don't leave me honey

Information is to behaviour change as spaghetti is to a brick


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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

12 comments

  1. Coffee hit the screen when I read the title of this post to my nuclear physicist husband a few feet away at his desk!! Thank you for the Monday morning guffaw.

    1. Ahhh, but did you know who coined that phrase? It apparently was Wilbert Fordyce and it’s become a bit of a mantra for behaviourally-oriented cognitive behavioural therapists, obviously including me! I hope the message got through too! LOL

  2. Can you explain why you are fond of the “Explain Pain” book? I was given it to read as part of my pain management program. Mostly it covered what I knew anyway, but it was just as well. The doctor who gave it to me to read said that it explains modern pain science in accessible terms without talking down to patients. I, personally, felt frustrated and talked down a lot of the time. An inter-vertebral disc is a disc, it’s not a “living force transducer”, or whatever new term they coined. This just confuses everything and interferes with me trying to place the information I am reading in context of what I know. Plus, even though the book has a lot of references, a lot of what is used to justify the theory seemed to be individual case studies with many possible explanations. I don’t remember examples anymore, but I remember reading it and thinking that if I dared to put anything like that in my research papers, the reviewers would be immediately up in arms about speculation not confirmed by proper statistical data. I can understand general educational value for patients, but I would be very disappointed if my doctors took this book as a genuine guide to science behind pain.

    1. I guess what I like about the book is the accessible language – and that I know it is underpinned by science. They use case studies to illustrate principles rather than citing loads of references that many people won’t either read or understand because of the jargon. I wouldn’t ever give it to someone without sitting down and going through it – but that’s partly because I know that ‘information’ alone doesn’t change a lot, except in a very few patients. I guess that it is one of the very few books that have tried to pull together the information that is current, and tried to put it into a form that is user-friendly. I know that many of the patients I’ve worked with have said they really enjoyed the book and found it helpful – but that you didn’t find as helpful just goes to show that we need to have an individualised approach to suit the people we’re working with.
      cheers
      Bronnie

  3. I guess this is a problem with being a scientist. I am used to read everything related to medicine with my “critical argument” filter on, and that book just set it off all the time. If I think about this again, case studies are not a problem per se – there are a lot of those in medicine, and they are unavoidable when evidence may be difficult or impossible to collect. To be more precise, the book didn’t convince me that the case studies were cited appropriately. Some analogies make sense – phantom limb pain is one of the well known motivating examples of why pain is not necessarily a direct reflection of what is going on with the body. But they kept pressing points which, to my mind, were big leaps – what people feel or didn’t feel with extreme injury/shock, for example. One would have to build a lot more detailed argument to convince me that this has significant bearing on chronic pain (other than very general, “pain sensation can be felt with some delay if your system is overloaded with other sensations”). There were other places, as well, where I kept going “I can come up with at least one alternative explanation on the spot. You are presenting this as a definite fact. There are a lot of unfilled blanks here”

    Maybe this just goes to confirm what your original post says about information not being helpful or persuasive in isolation. In general, I would want to my critical reading approach – that’s better than believing testimonials about wonderful alternative healers😉 But with a book like that, the only way it could possibly work for me is if I had a lot of time for discussing the information there with a medical professional, so that I would not be tempted to throw away all the information there together with the unconvincing parts.

    1. And you’ve hit the problem with ‘info-dumping’ on the button there! It’s so important to be able to discuss your understanding and be able to have a conversation about the meanng of information to you personally than to be given information that might not have relevance to you. I can understand your caution about acute pain examples being quite different from chronic pain – although I do want to reassure you that the same mechanisms do operate in chronic pain when it comes to attention/interpretation/descending inhibitory systems and so on.
      So the mechanisms are apparent from research and case studies, but perhaps were explained using acute pain because they were more familiar to people than chronic pain examples.

      1. Ah! I think what you said finally crystalized in my mind what went wrong with that specific pain management program for me. I think “info-dumping” describes it very well. It was not just the book. In general, I had one-on-one meetings with a physical therapist retrained to do CBT, but what would typically happen, he would start talking about some topic or other, and go on without stopping for anywhere between 5 and 15 minutes, in a way that I could not interrupt. And I would go, mentally “Right, I know that… Right, but I don’t think this applies to me… Oh, yes, this is interesting but I have a question – oops, cannot ask it, there is more talk coming at me… Right, but how do I apply it in my circumstances… Well, I disagree… Oh, I know this again…”. By the time he stopped talking, I felt that there was a whole load of information dumped on me, and I didn’t even know where to begin addressing the whole bunch of disparate issues that came up for me while he was (in his own words) “educating me”. When you said “info-dumping”, I realised that this fits perfectly how I felt.

        Not that it helps me right now, but it’s good for me, personally, to know what worked and what didn’t, and why, because clearly I am still in the process of figuring things out and finding my way to manage my condition.

      2. I should also add, given how negative I sound. I do have a GP and a physical therapist whom I really like. They both share this property that when they talk to me, I feel like I can ask questions as we go along, and I never feel overwhelmed by the amount of irrelevant information. As a result, I also found that I don’t feel nearly as compelled to question everything they say. I still do my research on what they proposed, because I like to stay on top of my health care, but I also feel comfortable saying “OK, I trust you, I will take your advice because my immediate concerns are addressed, and anything else that comes up, I can deal with next time.”

      3. Im glad you do have someone you feel is helpful – and to be informed is what every person should aim for, after all, your body and your experience is the only indication of whether an intervention is having an effect, so you do have some responsibility to know what you’re putting in/doing to/engaging in to your body!
        Sounds to me like your experience of CBT and ‘information dumping’ isn’t quite what a cognitive behavioural approach is intended to be!

  4. Nice article and I completely agree. A communication style for behavioral change I have found helpful is MOTIVATIONAL INTERVIEWING. there are some good books on it including a health care one and also look up courses type in MINT trainers in your browser.

    1. Hi Darrell – thanks for the tip on MI, it’s been one of the more potent strategies for my practice, and I’m so glad I learned about it – so good to see that I’m not alone in finding it helpful!
      cheers
      Bronnie

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