Let’s Educate- one PATIENT at a time!

When we were first told to write a blog, I was scared. Then I was told that it’s not that big a deal. I must start reading a little more than I usually do, and that will make things quite easy for me. Now I wonder, if I wasn’t told and explained by my teachers how it works and not guided by them when needed, if I ever would be able to write my first blog. Doesn’t treating patients follow the same principle? I know what my patient is suffering from, I know what’s going to make him better and what isn’t. I also know what is going to make his pain worse. If I don’t tell them that and just let them be, how are they going to get better. If I don’t guide them appropriately they will never achieve their goal of well-being.

Pain Neuroscience Education:

When we talk about explaining pain to our patients it involves a range of interventions which aim at changing the way they perceive pain or their beliefs around the concept of pain. It’s about altering their understanding of the Biological process that drives the pain mechanism. The core objective of the approach to treatment is to shift one’s conceptualisation of pain from that of a marker of tissue damage or pathology, to that of a marker of the perceived need to protect body tissue¹.

• The first step toward pain education would be to determine the factors that drive the pain in an individual followed by using positive influence for example, tell the patients that their pain is real but not necessary that it is an effect of a certain tissue damage thus attempting in increasing patients understanding about the neurophysiology of chronic pain.

• We know every patient that comes to us represents a different model of pain. No two patients are same, similarly their way of Knowledge and understanding, their expectation from the treatment will also be different. Another key factor in Pain education would be to find out what your patient wants depending on the goal they set for themselves.

• Get to know the learning styles for your patient. If your patient falls under the visual category, you could make use of images for them to understand information. For patient who prefer Auditory they will merely listen to what you say and follow the lead. You can make use of flyers for patients who fall under the Read/Write category. Lastly, for the patients falling under Kinesthetic category, you could go ahead with hands on approach.

• The idea of shared decision making which has come into light very recently is another great way to educate your patient. Shared decision making is defined as: ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences”². SDM is supported by 8 Randomized control trials showing that patients who gained more knowledge, took part in decision making, were more actively involved elected for a more conservative treatment³.

 

Why is it important to educate a person?

One of the most important reasons why we need to educate patients is catastrophizing. Catastrophizing, a set of negative emotional and cognitive processes, is widely recognized to be associated with increased reports of pain⁴. The fear model has theorized that negative beliefs about pain and/or negative illness information leads to a catastrophizing response in which patients imagine the worst possible outcome. This leads to fear of activity and avoidance that in turn causes disuse and resultant distress, reinforcing the original negative appraisal in a deleterious cycle. It also suggests that patients without catastrophizing and fear-avoidance beliefs (FAB) are more likely to confront pain problems and are more active in the coping process⁵

 

In a study done by Moseley G and Butler D, they said that the concept of explaining pain to patients emphasizes on the fact that evidence of danger to the body tissue can increase pain and any credible evidence of safety to body tissues can decrease pain⁶. To put it in simpler words, If I motivate my patients to not depend on their fear of pain, and move beyond that I can achieve better outcomes. Another Systematic Review was conducted on Pain Neuroscience Education for chronic low backpain. The review was carried out to examine the evidence of pain education with chronic low back pain on outcomes on pain, physical activity, psychological function, and social function. The initial work included in this review suggested that PNE is a promising intervention for the primary outcome measures of pain, physical-function, psychological-function and social-function. However, based upon the Cochrane quality of evidence classification system, the evidence base for PNE was graded as very low quality ( Furlan et al., 2009).

As Albert Einstein said, “The important thing is not to stop questioning; curiosity has its own reason for existing.”  I decided to explore more on this topic. After finding a detailed explanation as to why it’s necessary to include patient education in our practise I questioned myself; Is this really enough? Is there something else that I might have missed? Is educating the patient the ultimate, the most valid explanation to cure pain? This triggered me to do some further reading; A study done by Lorimer Mosely⁷  on combined effects of neurophysiology education and physiotherapy intervention for patients with chronic low back pain. It was a randomized control trial with a physiotherapy group and a control group. Each subject received two physiotherapy treatments per week for four weeks. Manual therapy treatment involved symptom management per the discretion of the treating physiotherapist, who chose from spinal mobilisation/manipulation, soft tissue massage, and muscle and neuromeningeal mobilisation techniques. These patients also participated in an educational session once per week for four weeks. The session focused on the education of neurophysiology of pain. Whereas the control group continued their visits with the GP and were specifically asked not to undertake any physiotherapy treatment. The results of the study strongly suggested that the combined physiotherapy treatment, consisting of manual therapy, specific exercise training, and neurophysiology education, is effective in producing functional and symptomatic improvement in chronic low back pain patients. The effect is maintained at 12 months’ post-treatment and patients subsequently seek substantially fewer health care visits than those under ongoing medical care.

It is true that educating your patients regarding pain will definitely change their perspective of looking at the injury or limitations and result in a better outcome, but it doesn’t mean that this current and new way of management should be our “voted as the best this year” approach. Like I mentioned in my previous blog, we need to adapt what is new, and combine it with the effective and evidence based “not so recent” techniques and include then in our treatment regime. Everything that I have explained above forms the basis for Biopsychosocial model of physiotherapy that we all are trying so hard to be a master in.

When I made up my mind to study this master’s course I had a brief idea of what I had signed up for. Today as I look back, I realise I have achieved so much more than I initially thought I would. This realisation came after the first exam that I gave last week. I had been reading so many articles on how I need to treat a patient. Would treatment “A” be better than treatment “B”, or should I combine both these treatments together? I have learnt that in order to decide what’s the best, I need to educate myself first. There was an article which stated that, eight weeks of a Multimodal Physical Therapy Program seemed to moderately enhance the general health state and Health Related Quality of Life of patients with chronic musculoskeletal diseases. What I am trying to say here is that, we need to open our minds and broaden our perspective and grasp the new ideas of treating an individual. Let’s not stay focused on one joint all the time. If we intend to give a multimodal approach to our patients, then let’s educate ourselves in a multimodal direction as well. I think I have been successful in doing that so far. I have deconstructed myself completely in order to start rebuilding. I’m back to being a Physiotherapist in the making. Well to be honest this concept of Biopsychosocial model is a little tricky subject I won’t lie but at the same time, not very difficult to understand. It just needs us as Therapists to read more, learn more and educate ourselves FIRST! ONE STEP AT A TIME!

 

References:

1. Moseley GL, Butler DS, 15 Years of Explaining Pain – The Past, Present and Future, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.05.005.
2. Elwyn G, Coulter A, Laitner S, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ. 2010;341: c5146.
3. Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner, M Llewellyn-Thomas, H Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011;as well as(10):CD001431
4. Claudia M. Campbell, Ph.D.1, Kenny Witmer1, Mpepera Simango1, Alene Carteret, M.S.2, Marco L. Loggia, Ph.D.3,4,5, James N. Campbell, MD2, Jennifer A. Haythornthwaite, Ph.D.1, and Robert R. Edwards, Ph.D.3. Catastrophizing delays the analgesic effect of distraction.
5. Wertli, M.M., Eugster, R., Held, U., Steurer, J., Kofmehl, R. and Weiser, S. (2014) ‘Catastrophizing—a prognostic factor for outcome in patients with low back pain: A systematic review’,The Spine Journal, 14(11), pp. 2639–2657. doi: 10.1016/j.spinee.2014.03.003.
6. Moseley G, Butler D: The Explain Pain Handbook: Protectometer., Noigroup publications, Adelaide, Australia, 2015.
7. Moseley L (2002): Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal of Physiotherapy 48: 297-302]