be avoided. But pain is such a broad term, and therefore I think we can't generalize on a lot of things concerning it. With that said, just to contradict mysef, I think overprotection ain't good, no matter what. But if we concider bioplasticity and persistent pain, IMO the "suck it up" attitude isn't necessarily the best approach. And just to make that clear, in my book, to not be overprotective is not the same as to have a "suck it up" attitude.

[Jo Bowyer]

So,

1. What is wrong with me? Don't know exactly.

2. How long will it take? Don't know exactly.

3. What can I do about it? Put cold/heat/nothing on it and move.

4. What can you do about it? Here is a plan of care, please pay the receptionist.

We should be honest about this. Too many practitioners try to give patients the impression that we can do more than we can, thereby shooting the manual therapy professions in the foot.

Fishing guides might tell their fishers that "there's no fish in the river, it's too cold, too high/low/dirty and that they'd have been better off going to to the pictures." and still have people desperate for their services on the off chance that something wonderful might happen.

Patients appreciate authenticity, I have learned a great deal from fishing guides (and fencing coaches) about how to get the best from and for those who employ me.

[proud]

proud,

Not speaking of pain that is non-pathologic doesn't mean it will disappear. You're acting as if the culture surrounding the person in pain has no role in this.

Quite the opposite. I know that speaking of pain as non-pathologic doesn't mean it will go away (it hasn't for me in 6+months).

And I know that a Physiotherapist who practices in the manner I suggest is essentially having about as much overall impact as a butterfly fart in a tornado.

Culture dominates.

But at least I can look at myself in the mirror at night...having not stabbed someone with a needle as if that is going to help....

[proud]

So,

1. What is wrong with me? Don't know exactly.

2. How long will it take? Don't know exactly.

3. What can I do about it? Put cold/heat/nothing on it and move.

4. What can you do about it? Here is a plan of care, please pay the receptionist.

We should be honest about this. Too many practitioners try to give patients the impression that we can do more than we can, thereby shooting the manual therapy professions in the foot.

Fishing guides might tell their fishers that "there's no fish in the river, it's too cold, too high/low/dirty and that they'd have been better off going to to the pictures." and still have people desperate for their services on the off chance that something wonderful might happen.

Patients appreciate authenticity, I have learned a great deal from fishing guides (and fencing coaches) about how to get the best from and for those who employ me.

While those responses may reflect reality...they are not therapeutic in any way...and that's our job right?

I'm not suggesting we cannot help patients. Not at all.

What I am saying is that helping people understand their own ability to cope (without a giant toolbox of "cheats" designed to tap into whatever thing the patient seems to "prefer" etcetera...Like Zac Cupples seems to advocate)....is the way forward.

I just think using all these fancy...often nonsensical "tools" essentially strips the patient of a prime opportunity to learn coping skills...or self efficacy if you like.

I think you can answer those 4 questions in an honest and helpful way.

[Bas Asselbergs]

In the light of the last two posts:

1. We can eliminate most any red flag - decrease patho-based thinking and needless worry. Big components of pain amplification.
2. "How long it takes depends on too many factors, but these are things you can do to facilitate management/resolution of pain"
3. Advise, teach, help one feel/move initially.
4. What can you do about it? See all of the above; let's keep in touch and see if we can add some higher levels of activities to your self-rehab.