Saturday, March 23, 2013

Top 10 things you should expect when visiting any Therapist for pain.

This list is 10 things that I feel any patient in pain should expect (possibly demand) when they visit a Therapist of any kind for help relieving their pain.

1) Their attention
If you are being treated by a professional who claims they can help you with your pain expect them to be paying careful attention to you. You are presenting expert evidence of your current experience and situation. This has nothing to do necessarily with the long story you tell about your pain to the many people who are not really interested in listening. This has to do with someone who is directing their caring attention towards you and noticing cues that you might not even realize you're demonstrating. According to the IASP definition, Pain is a sensory AND emotional experience. To resolve pain you need help sometimes from another person. A therapeutic relationship serves many more complex purposes than that of a mechanic working on your car at a garage. If they don't make a solid and consistent attempt at understanding you they can't help you.

2) Some education
The field of pain science has improved so much in the last couple decades. We all need to learn updated explanations for what is going on when we are in pain. Knowledge is power. And in this case knowledge is pain liberating. Learning what pain is and why we have pain experiences actually can go a long way towards the resolution of pain. In some cases, just learning why we hurt can resolve the pain! Neil Pearson offers some great stories and explanations in his 3 part series on Overcoming Pain. Part1, Part 2, and Part 3. A good Therapist should help you understand this better

3) A time frame

Any decent Therapist should have made some positive impact on your pain within 10 visits. Treating pain should not be like renting an apartment. You're not signing up for a 1 to 5 year lease with options for renewal. Unless you're recovering from a recent injury or major trauma (and even then really) there should be some expectation on your part that what your Therapist does is working or at least having an effect. I hear of people who continue to visit their Therapist of choice for years because it has been argued that they need the treatment to prevent pain from recurring. This is garbage. These Therapists are building additions on their house and taking trips to Bermuda because of the fear that they have instilled in you.

4) Atmosphere
It all matters. A clean organized room that is separate from others. An absence of distractions especially from other therapists treating patients. The context of the room is an input to your nervous system, it does not need to be a resort spa [although that wouldn't hurt in the least] but the focus should be on reducing the disruptive input to your nervous system. i.e. calming. Now professionals like Joe Brence suggests that patients may come to a Therapist with an expectation that therapy happens in a gym like environment and that it will probably be hard work. A Therapist may offer things to a patient because of these expectations. Keep in mind that this is part of the context of the input, and it is possible that some of your expectations will need to change. If in doubt, ask your Therapist about this and especially inform them if the environment feels distracting, overstimulating, or otherwise unnerving. A good Therapist will adapt.

5) Empowerment
The inner locus of control is fundamental to the patient / Therapist relationship. At the end of each encounter you should feel more in control and have a greater understanding of the importance of your role. I wrote this in the last 10 but it bears repeating. If you are becoming more dependent on your Therapist to "save you" or "fix you" something is wrong with the way the therapeutic relationship is going. At first you will be handing yourself over to a professional, but by the end (or hopefully very near the beginning) they will be putting you right back in the drivers seat.

6) Honesty and comfort with uncertainty.
Sometimes it is beyond a Therapist's knowledge level. Consider that your Therapist does not need to be an answer machine. Instead invite them to be a co-conspirator. Someone with some technical knowledge and skills willing to team up with your extensive experience in being you. Together, the two of you can problem solve, goal set, and scheme your way to overthrowing pains reign over your life. Some Therapists are afraid to be uncertain. Even when they are wrong they deflect it by saying you were the problem. This is nonsense! You need them to assist you in taking your inner locus of control to the street and kick some pain ass!

7) Encouragement to find movement
There is a great saying "motion is lotion". However, sometimes a Therapist will get locked into a prescriptive set of movements that they think are the cure-all for every condition. Movement is good, exercise is good, but we're not entirely sure why some of it works. Cory Blickenstaff advocates novel movements and has a number of interesting videos that show how you can use novel movements and a very basic knowledge of the nervous system to feed your brain new information. This new information can cause your nervous system to form a new, pain-free, opinion of the state of your body. Check out his whole series on YouTube.

8) An allergic reaction to pseudoscience
Phrenology was really in vogue in the 1800's. Back in those days neuroscience was a complete mystery and many Phrenologists thought they were practicing the cutting edge of science. But once Phrenology, and many others foolish notions [like Homeopathy] were proven wrong it was time to move on. Unfortunately, even though some of these old, outdated therapies have been thoroughly discredited, they still exist. Luckily, people like Edzard Ernst (an MD and former Homeopath) are working to remedy this. It is reasonable to understand that the Therapist who has invested many hours and many dollars learning a particular method or modality will have a hard time letting go. Hey, they can keep the business cards but ditch the explanatory model OK? If a Therapist's primary concern is with helping patients get better it should not matter. We have all moved on from the Tooth Fairy and Santa Clause. Sure it hurt to grow, and we lost the money and presents, but hey, we're all grown up now.

9) A passion for learning
It is also reasonable to ask your Therapist what latest article, book, or blog post they read regarding pain or therapy. Do they read from a variety of sources? Or do they cling to one particular guru who they've learned all their masterful techniques from. There is no one person that understands it all. There are many people and organizations today doing truly awesome research. A Therapist who is not interesting in at least improving their understanding in some way probably hasn't read anything decent in the last few years or more.

