One of our readers recently sent us the following story
I like to think our physiotherapy department, situated in a public hospital, is quite switched on about pain education, and usually one can hear the echoes of neuroscience nuggets and all sorts of inventive metaphorical gems bouncing off the walls. We are in a rural area with no access to any secondary persistent pain services, but we do our best and generally I think we do pretty well.
We’ve had a middle aged woman attending our outpatients department sporadically for 6 months after a fall where she had tripped up in the dog’s lead and hit the deck. Fortunately nothing had been broken and apart from being shaken and bruised, the initial expectation was she would repair in a timely way.
This has not gone to plan.
The first physio who had assessed this particular lady, maybe a month after her fall when it became evident that she was not doing so well, had uncovered some of those yellow flags we read about and, not wanting to risk reinforcing false assumptions about structural sources of pain, or risk merely medicalizing the patients misery, embarked courageously on a pain education pathway and consciously veered from any manual therapy input (a policy decision as much as a clinical one). The patient attended a couple of sessions, then failed to attend a couple. She moved in with her daughter because she wasn’t coping, attended again for a couple of sessions, and then slowly became more reclusive; scared to go out of the home much at all.
The physiotherapists, as all new public physios do, rotate. A young colleague took over the follow up and after reading the notes before the next consultation came to me as the senior in charge.
“This is supposed to work better than this ….what is happening?” she implored. I read the charts, absorbed lots of information about observations and impressions, opinions from doctors and from the physiotherapists, but- there was nothing recorded about the opinion of the patient herself.
“Talk to her” I suggested, “go and ask things like; How do you think this is going for you? What do you think you need to do to be well again?”
The patient’s response floored us initially but led to two light bulb moments and powerful learning.
In a quiet voice the patient explained that in all the time she had attended the clinic, no one had touched her,
“I know why” she clarified, “I’m too damaged to be touched and they were afraid of doing more harm to me. Its ok, I know that’s just the way it has to be”
Light Bulb moment Number 1
For the therapists in our department– Don’t let adherence to code or your aversion to making a mistake dull your intuition or your empathy. Don’t underestimate the power of touch for establishing a deeper connection. Yes, I get it, her pain is not going to be found in the periphery, or mobilised out with the latest wiggle or thrust, but, afferent information from the periphery in the form of safe, supported , gently coaxed, guided movement will open up some learning opportunities for her nervous system.
Light bulb moment Number 2
For the patient– Addressing this misconception was a pivotal moment- both the patient’s daughter and the physiotherapist reported seeing a ‘lifting of a burden’. Boundaries that seemed impassable were pushed away, limits were lifted, and although this person will need more support, this one session has massively changed the course of her recovery.
Talking with people on Explain Pain courses, it is evident that there are some misconceptions at times about where therapeutic education fits in. It’s not uncommon to hear the question asked “so, should I stop massaging/mobilising/touching people?” The answer is generally a resounding ‘no’, but with a significant caveat- there needs to be an underpinning rationale based on modern, neuroimmune concepts of pain and an overarching story that is plausible and consistent.
This story is also a powerful reminder that it is the things we don’t do and don’t say as much as it is the things we do say and do that can be memorable and have lasting impacts of the people we treat.