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Why are we so bad at treating chronic pain?

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  • ??? Why are we so bad at treating chronic pain?

    This is something I think about a LOT, so I would appreciate any sincere responses.

    With all the great advances in medicine and science, why are we (inclusive of all health care providers) generally so awful and unhelpful for people experiencing persisting pain problems? Even with more and more resources thrown at the problem, and additional research happening, I don't see much evidence of things improving generally.

  • #2
    It's complex, multifactorial and sometimes the systems within which we work don't do us any favours. We are reductionist in our thinking, which is useful to us in understanding it, but often isn't helpful to the patient. I have the advantage of a family practice and no one on my back telling me what, when and how much or little to do. I know my patients, their families and often their workplaces. In recent years I have seen several from different branches of the armed forces.

    If we find it difficult to understand, it is not surprising that patients find it almost incomprehensible, some of my patients are with me for decades, the expert patients may come in every few years and manage themselves with occasional email input from me. As an old physio and ex sports person I could make a list right now of painful bits but much of the time I don't notice it, in the same way that I don't notice my wedding ring unless I think about it.

    It hasn't changed, but patient expectations around it have. It's our collective fault, we make promises and don't deliver. Louis Gifford's final work Aches and Pains Vol 1 -3 is worth revisiting and contains great descriptions of how a family practice can work within a community. At the other end of the scale there is Dr Thacker's amazing work and the CauseHealth movement.

    Attempts at McDonaldization does no one any favours.
    Jo Bowyer
    Chartered Physiotherapist Registered Osteopath.
    "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

    Comment


    • Monica Noy
      Monica Noy commented
      Editing a comment
      Nice description Jo.

  • #3
    I just think it's a bit embarrassing. You take something like persisting low back pain, that is common as dirt and we see almost daily. We (PTs) go to university for many years supposedly so we can understand it and treat it. But the experience of most patients is one of confusion and largely ineffective management. The profusion of wildly different approaches suggests a lack of a coherent strategy, and more of a "grasping at straws" approach. What can we do to change this?

    Don't get me wrong, I think our profession actually has the potential to do great work in helping patients with chronic pain to help themselves.

    Comment


    • #4
      http://chewshealth.co.uk/tpmpsession53/



      If any of you were following our live Tweets from the Pain Cloud conference last month, you might have noticed a common theme emerging from the speakers that included Mary O’Keeffe, Derek Griffin and previous pain patient Joletta Belton: listen to your patient. In May’s session, Jack did just that and opened his and our ears to the voice of Adrian McGregor, a former firefighter, patient and most importantly, human being with persistent pain.





      Adrian told us his story: a long and at times frustrating; at times enlightening, wade through a biopsychosocial swamp with varying degrees of obstacles versus life jackets.



      He challenged us to reconsider our ideology of the ‘pain free individual’: what happens when your patient aces all of the tests and performs the ‘perfect’ birddog but it’s still painful?



      Is ‘selling a fix’ ok? Adrian described the financial costs of his treatment and the dangerous combination of desperation and trust in healthcare professionals who are perhaps focussed on only one piece of the puzzle, or whose treatment aims are perhaps physiologically unrealistic. We’ve talked a lot about reforming reasoning recently – this is why it’s important.



      Adrian has advice for us as Physiotherapists working with people in persistent pain: Be capable. Not of ‘fixing pain’ but of explaining pain in the context of the individual in front of us. Be capable of reassuring them that this is not unusual. Of articulating all the pieces of the pain mosaic. This is our role and we can’t hide behind ‘not being psychologists’ because psychology IS biology and pain is a human experience - and we deal with humans!



      Persistent pain is a challenge for those who live with it and those who treat it, particularly if you are working within the time constraints of the NHS. Adrian acknowledged this but encouraged us to use our time wisely to listen and learn from patients. It reminded me of Joletta Belton’s words from Pain Cloud: “Humans are nuanced and complex. Being listened to makes you feel valued and your patient may not have experienced that in a long time.”



      It would appear that we can contribute as much to chronicity of pain as we can to preventing it. If ever there was a time to put in an order of new hymn sheets to distribute among the Physio congregation, it is now. People like Adrian have had the old songs stuck in their head for too long and he’s urging us to learn new lyrics.



      Does Adrian still experience pain? Yes. Does his function depend on it? No. What made the difference? In his words taken from Twitter: it took ‘a Physio with eclectic talents to show him how to put the jigsaw together and develop the ‘strong therapeutic alliance’, give him a tool box, listen to his stories to ensure he has the right tools for the job’.

      Be the facilitator and the therapist who teaches self-efficacy, Adrian says. And the golden rule again: be a listener.

      Jo Bowyer
      Chartered Physiotherapist Registered Osteopath.
      "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

      Comment


      • #5
        Thanks Jo, that is good.

        Comment


        • #6
          The Big Picture of Pain

          https://www.bettermovement.org/blog/...icture-of-pain


          Tod Hargrove's take.