10) A willingness to treat pain
Barrett Dorko has a great saying "if the primary complaint is pain, the treatment of pain should be primary". If you visit a therapist because of pain in your shoulder and they spend all of their time trying to increase your range of motion, improve your core strength, or something silly like balancing the difference in your leg lengths, run. Pain is a reasonable thing to treat first and if any exercise or movement activity is prescribed it should be in reference to lessening the pain experience. Pain is just not treated well and soon enough. Do not tolerate a Therapist who ignores it, have them address the pain or get out of there.

Pain is a really complex experience. Going into just any corner store for some good ole therapy is not going to help you get better. Learn everything you can and demand quality care from the people who earn their living from it.

*Side note all of the people referenced in this article have tons of credentials. I didn't post the alphabet after their name but you can easily look that up.

Saturday, March 2, 2013

10 things I wish my Doctor had told me about pain!

Jake Tumber, PT asked me what things I know now about pain that I wish I was told in 2002 when I visited my Family Doctor after a minor car accident. I decided to get it down on a list here:

1) You are probably not damaged!
Despite all the impact demolition derby drivers sustain, they have ultra low incidence of chronic whiplash and persistent neck pain. It has nothing to do with the forces (they get blind sided too) but everything to do with the meaning and context of what happens. This study may not be the most robust (Retrospective). But it does pose a pretty challenging question to some base assumptions. Physical damage is a poor predictor of how much pain you will experience.

2) Move it or lose it!
If you treat your body like it is fragile and damaged, it will become more so. There is a something called Hebb's Rule after Donald Hebb which states "Cells that fire together wire together". What this means in this case is that if you move less, you will lose some of those capacities to move. That sounds kind of dire but of course this happens over time. And time is pernicious when it comes to chronic pain. If you allow yourself to act fragile and breakable you will slowly, physically and mentally, change to support that belief over time. You are much more robust then you realize and with a little creativity you can find something that you can do. This makes all the difference in the world.

3) Banish fear!
Being afraid of the pain getting worse makes you fearful of movement. Along with point 2) this kind of attitude can lead to catastrophising, depression, and more fear. All these may cause you to stop exercising or challenging yourself which creates self perpetuating loops that slowly paint you in a corner. This is why "letting pain be your guide" is not helpful to your recovery.

4) Pay attention!
Blasting past the pain and ignoring flare ups will piss off the nervous system. And nobody's happy if the NS isn't happy. Diane Jacob's talks about the "Critter Brain", Todd Hargrove mentions the "Wild Animal". They are talking about that older part of you that is constantly monitoring threat and mounting defensive responses if it deems it necessary. Treat your newly sensitized nervous system like a wild animal or ancient critter brain that you are attempting to tame and soothe by building trust.

5) Exercise and move for the general benefit!
You can't stretch out the pain. And strengthening only indirectly affects pain, most likely because exercise and movement are so helpful in general. So forget about weak muscles and asymmetry, if you walked in the room and didn't fall over your core strength is just fine. Paul Ingraham started me on a wild journey a few years ago with that first stretching article, his site is well worth a visit.

6) No therapist should increase your pain!
If you ever have any therapist that increases your pain during therapy and implies that it is somehow good for you. Punch them and get out of there. (I'm talking to ART people especially here.) Increasing your pain through therapy can heighten the sensitivity of your nervous system which is the exact opposite of what therapy should be going for. Sometimes the best thing a therapist can do is Do Nothing as Barret Dorko writes.

7) Looking inside isn't going to help!
Getting any imaging done should be an absolutely last resort. Unless there is a serious red flag, chances are any findings on MRI's, X-rays etc will just cause you to worry about something unnecessarily. Many people have no pain and would have plenty of abnormal imaging findings.

8) Your brain is king (or queen) of it all!
Your brain is in complete control of the pain experience. Pain is produced as a pain experience just like hunger and thirst. Only with pain it is similar to a car alarm that has been set on high sensitivity. Sometimes the alarm may go off because a strong wind has just blown or some car stereo bass shook the windows as it went by. With pain, there doesn't have to be anything wrong for the experience to occur, it can be simply because the sensitivity is up to high. This one is the most vexing because it feels so real. And it often feels like your pain has a distinct location. You would swear under oath that something is wrong "right there". But our brain can be tricked very easily, I mean very very easily. You can't trust your experience.

9) Your brain can get cranky!
Your brain extends throughout your entire body. 72kms. All nervous tissues have their own blood supply and can get very cranky if they are not well fed. This is where you may need the help of a competent therapist. And the earlier the better. A proper therapist will always help you regain your inner locus of control, they will never attempt to be the "healer" or the "guru" with special knowledge that only they understand leaving you dependent on them for recovery.

10) Quacks are after your money!
Finally, here is a quick list of money wasting therapies. Craniosacral Therapy (CST), Ultrasound, Myofascial Release (MFR) Acupuncture, Cupping, Moxibustion, Ayurveda, Homeopathy, Naturopathy, most Pathy's, reiki, Therapeutic Touch, energy work (of any kind), TENS, Chiropractors that believe in Subluxation Theory, traction devices, most anything that buzzes, whirs, bleeps, or rumbles, magnetic anything, copper bracelets, quite a lot of surgeries, any instruments that are used to scrape the skin in some way (especially aggressively), or any treatment that approaches the body as some dumb lump of meat that has no super sensitive tissue permeating every square millimetre of it.

Knowing this stuff 11 years ago would have put me on quite a different (and less money wasting) track than the one I ended up traveling so I hope it gives someone who is starting out now a leg up. I would love to hear from your experiences if you'd share them below.