Too damaged to be touched

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.

-Tim Cocks

www.noigroup.com

 

Get your think on and get up to date at a noigroup course, or immerse yourself in some brainy books with Explain Pain 2nd Ed and The Graded Motor Imagery Handbook

10 Responses to “Too damaged to be touched”

  1. davidbutler0noi

    Thanks for this important post. I loved hearing of a rural physio department with “echoes of neuroscience nuggets and all sorts of inventive metaphorical gems bouncing off the walls”. (Whatever happenned to faradic footbaths, ultrasound and short wave diathermy?)

    The post says it all. Of course therapeutic story telling does not involve reducing the quality of evaluation process and it should take clincians to a therapeutic process where the patient’s thoughts and feelings in real time are explored.

    Touch – use the precious licence that we have!

    Thanks

    David

    Reply
  2. Efwef Gwerb

    G’day Tim,

    I don’t do pain education nowadays, because clients just don’t get it. Or if they do get it, they don’t like the implications. Even if you use very simple explanations and metaphors, the message rarely comes across as intended.

    I know this is the case because (as usual) I have done my own clinical experiments. At the end of the talk, you ask: “Now that I’ve finished I’d be interested to see what you understand about these concepts”.

    Nothing. They typically understand nothing at all! But it’s not surprising really. These concepts are too foreign, too big a stretch. It’s not the client’s fault. There’s plenty of studies which show that people attending GP consults retain very little of what they are told, and yet we try to explain pain neuroscience to them?? How much of that is going to stick?

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539560/

    The idea of being a therapist is to meet the client where she is, not to get her to adopt to your neuroscience worldview. This case mentioned is so goddamn easy to treat. You ask where the sore spot is and you rub it. You can even do it over the clothes if short on time. When she says anxiously “is it ok to walk the dog again?”, you say “sure it is!”.

    And as usual, all this must be done with a congruent attitude, otherwise it will fail to have any impact. Therapists have not cottoned onto this yet.

    EG

    Reply
  3. Wouter

    Hi tim,
    Thanks for the post! Wanted to respond to camerons post…. Maybe therapist should reflect on why some patients don’t get the neuroscience? Is it really the patient? Is it a lack of background or intelligence on the patients side? First problem: teacher student approach in most cases does not work, neuroscience ed is not rambling the same story over and over again, its finding a way in, finding a loophole where the patient can connect…. Secondly, maybe we should try a let the patient lead the conversation…. And only pitch in with simple words…. Our job is not to make patients specialists in neuroscience… Just trying to adjust or reflect on false beliefs can be enough to alter or make a change….

    This congruence thing, i get the feeling YOUR state of mind is key to get patients better… I thought it was all about THE PATIENTs state of mind…. Some listening and empathy from our side will make us go a long way….

    Thx

    Reply
  4. Mark Hollis

    Cameron, an equally viable alternative hypothesis could be that your clients could get it but that your ability to deliver neuroscience isn’t congruent with their ability to receive it.

    ‘The idea of being a therapist is to meet the client where she is, not to get her to adopt to your neuroscience worldview.’

    While I’d agree with the first half of the sentence, once you’ve met them at where they’re at then what’s wrong with using the qualities, relationships, and processes that neuroscience describe to show them (while you’re there with them) an alternative place to be. Therapeutic Education doesn’t have to be thought manipulation, the same way that therapeutic touch doesn’t have to be spinal manipulation.

    They don’t have to adopt a neuroscience worldview but there may be aspects of our story that, by their choosing, they are able to adapt and use for their own benefit.

    I agree we can tell stories congruently or incongruently, it’s merely expression of self using tone and sound and tempo as words as much as my breathing or body position or type of touch/force or facial expression is equally an expression of self/congruence during the interaction. I’d be surprised by clients that don’t understand stories of inhibition and control and adaptation or stories where the state that they’re in has the potential for malleability, plasticity, and change, aren’t they some of the foundations of the process of hope?

    Reply
  5. davidboltononoi

    Hi Tim,
    A beautiful story that should be read by every physiotherapist. It reminds us of the quote “Joints don’t hurt, muscles don’t hurt, bones don’t hurt………People Hurt”
    DB
    Back at the front line 😀

    Reply
  6. Efwef Gwerb

    Gday wouter,

    I think Dave and a few others would agree with your points on the education aspect. I’m all for pain education, but try as I might the stickiness eludes me/us. I have read a lot about how master story-tellers like Milton Erickson achieved great things with this approach. So I’ll take your point – it’s probably lack of skill on my part. I lose spontaneity when I’m working to a script, and I don’t like that feeling, so I choose other ways to reduce fear. Erickson used to stay up all night writing and rehearsing how he would approach certain aspects of his story telling, tailored as it was for each client! I admire his commitment, but I don’t think the work:reward ratio is particularly good.

    By chance have you asked your clients what they have gained after an education session? I was quite shocked what I heard back! :)

    Clients determine what and how to think based upon what they observe the therapist doing. So yes I definitely put the therapist at the centre of the clinical picture, leading the game. And it is very much a game, imo.

    EG

    Reply
    • Wouter

      Hi cameron,

      For sure i ask patient what they take out of it… Its crucial, and sometimes i too am astonished of what they retained….. But this feedback does not demotivate me to explain pain…. I see it as an opportunity to alter the strategy…. If we tell something that is too abstract or not personal enough, so the patient does not relate to it, input gets lost and misses effect….. Explaining pain does not have to be neurophysiology, explaining pain is talking about real life stuff….

      Reply
  7. Efwef Gwerb

    Mark, this is the limit of what I say nowadays – two sentences – “The injury has completely healed. The pain you’re feeling is due to irritation of the little nerve endings in the area, but they will settle down with a few treatments”.

    Whether the content is technically correct or not doesn’t bother me; the aim is not so much to educate but to reduce fear. And it does this, *quickly*. I wait until I sense the patient is unguarded so I can bypass his critical (conscious) mind. The moment I see the opportunity, I pounce, and the words “completely healed” are emphasized. The whole thing can be done in seconds.

    This reminds me of something….

    There was an article* a while back on Body-in-Mind where the author found that instead of using a huge questionnaire to find out if a person was depressed, all you need to do is ask: “Have you been feeling down lately?” She found that this was in fact just as good as the huge questionnaire. I think we might find the same is true for pain education.

    I’d like to write a blog entry on patient receptivity to suggestion if I’m allowed here. Tim?

    *http://www.bodyinmind.org/is-one-question-enough-to-screen-for-depression-and-anxiety/

    Reply
  8. davidbutler0noi

    Hi all and thanks for the posts – I am going on the current science route here – There are (I think) at least 14 RCTs on Explain Pain education with many still brewing plus two systematic reviews. Outcomes are all fairly similar – it works on a number of domains including movement, cognitions and cost. There is currently nothing better that biological education for chronic pain. But I am convinced that we can do a heap better.

    Some get “it” quickly – a radical reconceptualisation or revelation perhaps but for the vast majority it is a slog. For me, “it” is when the patient believes they are better not when a health practitioner declares they are better (eg “the surgery was a success”).

    But learning is complex – the world of health and the world of education rarely share secrets but a fundamental doctrine in education (in most countries) is that the NNE (number needed to educate stat) is 1. If you walk around an education faculty , the names on the doors give it away – departments for the gifted, the dyslexics, early childhood, learning problems etc etc – ie education has adapted for the learner – this is yet to happen in health. In fact I think it is time we drew back from health psychology for chronic pain and gave education psychology a look in – but that is another blog topic.

    PS. We love getting blog post submissions so Cam – send it in.

    David

    Reply

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