Changing Pain vs Smoke and Mirrors?
One of the common things I see in clinical practice is therapists making patients adjust postures or movement patterns to see if it changes pain. Now i think that this is a very worthwhile way to approach patients. I do it all of the time. There is however a common error that I think we often make in regards to this approach, and I have regularly made it in the past.
As per how Jeremy Lewis and many others approach patients I think it important that any change in pain is meaningful. At least a 30 percent change in pain or function is meaningful – see here and here for more information. Anything less than this is probably not meaningful enough to the therapist, or even more importantly to the patient. Whilst on this topic, patients will often say, when asked how much better it is, “oh a bit better”. I think it is important to chase a figure from them. Otherwise you might be dealing with a 5% change, or they might just be being nice and not wanting to offend you!
That’s really nice of them but it doesn’t really help does it. I like to tell them to be honest so we don’t waste time treating something we don’t need too.
I also agree that sometimes it is a cumulative percentage change by combining 2 or more “techniques”. But we still should at least be chasing a cumulative 30% improvement.
Depending on the patient sometimes dealing with a percentage might be difficult. Alternatively perhaps ask the patient to express it as a fraction. How much better? 1/4, 1/2, 3/4’s or pain completely gone. Anything less than 1/4 is not meaningful. Perhaps using a value from 0 to 10 is another idea, but once again at least a 3/10 improvement is warranted.
I know some of you will argue with the minimum 30% change. For example:
“My patients pain reduces by 10% when they pull their tummy in. Therefore they need to improve the strength of this muscle before their pain improvement will become meaningful.”
Ok, that’s a reasonable argument, but how long should it take for those improvements to become meaningful (i.e. at least 30% better or more)?
- 4 to 8 weeks is plausible.
- 12 weeks? I reckon you might be pushing the limits.
- 6 months? Nope. Sorry. No way.
If you can’t change their pain significantly then you’re not focusing on the primary contributing factor(s) in their presentation. What might some of these other factors be?
- Psychosocial Factors.
- Pain Sensitivity – their painful area might significantly irritated or severely painful. Maybe they have an acute inflammatory reaction, or a neuropathic pain state. Maybe they are centrally sensitised. Perhaps, to put it even more simply, they have dominant non-mechanical pain.
- They might also just simply be weak or de-conditioned. For example they might not be able to lift their arm all of the way through full shoulder flexion range because of loss of muscle strength subsequent to their lack of normal use of their arm. Their pain might be nothing to do with ther “posture” or “motor control”. They might just need to strengthen their arm. I know that’s not very “physio sexy” but that might be all they need to do.
- Don’t forget about red flags or a significant “structural” injury either.
So to summarise, absolutely see if you can change patients pain levels with techniques such as manual therapy, changes in postural strategies and “biomechanics”. I think it is exceptionally useful in clinical practice, whether it makes a meaningful change or not. But make sure any change is meaningful, otherwise I reckon you might be kidding yourself and your patients, and your treatment might be just smoke and mirrors.
Thanks for reading.
About the Author: Mark Gibson
Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.Subscribe
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Absolutely. Good post Mark.
30% is also my cut off mark. Not just 30% change, but 30% within 30 minutes, regardless of intensity or chronicity. Preferably 60+% within 30 minutes. Then I know I’ve done something worth paying for.
Needless to say I fall short sometimes (that’s another issue). But I’d be hugely unsatisfied if I had to go to work and be faced with the prospect of eg. 20% change in 6 weeks. There’s no way you can claim credit for that.
Interesting this, especially for me as I am not interested AT ALL in changing a patient’s pain whilst they are with me. Differing approaches eh? One thing I will say though, is that I find quite a few patients struggle with scores and percentages, as pain just isn’t that easy to quantify, and so I try to steer clear of them as much as possible. I also try to take their focus off the pain as much as possible, hence one of the reasons I don’t keep asking them about their pain.
How did you come up with 30% as being a meaningful change? Who’s to say it shouldn’t be 40, or 50 etc?
