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Why are we so bad at treating chronic pain?

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  • #16
    I am now of the opinion that we know too little and there are not enough ways of easily gaining the information we need. Having just done some formal pain neuroscience education I realized that as much as I'd gotten really great information from social media and self-study, there were dots I hadn't connected and information that I hadn't really been able to apply. It's left me wondering just how much more I don't know, and how much more help I could be if I did.

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    • #17
      Can you share any of the additional important points you learned, and how we might apply the information more effectively?

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      • #18
        Originally posted by Monica Noy View Post
        I am now of the opinion that we know too little and there are not enough ways of easily gaining the information we need. Having just done some formal pain neuroscience education I realized that as much as I'd gotten really great information from social media and self-study, there were dots I hadn't connected and information that I hadn't really been able to apply. It's left me wondering just how much more I don't know, and how much more help I could be if I did.
        I respectfully disagree. My ideas of how to treat chronic pain have changed over the years. I used to feel like you that I need to know more about exactly was going on. Now I feel the opposite. Pain is an output from the patient's brain and as a therapist I am never going to mobilize or tape their brain to reduce their pain. What I can do is treat the patient so they can treat their pain signal / protective response. That means treating all of those multi-factors. Psychologically, socially, emotionally, physically, medically etc. (PLEASE don't say you are not a psychologist so you can treat a patient psychologically) and you may need assistance from a team of medical professionals depending on the patient. I still think we are the best profession to work with chronic pain patients.

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        • #19
          Originally posted by gilbert View Post
          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.
          Gilbert, I understand what you are saying in terms of deep understanding and consistency. However, if we are treating patients as individuals then we need to be able to treat them according to their Individual needs. Honest question: As much as WE may want a more standardized approach to help give some consistency to our profession, Is that always in the best interest of our patients ? Will it be like our education system ( in the US) where we try so hard to standardize how we educate students that we lose all the individuality, don't educate to the needs and learning styles of the students and wonder why they struggle? Basically, does our diversity actually give us the ability to meet the needs of more of the population?
          Last edited by Chocco; 03-06-2018, 05:34 AM. Reason: Poor word choice

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          • #20
            This last week brings me back to the thread.

            I had an individual with severe shoulder pain, limited strength and function. Her statement was "I can live with the pain, I just don't want surgery."

            The next individual presented with shoulder pain, full function and full strength, just pain. Her statement was: "I can do whatever I want, I don't have any limitations. I just don't want this pain."

            It might not be "us." It might be those we are attempting to help. Trying to treat a "thing" like pain for people unable to cope with it, is a lost cause, in my humble useless opinion. It is too complex to have a direct impact. While we want to speak highly of multidisciplinary care, the fact is its not that effective for people unable to accept and live with pain. Lets be honest, they, the patient will have to accept and live with pain. We all do. We all manage it daily. Its while I shifted from my left to my right glute sitting here. Maybe a more direct (albeit tougher???) message would help. Stop talking about fixing pain, the war on pain, or acting like pain should be eradicated. It is normal, natural and necessary. Sometimes it signals a serious problem. Sometimes its just a "check engine" light, other times its a false alarm, and sometimes it just goes off for no reason. Keep calm and crack on...
            "The views expressed here are my own and do not reflect the views of my employer."

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            • #21
              I think this belongs in the discussion. There isn't much I disagree with in Bronnie's writing:

              https://healthskills.wordpress.com/2...or-disability/
              Last edited by Johnny_Nada; 03-06-2018, 04:10 PM. Reason: wrong link
              "The views expressed here are my own and do not reflect the views of my employer."

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              • Chocco
                Chocco commented
                Editing a comment
                Nice read, thanks

            • #22
              Originally posted by Johnny_Nada View Post
              This last week brings me back to the thread.

              I had an individual with severe shoulder pain, limited strength and function. Her statement was "I can live with the pain, I just don't want surgery."

              The next individual presented with shoulder pain, full function and full strength, just pain. Her statement was: "I can do whatever I want, I don't have any limitations. I just don't want this pain."

              It might not be "us." It might be those we are attempting to help. Trying to treat a "thing" like pain for people unable to cope with it, is a lost cause, in my humble useless opinion. It is too complex to have a direct impact. While we want to speak highly of multidisciplinary care, the fact is its not that effective for people unable to accept and live with pain. Lets be honest, they, the patient will have to accept and live with pain. We all do. We all manage it daily. Its while I shifted from my left to my right glute sitting here. Maybe a more direct (albeit tougher???) message would help. Stop talking about fixing pain, the war on pain, or acting like pain should be eradicated. It is normal, natural and necessary. Sometimes it signals a serious problem. Sometimes its just a "check engine" light, other times its a false alarm, and sometimes it just goes off for no reason. Keep calm and crack on...
              Johnny, While acceptance and "living with it" are important, I do not agree that this is the best we can do. In my opinion we have a role in guiding people to be more active, less fearful, and better at pacing themselves. Improved self-management can sometimes lead to reduced pain too. I agree with you that not every patient is ready to take on the changes that would likely help them. But we can and should do more than just advise patients to "deal with it".

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              • #23
                Gilbert,

                For what its worth, I'm not saying to "deal with it" to patients. That is a bit callous. I am much more tactful.

