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.

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  • 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]

Yesterday’s Focus Versus Today’s Approach.

It seems like there is a never-ending debate over the biomedical and psycho-social aspect of Physiotherapy. Honestly, I didn’t know such a debate even existed until very recently, and now I find myself to be just another victim like many others. Well, if you were to ask me, there is a clear difference between the two terms. When we talk about biomedical focus, we are clearly talking about the tissue damage, joint congruency and movement, biomechanics as well as explanation of several pain mechanisms. Psycho-social on the other hand explains nothing about the above jibber-jabber, it’s about how a patient deals or feels about his/her pain. It could be their fear, anxiety, perspective or a form of belief related to the experience of their injury or problem. This raises a question, how do you bridge the gap between these two and POOF, you have the answer – Biopsychosocial model.

This recent concept (at least to me it was) called Biopsychosocial model talks about moving ahead of the fear that limits you from movement, it’s more about goal setting and encouraging the patient to do and get better. This model is more of an approach rather than a focus.  Let’s just say, Biopsychosocial approach is the moderator for the debate between the other two focuses!

Clinically,

As a Therapist, I always believed in having a structured protocol as a part of my treatment plan. It included a lot of Passive and Assisted handling, a lot of recently learned and totally exciting mobilizations and ‘over the top’ exercises. My advice to the patients would be on the following lines:

  • If bending your knee gives you pain, then don’t do it
  • Mobilizing the joint is the only way I can fix you
  • You are young you can do 10 repetitions/ you are old you shouldn’t be doing 10 repetitions
  • Stay fit and active, try to be stress free and so on

While referring to the available literature on this subject, I read an article by Paul Ingraham about Central Sensitization. He makes it a point to mention that this is a phenomenon where pain can alter the Nervous System, due to which the patient becomes more sensitive to the nociceptive stimuli and experiences more pain with less provocation. So, when I think about it now, if I have a patient who walks in with a painful knee and I am going to go all passive aggressive on him, there is a high chance that in the hope of making him better I am making his condition worse with every little forced movement. On the contrary, on what basis have I decided that the patient is a victim to central sensitization? Isn’t there a possibility that the pain is arising from an underlying tissue or pathology? There is no specific clinical test to determine presence of sensitization. And the only explanation or proof that I have of the patient’s pain is his own experience and previous memories with it. This gets me to a dead end. What next?

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Next step would be getting to know more about pain, and its pathways to support and act as a backup in our decision making. I will be talking more about the pain and its pathways in general in my next blog.

For now, let’s talk about a patient suffering from chronic pain. Assume he is a case of osteoarthritis of the knee. Now we know that chronic OA is characterized by pain and local tissue damage. It’s the wear and tear of the joint most of the time because of old age. Historically, cartilage was believed to be the root cause of pain but recent research material tells us otherwise. Cartilage is an avascular aneural tissue and hence cannot be the root cause1. Pain is likely to be more complex and arise from the surrounding structures such as the bone, tissues, ligaments or synovium which influence the activation of central pain pathway2. Hence it is of utmost importance that as clinicians we know more and study more in detail about the central pain mechanism that may form the major outline for the patients complains regarding persistent pain.

In recent studies, the use of functional MRI (fMRI) has increased in investigating how the brain processes noxious stimuli in OA and the cortical location to which perception of pain is mapped3. The schematic representation below shows the central pain processing pathway in OA knee:

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Talking about evidence, a recent work carried out by Baliki et al has reported that movement causing pain at the knee joint in an Osteoarthritic Knee was associated with activity in different areas of the brain such as, Thalamus and the Cortex. This suggests that nociceptive stimulation at the knee engages with the brain leading to Central activation of the Nervous System causing pain in OA4. Keeping this in mind, if we are going to treat the patient at the local area there will be no reduction in the symptoms, pain will persist and there might be chance that he/she might expericence more discomfort due to repetitive input of nociceptive stimuli which are given as treatment because of the dearth in our knowldge.

Conclusion:

Let me start framing the last bit of this blog. When we talk about the clinical reasoning and the recent development in the field of Physiotherapy, I think some things remain the same and some don’t. According to me, the most crucial part in diagnosing and decision making is listening to the patients. The best content that you will need is always in there. The Biopsychosocial approach tells us to look at a patient in a more broader way, by including the good from the past experiences and practices and incorporate the new ways such as clinical reasoning, evidence based practice and combine this to get the maximum out of your patient. As mentioned earlier since there is no specific tests to determine the presence of central sensitization, a detailed evaluation and knowledge around the area of pain is necessary. As explained by Greg Lehman in his article about treating pain with simple fundamentals, let’s keep the key aspects in mind such as ruling out red flags, and the major stress component.

