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Tiny breakthroughs (clinical)

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  • CT Tiny breakthroughs (clinical)

    I had a tiny breakthrough regarding pain education for CP. It's quite tiny, but it's really useful and reasonably easy to integrate into practice.

    The model I use holds the following premise to be true:

    Chronic pain is an ego defense position, maintained by the sympathetic NS. [Here, the ego is the homonculus with all its associated memories; the mind's misinterpretation that this body is 'me'].

    The following is only for the most difficult, tightly-wound balls of defense.

    Treatment 1: "We all have tissue damage on MRI, and that doesn't have to result in pain. Your pain is the result of blood and oxygen not getting through to these tender spots". Limit it to 2 sentences. The second sentence is probably true to some degree, but the important thing is it's simple and easily digestible. The last thing I want is for the patient to think they have a complex problem, because that's the ultimate danger signal. Expediency is crucial in the early stages. Expedient technique tells me to do whatever is needed to get the best outcome possible.

    Treatment 2-4: Congruence (+ some gentle poking).

    At the endof 4 treatments, even the tightest balls of defense will have recognized and integrated my congruence. That creates trust. I just have to be prepared to put in 4 treatments of foundational work for no appreciable change. To introduce a threatening pain ed. message before deep trust is established will fail.

    End of treatment 4:

    "What I bring to the table has a certain value and I think you recognize that..." (Really important reminder that the first 4 treatments provided a very valuable base for growth).

    "...But the symptoms haven't changed much, and to create the successful outcome you want, I need to ask you to do something".

    Then introduce the idea of a pain diary. Phone bleeps every hour, note the activities of the previous 20 minutes and rank pain out of 10. That's all. KISS.

    Explain that we are trying to find out potentially hidden physical causes of pain eg. sitting for too long. In reality we're trying to help the patient see the link between emotions and pain. If I'm to use the diary data to move towards a successful outcome, I'll have to continue to demonstrate a certain level of congruence, otherwise I can see it will fail. I have to demonstrate to the patient that I am capable of living from the heart/gut, rather than from my head, and that this is healthy.

    So that's it - just put in 4 treatments of really hard congruence work, then introduce the pain diary as homework.
    Last edited by EG-Physio; 02-07-2017, 12:31 PM.

  • #2
    But I do want to keep the education component as small as possible. An analogy...

    Imagine going to a top restaurant. You place your order for a tasty dish. Instead of the chef cooking it, he comes out into the dining room and reads out the recipe for your dish. That's right, you can do it yourself - here's how! How would you feel? Aren't you paying for the chef to give something of himself?

    And yet in pain clinics, it seems ok to tell a patient to help himself! "Yes, just walk every day, see the psych once a week and do your hydrotherapy!". I think we need to be very careful to avoid this approach. If therapy was just about information, patients could search the internet.

    What can we give of ourselves that has the highest value?


    • #3
      Yes, no therapist needed. Why are there even therapists or therapy schools?
      Barrett L. Dorko


      • #4
        Originally posted by Barrett Dorko View Post
        Yes, no therapist needed. Why are there even therapists or therapy schools?
        There's an enormous need for therapists for chronic pain. None of us will ever be out of a job. Potentially, Physio is a far more rewarding job than medicine or surgery, because we have a chance at getting to the core of the matter. But it takes a lot of training to get good results, and most of this training isn't hinted at in existing courses.


        • #5
          Therapists only needed for "chronic" pain? Not "acute" pain?
          Barrett L. Dorko


          • #6
            Acute pain benefits from therapy. I think of acute pain as having the same root cause as chronic pain. I know the physiological effects are wildly different between the two groups, but I believe the root cause is the same.

            Consider: emotional pain and physical pain light up the same brain regions.



            • #7
              Barrett L. Dorko


              • #8
                Therapy is not a restaurant!
                Therapy is not a spa!
                I hate diaries of pain!
                Why wouldn't you ask them to at least keep a diary of fun activities?


                • #9
                  Originally posted by Josh View Post
                  Why wouldn't you ask them to at least keep a diary of fun activities?
                  Because I don't want to jolt them. This is such a delicate business. "Oh you feel bad? Well then, find some activities that feel good". Such an approach never works.

                  Do you remember the lyrics of that morose song by Sinead O'Connor? She's drones away with such self-indulgent woe.

                  As an exercise I once asked colleagues if they enjoyed treating chronic pain. "OMG I can't stand those people!!!". It's true, these people are very difficult to be around, but that's the training - it's rigorous. If you're not getting results, the risk of burnout is high.
                  Last edited by EG-Physio; 08-08-2017, 06:28 AM.


                  • #10
                    Hello there guys


                    • #11
                      I feel like I have to defend poor old Sinead O'Connor. She did not write those lyrics, Prince did. So whatever you ascribe to her about those lyrics is wrong. As for the rest of your post, I have no idea what you are doing in the clinic that makes people so defensive all the time. If I truly were a psychologist (which I am not), I would wonder about projection. And pain diaries? I thought they went the way of the dinosaur (or used only by lawyers looking to maximize the 'reward' for the suffering of their client).


                      • #12
                        "Dinosaur" is a good one.
                        Barrett L. Dorko


                        • #13
                          The patient mentioned above never returned. So I'm really angry about that because we were going well up until I decided to introduce pain education. I spoke to her father recently (also a patient), who told me she was "better in her head" since treatment, but symptoms...? He wasn't sure about symptom severity.

                          Just makes me think that intervention of any type is counterproductive. Minimal intervention is probably ok, but educational intervention is so easily interpreted as "try to live your life differently", and of course no one wants to hear that. Sinead!

                          I think as therapists we tend to intervene to make up for deficiencies in therapeutic presence. Lately I've been trying to objectify therapeutic presence, and a good proxy measurement seems to be high a mind-heart coherence and definite peak in the coherence spectrum around 10. Pic below is from
                          Last edited by EG-Physio; 08-08-2017, 06:58 AM.


                          • #14
                            I do not understand why (but yes) you continue to believe in hearthmath and its bullshit.
                            Last edited by bernard; 08-08-2017, 08:14 AM.
                            Simplicity is the ultimate sophistication. L VINCI
                            We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                            Everything should be made as simple as possible, but not a bit simpler.
                            If you can't explain it simply, you don't understand it well enough. Albert Einstein


                            • #15
                              "So I'm really angry about that because we were going well up until I decided to introduce pain education." "Just makes me think that intervention of any type is counterproductive"
                              Please consider that it may be YOU who is ineffective in pain education. and this: " but educational intervention is so easily interpreted as "try to live your life differently", "

                              Even the nebulous "therapeutic presence" is an intervention in itself.
                              We don't see things as they are, we see things as WE are - Anais Nin

                              I suppose it's easier to believe something than it is to understand it.
                              Cmdr. Chris Hadfield on rise of poor / pseudo science

                              Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                              We don't need a body to feel a body. Ronald Melzack