                I too want to place myself/ourselves on a pedestal. I too am of the opinion we have a role. But the evidence and literature say something else, despite what I want and my opinion.

                Regardless of the message or strategies, the vast majority of approaches (TNE/CBT/ACT/MI/etc) are teaching people to live with it, whether they say it directly or indirectly is another story. Even Adriaan Louw and his group will say TNE is a method by which we teach people its okay to move forward and live well despite pain.

                What does someone with a diagnosis of MS do? Do they want a cure? Sure. Is there a cure? No. So they have an option to live well with MS or not. I view pain as no different. Yes there are some outliers able to make their way out of the dark hole, but those folks have made up "their" (not us; though we may be a catalyst for change) minds for life changes. Many folks are not ready to do so. For many folks with chronic pain, these life changes are beneficial and potentially necessary. In the worst case, not possible.

                We all "deal with it" on a daily basis at some level. Some of us are doing it on a much longer basis and in some instances, more limiting capacity.
                "The views expressed here are my own and do not reflect the views of my employer."

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                • #24
                  Johnny, I get it. The literature says we're not very good at helping these people (see title of thread).

                  This makes me ask myself, how can we do better??

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                  • #25
                    Could it be because we are trying to measure "pain?" How effective can we be trying to objectify/measure something that isn't objective?
                    "The views expressed here are my own and do not reflect the views of my employer."

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                    • #26
                      That's a good point. I do try to shift emphasis off the "p-word" and talk more about what the patient is able to DO (function). Could it be that some people need "permission" to start living their life again? "Yes you have this problem, but does it really need to prevent you from taking a walk with your wife, gardening, or going to work?"

                      But often the patient's goal is to "get rid of the pain" so that is where their focus is, naturally.

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                      • #27
                        I can't help but see a divide between the patient's desire/expectation/goal (pain relief) and what rehabilitation provides (function restoration). Not only is the desire pain relief, but pain relief NOW. In many cases pain is why function is limited. I understand. But if we are honest with ourselves, as a PT/OT/Massage Therapist/DC chasing pain to provide pain relief is a pipe dream. It may send a non-verbal message you're helping and care, but its still a pipe dream.

                        Your statement above is what I've been attempting to convey in my posts. Unfortunately, when asking a question like that, in many cases the answer is yes. Another answer is not returning. If you're not fixing the cause of pain or attempting to get rid of the pain, this place isn't for me.

                        Until we educate the public pain is normal, necessary and okay to have and live with, we'll continue having large populations filling up healthcare offices despite the lack of effectiveness, harms, direct and indirect costs.
                        "The views expressed here are my own and do not reflect the views of my employer."

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                        • #28
                          Explaining to someone that we need to do Functional Restoration first and not "wait until you feel better" is a huge challenge. But the thing is, functional restoration will make your LIFE better and may even make your pain better in the long run.

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                          • #29
                            In the UK's National Health Service, pain patients have a separate pathway.

                            In the private practice where I work as an associate, my principals' pain patients see me for education and sometimes ongoing management. Usually I send them back to her, with review by me as an option. We try not to make it into a huge issue, although it often starts that way for the patient, because they feel hopeless or angry and have not yet managed to find coping strategies.

                            We have a similar set up for patients with head / neck pain and disequilibrium.


                            Much has to do with personality, if I feel that my principal would be a "better fit" for someone who started with me, I encourage them to see her. The receptionists sometimes triage new patients to one or other of us during the initial call. I think that if we can start with a biopsychosocial approach, the patients have a smoother journey

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

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                            • #30
                              Here are a few thoughts Gilbert:

                              Ignorance and over-confidence (cynically speaking: bias and incentive)

                              Healthcare’s interventions have continued to show an ineffectiveness for pain related conditions, namely MSK related issues. I'm sure anyone reading could point to an article or "evidence" showing "effectiveness" but I would caution them and ask: is the so-called effectiveness meaningful to the patient? The answer has to be no. One look at the data supports this in my opinion. Healthcare interventions are far too unidimensional to tackle a persistent pain condition on a wide-spread scale. Working in a healthcare system I see ignorance and over-confidence daily. Lack of informed consent and education are everywhere.

                              Maybe we should demand more from healthcare professionals, researchers, authors and publishers to make the evidence and decision making "crystal-frigging clear" for the public. No spin, no BS. Here's an idea: openly publish and educate the exact findings from the research and our currently knowledge.

                              How much can you expect your pain to change? Is that meaningful to you?
                              How much will it cost you? Are willing to pay that?
                              How many visits is that? Are you willing to make the sacrifice to attend? Is the "juice worth the squeeze?"
                              How much time off work or away from your obligations; i.e. indirect costs? Do you have the flexibility?
                              Harms? Legitimate physical harms, financial, otherwise? Do the benefits above outweigh these risks?

                              "Based on the results of the research on your current condition doing nothing different in your life, doing exercise or reading this booklet are all equally effective. How would you like to proceed?"

                              It reminds me of the picture showing two theaters: one is showing an inconvenient truth, the other a re-assuring lie. Guess what theater has a line out front? We can't be afraid to provide the inconvenient truth and public needs to accept it. Otherwise they'll continue standing in lines...

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

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