Cheers, Pete
Hi Pete,
Thanks for the comment. Can I ask why you are not interested AT ALL in changing a patients pain whilst they are with you?
Being able to change pain, or not, is an important part of the clinical reasoning process in my opinion. But as you say, differing approaches. I am keen to hear more of your thoughts as I like to hear of differing approaches/thoughts.
If you can change the pain it is a great way, in my opinion, to improve their compliance with the management. For example if they can see they can change their neck pain by 50% by changing their “posture” then it is a pretty good way to show them that working on their “posture” is important. It also shows me that there is value in having them target a particular exercise.
The 30% is the minimum that most research would suggest is “meaningful/significant”. Please see the references in the post for more info. Ideally the more you can change the pain the better though! I reckon its great when you get the occasional patient who can have most or all of their pain abolished. 🙂
Thanks again for taking the time to comment.
Cheers
Mark
OK, here’s the tough bit, me attempting to articulate my thoughts…..
Why do I not worry about changing a patient’s pain? Primarily because, with the majority of my patients, pain is not the prime focus of my treatment, and I want to do everything I can to take the patient’s focus away from their pain (assuming I am happy that there are no red flags of course). I do everything I can to empower the patient to undetake rehabilitation to improve specific functional goals, with a reduction in pain being an added bonus at the end of (or during) the process. I don’t really want to promote the notion that success is only about decreasing pain, and I certainly don’t want patients to rely on me to do it. I often say to people, that I merely facilitate in all of this, they have to do the work. Now I admit, if you’re in pain and you see somebody who adjusts something that improves your pain instantly it must be lovely, but I try to think a bit more broadly than that; not just about helping their current symptoms, but also about how to improve their quality of life and how to manage future flare ups, through goal setting, graded exercise, pain education etc.
One problem that I come across fairly frequently is that patients have managed to find strategies to decrease their pain, either discovered by themselves or by other healthcare professionals, which, although giving them some relief short term, hasn’t actually helped improve their quality of life. They end up becoming a slave to whatever the little technique is that they have to keep on doing, just to get a moment’s relief. For example, I saw a woman in her 30’s recently with persistent low back pain, and she has found that if she tenses her tummy when sitting, it reduces the pain a bit. Great. Except that it hasn’t lead to her being able to do more exercise, or walk any more comfortably, or look after the kids any more easily. The only way that she is going to improve in those areas is with a graded exercise programme, where function and activity is the focus, not the pain. If someone is constantly searching for reductions in pain, what happens when they have a flare up? Fear avoidance? Despondency? So I think the less importance we place on pain, the less people will worry about it if they do have a bad day.
I guess another big reason I moved away from trying to change someone’s pain instantly is that, what if you can’t change it? What then? What is the focus of your treatment going to be, if you cannot achieve your primary objective of reducing pain? I have found that since moving away from a manual therapy predominant approach to a much more cognitive behavioural one, patients take far fewer sessions to get to where they want to be. I guess I occasionally struggle for compliance, but I would say less so than when I was using a lot of MT. But that’s healthcare isn’t it? There will always be those who aren’t ready for what we can offer, whatever approach you take. But I would say that actually no, being able to change pain isn’t a vital component of our clinical reasoning. Screening for red flags is. Being able to determine whether this is a pain processing problem or a tissue problem is. But changing pain, for me, can actually be a bit of a false dawn.
Anyway, I hope that makes a semblance of sense.
Pete
Hi Pete,
Very well articulated! Thanks so much.