Another very important point I would like to mention is about the handling and treatment of patients by deconstructing our rigid opinions about “I know what is right and this is the only way I will go ahead with my treatment”. We (specially me) must stop concentrating on the local area and thinking of fixing that one issue. Let’s look at every aspect of the individual. Let’s split it into the biological the social the psychological aspect and draw a conclusion as to what really is the underlying cause. Let’s not tell our patients to stop doing the activity which gives them pain, instead let’s focus on changing the biomechanics and loading of the joint, simultaneously building tolerance towards the painful activity5. Avoid stimulating the already excited nervous system and cause more pain that there already is. Instead try and make the patients more comfortable with the idea of pain and the reasons for its cause and direct them as well as ourselves towards being more gentle in our treatment ways.

Let’s not try and fix our patients; they aren’t broken objects. Instead, focus towards getting them moving and feeling more safe about and around their pain.

References:

  1. Ejindu, V., Kiely, P., Sofat, N. (2001). What makes Osteoarthritis painful? The evidence for local and central pain processing. Journal of Rheumatology, [Online]. Available at http://rheumatology.oxfordjournals.org/content/early/2011/09/26/rheumatology.ker283
  1. Conaghan PG. Structural correlates of osteoarthritis pain: lessons from magnetic resonance imaging. In: Felson DT Schaible H-G, eds. Pain in osteoarthritis. New Jersey: Wiley-Blackwell, 2009.
  2. Ogawa S, Lee TM, Nayak AS, Glynn P. Oxygenation-sensitive contrast in magnetic resonance image of rodent brain at high magnetic fields. Magn Reson Med 1990;14:6878.
  1. Baliki MN, Geha PY, Jabakhanji R, Harden N, Schnitzer TJ, Apkarian AV. A preliminary fMRI study of analgesic treatment in chronic back pain and knee osteoarthritis. Mol Pain 2008;4:4
  1. Lehman, G., Don’t Freak Out: Treating Pain with Simple Fundamentals A Blog Article. [Online] MedBridge. Available at https://www.medbridgeeducation.com/h/blog-article-greg-lehman-dont-freak-out-treating-pain-n-af

Stumbling between best of both Worlds- A stepping stone.

Ready steady go!

Namaste to all you lovely people! My name is Manasi and I’m a budding Physiotherapist from India currently persuing my MSc degree at the University of Nottingham.

So, I see a lot of people starting their articles and blogs with quotes and great phrases given to us by greater people. Well, I thought to myself why not try something different,

Keep on moving

Keep climbing

Keep the faith

It’s all about the climb.

Yes, you’re right that’s a song. And if this song is what inspires me to write this blog be it. I’m going to turn the music up and let my keyboard dance on its tune!

I still remember the days when I was looking up for a master’s degree to study, and I came across the advancing practice course (the one I’m studying now). It seemed interesting and the next thing I know I was sending out emails to professors, course conveners, previous year students practically the entire university. Few months down the line and I’m packing my bags and headed here to achieve that Advanced Practitioner Title.  If only it was as easy as it sounds.

Where I come from, Physiotherapy Practice is mostly clinical. We asses our patients and then we get on with the list of things that need to be done to get the patient “moving”. And I admit, I have been practicing the same way for quite some time now. If I may add, there is absolutely nothing wrong with the way we approach or treat our patients but, I do think that we are just lacking at certain aspects of Physiotherapy. During my lectures at the University my mind kept drifting back home, thinking how would I have done this, how would have I handled a certain patient and what I realized is I have always targeted the joint or area to be treated rather than the person as a whole.

For instance, let’s rewind to the time I was practicing back in India. I have a patient with grade two ankle sprain. I asses him and decide to treat him with certain mobilization technique. His ankle dorsiflexion range gets better the pain persists, so I prescribe some gentle exercises for his ankle and send him away. Now, did I study or try to find a reason for his persistent pain? Did I consider the possibility of central sensitization? Did I think of including proprioceptive input as a form of treatment? Did I do anything new or better for my patient? The answer is NO. Because I did not have an open mind, I lacked the curiosity needed to learn more, to find out more about a condition/treatment.

Let’s fast forward to the day I got on board with the MSc programme. I learned two new things called clinical reasoning and evidence based practice. Two very new unfamiliar terms, but great enough to create a havoc in my mind. Today as I sit here writing this blog I consider that Havoc as a blessing.  I finally know what is lacking in my practice and I feel like I have found the missing piece to my puzzle. This module has forced me to broaden my mind and change my perspective. It has taught me to question myself and find answers for them, to be more inquisitive in everything I do and lastly it has taught me that the area of Physiotherapy and the evidence that supports it is expanding and changing every day, and if I want to be an advanced practitioner it’s about time I started evolving with it.

I’m a fresher and I intend to stay here and keep blogging about what I learn and what I find interesting and obviously get better at this too. Suggestions, feedback and critics are welcome, I’ll be more than happy if you’re another reason for my growth!

So, let’s stay tuned and see what I come up with next!