          I am less pessimistic than you Gilbert, perhaps because I have been around for a very long time and have seen fads come and go. As a generalist I do get cross about people selling simplistic approaches and proselytizing their preferred techniques. There are no shortcuts.

          However, there is a ground swell out there of expert patients and practitioners who are beginning to demystify pain. I live in hope that we can get similar movement on dizziness / disequilibrium.
          Last edited by Jo Bowyer; 16-05-2018, 06:34 AM.
          Jo Bowyer
          Chartered Physiotherapist Registered Osteopath.
          "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

          Comment


          • #7
            I wouldn't say I'm pessimistic, but I'm looking for ways to improve what we can offer patients with persisting pain (both personally and our whole profession).

            A positive aspect is certainly the increased awareness of pain science, but what seems to be lacking is a deep understanding and a consistent way to apply this knowledge for the maximum benefit of our patients.

            Comment


            • #8
              A positive aspect is certainly the increased awareness of pain science, but what seems to be lacking is a deep understanding and a consistent way to apply this knowledge for the maximum benefit of our patients.
              This seems to be the experience of some patients who say that the physio appears to have learned a script and can't relate it to their individual situation.
              Jo Bowyer
              Chartered Physiotherapist Registered Osteopath.
              "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

              Comment


              • #9
                One of my former patients just sent me this article. Slight over-emphasis on chronic pain being "psychological" rather than looking at the whole process happening in the nervous system, but it looks like a good beginning to get some people thinking differently about pain.
                Chronic pain often has no physical cause. Psychotherapy can reduce the suffering.

                Comment


                • #10
                  Gilbert,

                  I saw this thread the day you created it and haven't stopped thinking about it. I keep reading blogs, listening to podcasts, reading articles about treating chronic pain. Some are optimistic of our abilities and our role. Some think we are next in line with all the opioid attention. I don't have an answer for you, only a question.

                  Are you asking the wrong question? Are we asking the wrong questions? Are we putting ourselves in the wrong position? Do we/should we "treat" chronic pain? Should we continue emphasizing our role? What about slowing our role, and asking more of the patient? Given the consensus on the multifactorial nature of pain, do we educate more and "treat" less?

                  I can't help but think of other similar conditions; PTSD and depression, we know so little. The "treatments" are "meh" for so many. These conditions create enormous disability on the individuals and a large burden on society as a whole. Everyone is trying to angle for there position help out. PT is one of many. Maybe we are feeding this monster. Maybe thats why we are so bad. We refuse to starve it.

                  I know this post is all over the place with questionable coherence. I just don't think its fair to say we "are so bad at treating chronic pain."

                  "The views expressed here are my own and do not reflect the views of my employer."

                  Comment


                  • #11
                    Johnny, thanks for your post.

                    I agree that may be the wrong question. But when I step back and think about the big picture, there are so MANY people living with persisting pain, with lots of unnecessary disability and suffering (not to mention the whole opioid discussion). They need help, and in many cases don't seem to be getting the right kind of help. I do think that we as PTs actually could get good at providing the kind of assistance these folks need in order to help themselves to a fuller and more active life that isn't dominated by pain.

                    Comment


                    • #12
                      Originally posted by gilbert View Post
                      Johnny, thanks for your post.

                      I agree that may be the wrong question. But when I step back and think about the big picture, there are so MANY people living with persisting pain, with lots of unnecessary disability and suffering (not to mention the whole opioid discussion). They need help, and in many cases don't seem to be getting the right kind of help.
                      I understand and hear every word you say. What about all those people with persisting pain, WITHOUT disability or suffering.

                      Whats the difference?

                      Is it a public health, socio-economic, educational issue, psycho-social issue?

                      A lot of people have headaches and back pain? Why do some live full, productive lives, while others move in the opposite direction?

                      Until we understand these things, I think we are ice skating up-hill

                      "The views expressed here are my own and do not reflect the views of my employer."

                      Comment


                      • #13
                        Originally posted by Johnny_Nada View Post

                        I understand and hear every word you say. What about all those people with persisting pain, WITHOUT disability or suffering.

                        Whats the difference?

                        Isn't that the goal? That their pain becomes a lot less 'troublesome' and doesn't dominate their life?

                        As one of my persistent pain patients told me recently "I don't notice it much or think about it during the day, and rarely need to take medication." Is the pain gone? NO, but it's less of a problem for her.

                        Comment


                        • #14
                          I think part of the reason we are so bad at treating pain is because we spend too much time trying to treat the pain and not enough time treating the patient.

                          Comment


                          • #15
                            Gilbert,

                            It's the goal for me. Unfortunately, not for the patient in many cases. There are some folks that can learn to cope with their pain. The don't suffer nor have disability from it.

                            To me, its a lot like exercise. As Greg Lemond said: "Hills don't get easier, you just get better at doing them." There are a group of folks that can and will put up with pain, unpleasant sensations and discomfort to improve their physical capacity. For many others, the moment an unpleasant sensation occurs is grounds to discontinue.

                            Dare I say it is similar to eating habits for many?
                            "The views expressed here are my own and do not reflect the views of my employer."

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