I’m a great fan of books like ‘Explain Pain’.
This delightful publication by David Butler and Lorimer Moseley gives accurate information about pain, particularly chronic pain, in an accessible format for both patients and clinicians, and I’ve used it often with people I’m seeing. I’m also a fan of helping people to understand what we do (and don’t) know about pain to give them more awareness of their ability to influence their own body.
But as anyone who has worked in chronic pain management knows, telling someone something doesn’t always make an enormous difference – and here’s a case in point. Before I go on, any cases I refer to on this blog are a compilation of several people and details are altered to protect confidentiality.
Yesterday I met with a person who has had chronic back pain for about four years. She has had a discectomy for what the notes stated was a ‘large disc prolapse compressing the nerve root with neurological signs’, so a good candidate for this procedure. The operation was a success four years ago – but, as is common in spinal surgery, she was left with persistent low back pain. Her surgeon told her to ‘be careful of heavy lifting, twisting and bending’ and she had taken this to mean she shouldn’t do things like carry a full washing basket of clothes to the clothesline, do the vacuum cleaning (I can understand this decision!), load the back of her car up with groceries, mow lawns, or even play golf. Ooops, I’m not sure the surgeon meant ALL of these things, but you never know.
We met with one of the doctors I work with to review her clinical chart and to talk about her back pain because she was very wary of doing any of these movements even under clinical supervision. The problem being that her surgeon, four years ago, had said she ‘shouldn’t’.
I want to add at this point that she was seeing us because of another, unrelated pain problem that was responding well to input although the pain from this other problem was not resolving. The other pain problem was in her knee, and it had stopped her from walking comfortably and had also lead to her stopping work. I also want to add that the doctor she was seeing with me is one of the best physicians I know for explaining medical investigations and treatment in a way that patients understand.
The consultation took about 45 minutes – so definitely not a quick’n’dirty consultation. Together we reviewed all the clinical information including medical notes from the surgery. We looked at a model of the spine and my patient was shown exactly what the surgical procedure was – she had no idea of what had actually been done to her vertebra or disc, and had visions of large chunks of bone being removed leaving a weak and vulnerable vertebra and disc that had lost most of its height.
We talked about the risk factors associated with having had one disc prolapse – that the risk of having other prolapses, and particularly another one in that disc, were somewhat higher than before her first disc prolapse. We talked about the relationship between disc changes and pain (which is not entirely straightforward). We discussed the signs and symptoms of a return of her original problem, and that her current back pain was quite different from the original leg pain.
And you know what?
Even though we followed best practice and used the kind of information that Lorimer Moseley describes in the paper I’ve linked this post to, and this woman has had this information given to her in several different ways by different clinicians in the Centre I work in, she is not convinced. To her, having pain in her back inevitably means her surgeon was quite correct to tell her to avoid bending, twisting and lifting, and that unless she is very careful she risks needing the much more significant surgery of a spinal fusion.
The power of a surgeon who, with a few words, has helped this woman become trapped into no longer doing what she used to love.
What’s worse – her GP has said that she should ‘think of doing another job because it’s clear this one isn’t going to be good for your back’ – she’s a taxi driver. So after the whole of her adult working life in the driving industry, at 52 she believes she needs to think of doing another job – even though she and her husband drive off in their motorhome every weekend, and she loved being a cabbie.
What to do, what to do. Information alone in these cases doesn’t help this person feel confident enough to contradict the explicit instructions of her surgeon, nor the advice of her GP, nor her behaviour over the past four years.
It was Bill Fordyce who apparently coined the phrase ‘Information is to behaviour change as spaghetti is to a brick’. While sometimes simply helping people to understand more about their body and what pain is and is not, can be enough for people to take their own steps towards changing their behaviour, for many others – and particularly people who are anxious about their health – it takes more. That’s because knowing in the ‘I can tell you about it’ way is not the same as knowing in the ‘I really understand it’ way.
At heart, I’m a behaviourist I think. While I know the value of working with thoughts and beliefs, and I thoroughly enjoy this part of my work, it makes very little difference to someone’s life if, after all our work together, they carry on doing what they’ve always been doing. That’s one definition of insanity – doing the same thing again and again and hoping for a different result. Something needs to change.
For me, with this person, I hope to start working using an exposure-based treatment. Graded exposure, by identifying the movements she’s currently not happy to do, developing a hierarchy of avoided movements, and starting to help her recognise that the relationship between what she thinks is going to happen and what actually does happen is not the same, is one strategy that can help. Underneath her almost religious adherence to this one surgeon’s advice is a potent fear that (a) she is going to do harm and (b) that she won’t cope with the changes in her pain if she disobeys his instructions.
Trying to convince her or to give her more information – even the very best information along the lines of Lorimer’s paper – isn’t, on its own, going to change her willingness to put her body on the line. Successfully encountering movements and doing them without the scary consequences is probably the only way to help her gain confidence that she can manage it – and return to her normal work.
A pox on people who work with people who have pain and haven’t yet got up to speed with modern scientific knowledge about pain mechanisms. And a bouquet to people like Bill Fordyce and Lorimer Moseley and David Butler and Nick Kendall who have, over the years, contributed so much to scientific and clinical knowledge about the biopsychosocial nature of pain and pain management.
Moseley, G. (2007). Reconceptualising pain according to modern pain science Physical Therapy Reviews, 12 (3), 169-178 DOI: 10.1179/108331907X223010