The lady who has her low back pain reduce a little with tensing her tummy is a great example. Unless that “tensing” changes pain at least a significant amount (that minimum 30 to 40%) then there is, in my opinion, no point working on it with her at all. In addition if it does change pain a significant amount then if it is something critical to work on she should at least be significantly improving her sitting tolerance within a month to two of working on it. If not then something is being missed or not treated (e.g. graded exercise etc). If her sitting is being targeted with treatment, but not her walking and/or exercise levels then something it certainly amiss. As you probably also do, I see far too many patients/physiotherapists persisting with management strategies that are quite clearly making no difference to pain and/or function over an extended period of time. Frustrating. 🙂
I also agree that treatment is often multifactorial. Graded exercise, pain education etc are critical in many patients and something I use almost all the time, in addition to quickly seeing if I can reduce pain levels in patients. If I can’t reduce pain levels I tend to move on from it pretty quickly into other domains as you have discussed. I don’t go into a treatment session with the primary objective of reducing pain, but if I can it is useful to help guide my treatment and re-inforce to the patient why I want them to “move” a certain way. As a quick example I reviewed a gentleman yesterday with a 5 month history of back pain. He was very overprotective of his lower back. When holding a 5kg weight out in front of him his back pain increased markedly. His back pain reduced significantly (50%) when he “relaxed” his trunk muscles and used his hips better (excuse the brief explanation). Now I didn’t just leave it at that and move on. Fear (he had one of those “terrible” bulged discs and his surgeon had told him his back was stuffed and was never going to work again) was driving his postural habits plus he was quite clearly de-conditioned and stressed because of being off work and doing very little physical activity. He needs a multifactorial program along the lines you have eluded to (cognitive behavioural type one).
I think we actually are on the same page about most things. I try to do it all. Screening for Red Flags is important and vital. I use MT, but less now than ever! I absolutely use a more CBT/CFT type approach now. I just think attempting to change pain is important, but I agree it is not always possible and not always the most important part. When you can change pain it has to be significant and then you still also have to get to the key “driver(s)”. In that patient example above one of the the key “drivers” for him was fear. Fear that his back was “stuffed” because of his disc bulge and that he now needed to protect it and not bend it. To put it briefly, he needs the fear addressed plus the rehabilitation (graded activity/exercise with avoidance of braced postures etc). Not just “relax and have a regular massage”, otherwise it often is a false dawn.
I hope that makes sense for my end. Yours made great sense. Thanks again for taking the time to reply. Best wishes.
Cheers
Mark
“I guess another big reason I moved away from trying to change someone’s pain instantly is that, what if you can’t change it? What then?”
What then is don’t drop your bundle. Never stop believing in complete 100% pain relief. Tell the patient a certain number of treatments may be required (say up to 5) and after that, treatment will cease. Most therapists fail because they buy into the patient’s frame. When I do treatments, I am the one who sets the frame, not the patient. The patient’s belief in impossibility of change is overridden. Rarely do I use exercise programs for anyone, because there’s no need. And my physical treatments are minimal. It’s all about the vibe.
Cameron, you sound like you have an interesting approach. Are you the same guy who wrote about ?congruence (I think it’s called that) on noijam a while back?
Hi Readers, I’ll try to just make a brief comment. If I make an appointment with a health professional I expect some pain relief – that’s why I made an appointment!
With my clients I too aim to see a significant change in both pain and movement. That’s why I love my Physiotherapy career. Have high expectations and always strive to get even better!
If
I can feel the tension/texture changing under my fingers when I am doing a mobilising technique
+ the client volunteers the pain is decreasing,
+ when I reassess the main restricted range of motion has improved
+ the client volunteers a statement “yes that is much easier/less painful”
then I know my approach is working.
Significant is 20-80% depending on the condition and my expectations from my assessment. If there is NO significant change in my or the client’s opinion, then I may modify the technique or do something different (like tape to unload a very inflamed condition, advise medication or a temporary brace/rest etc). I won’t be satisfied unless the client walks out the door either improved or with a new feeling empowerment from my explanation of what we need to work on to get better progress in a very chronic condition.
If I don’t feel I’m getting enough progress in two sessions then I need to reasess, review my analysis and/or refer on for more appropriate medical treatment or investigations. If you don’t have a goal how do you know when you’ve reached it? Hope this helps inspire someone, Cheers Helen Potter FACP
Thanks Helen.
Good advice for all. Hope all is well.
Cheers
Mark