This post is my little attempt to educate clinicians! Some of you will know I really don’t like the term “pain education” or “educating” people. The reason doesn’t go back as far as the original definition of “educate” which is, according to the Online Etymology Dictionary “educate (v.) mid-15c., “bring up (children), to train,” from Latin educatus, past participle of educare “bring up, rear, educate” (source also of Italian educare, Spanish educar, French éduquer), which is a frequentative of or otherwise related to educere “bring out, lead forth,” from ex- “out” (see ex-) + ducere “to lead” (see duke (n.)). Meaning “provide schooling” is first attested 1580s. Related: Educated; educating.”In other words, educate means to “bring out, lead forth”.
Pain education is a buzz word right now. It’s not a new concept, but it certainly has been hitting the consciousness of a whole bunch of people who previously would have thought of pain either in terms of “oh it’s something to do with the tissues” or “if I can’t find the cause, it must be something in the person’s head”. Learning about pain and the neurobiology of pain is an excellent thing, a wonderful first step for clinicians who may have missed out on learning this stuff in undergraduate training, and I’m not disrespectful of the need to know more. What I’m a lot uneasy about is thinking of pain education as a primary means for pain reduction, particularly when it’s carried out as “pain ed” where information is dumped without finesse.
We know that simply giving people information in order to change behaviour does not work unless the person is at the “preparation” stage of making a change. In fact, mass media campaigns about back pain education haven’t been altogether successful despite an early study in Australia showing some really positive gains (Buchbinder, Jolley & Wyatt, 2001; Gross, Deshapnde, Werner, Reneman, Miciak & Buchbinder, 2012). Despite this, there have been numerous studies showing that there are positive gains if people experiencing pain are given good information about pain neurobiology (Louw, Diener, Butler & Puentedura, 2011; Louw, Diener, Butler & Puentedura, 2013; Louw, Puentedura & Mintkin, 2012; Moseley, Nicholas & Hodges, 2004). So… why am I so antsy about pain “education”?
Well, mainly because I think we’re often not trained to do “education” very well. We’re clinicians, we’ve spent years learning about our profession, but on the whole we haven’t been taught to teach – or even, truth to tell, how to help other people change their minds! With the exception of my psychology colleagues, I think most of us learned about what to tell people, rather than how to lead or guide people. And none of us like to be told what to do!
So… how do I go about helping someone think differently about their pain?
The first thing is, I’m not “educating”. The end result of “education” can simply be “Oh goody now I can get on with the real work”, “Yay! I’ve told them what to think, and now if they don’t get it, it’s their problem.” I think if we can change our language we might begin to approach this part of our therapy a little differently. If we aim to help people understand, think differently, reconceptualise or make sense of their experience we can begin to use a whole range of approaches to get to that end result. If we “educate” we might only think about the process of giving information.
How else can we help people think differently about their pain? I think it’s a process of helping people discover for themselves because we know this is a more successful process for learning than if we just give the answers. Think about kids – if we tell a kid how to ride a bike, they probably won’t be very good at riding even though they might know all about centrifugal forces, and inertia, and coordination and how a bike is made. The reason we want to give information is that it might help give a kid more knowledge about what to think about when they’re riding – but it won’t change that they need to hop on the bike to learn to ride it. Similarly, in helping people who are experiencing pain, we want people to be able to do things again – and while knowing more about pain might help reduce the fear from not knowing, but in the end people have to DO something differently to truly enact change.
How do I help someone discover for themselves? I begin by asking what people understand about their pain. I ask them what goes through their mind when they experience pain, what they think is going on and how they feel. I draw a diagram like the one below, and begin to fill in the gaps.
I will ask then what they think is going on – their theory – and add that into the diagram. I might ask what do they think that means for them? What do they think they need to do now? What would it mean if that was true? What would it mean if it wasn’t true? What would it say about them if it wasn’t true? How would they know if it was true?
I might ask about other experiences in the body, other sensations, things the person might not notice – maybe by saying “what do you notice in your shoulders? your breathing? your hands?” and so on. And then what these things mean as well. I’m primarily seeking information on the presence of sympathetic arousal (“stress response”) because this often presents at the same time as people experience pain – pain can be anxiety-provoking, so it’s a common reaction but often not noticed.
I include external factors – like what other people might have said, their response to the person’s experience – like advice, warnings, or even behaviours. When I think of other people I often separate “healthcare professionals”, “family”, and “work”, and sometimes include recent media campaigns that may have influenced how the person interprets his or her pain.
The resultant diagram can look a lot like this – but with the person’s own comments and phrases contained within each circle:
The idea behind listening and completing a diagram like this is to help me as a clinician to really hear what the person has been experiencing. We know all these aspects affect the experience of pain, but so often we go in with our own ideas about the problem, and fail to put together this complex web of interactions that help us answer the two questions:
- Why is this person coming to see me in this way at this time?
- What can be done to reduce both distress and disability?
My intention at the time I work through this diagram isn’t to change anything. It’s simply to listen and reflect what I’ve heard and to assemble that information in a way that makes some sense. It’s only after I’ve done this that I feel OK to begin to consider intervention/treatment priorities. For some people there is no point in trying to change what they believe – anything I say is likely to be countered by all these other things the person is hearing from everyone else. So instead I might begin by exploring movements and how these might be influencing what the person is focusing on. Or I might think about the impact or effect of avoiding things and talk through “what if” pain was less of a problem.
Sometimes I will address the thoughts and beliefs, basing my suggestions on looking at either the evidence that the belief is true – or the effect of that belief on the person’s experience. We might work out some small behavioural tests to see what happens if the person tries something out – maybe trying a movement they’ve avoided, just to see if their memory of how it was is accurate, or as bad as they recall.
When, and only when, the person indicates they want to know more about their pain, or they’ve found that their assumptions about pain don’t work out (because we’ve established some discrepancies between what the person thinks they’ve been told and their own experiences), then I can begin to go down the pain neurobiology education route – but it’s embedded in two important things:
- That they’ve indicated a need and readiness to know more, and
- I’ve already listened and tried to understand where they’re coming from
To my mind, doing anything before these two conditions are met is bound to be met with resistance, and risks being either ignored or rejected.
To summarise: giving information alone is not enough (usually) to help someone change their understanding of their own pain.
Some people don’t need to be given the whole pain education thing – what they want is to be heard and understood.
People learn more by doing, and if we want to help people do more (ie be less disabled and distressed by their pain) then we not only need them to know more, we need to help them DO more.
That means a lot less talking and a lot more doing.
Telling is less helpful than exploring together.
Buchbinder, R., Jolley, D., & Wyatt, M. (2001). 2001 volvo award winner in clinical studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine, 26(23), 2535-2542. doi:dx.doi.org/10.1097/00007632-200112010-00005
Gross, D. P., Deshpande, S., Werner, E. L., Reneman, M. F., Miciak, M. A., & Buchbinder, R. (2012). Fostering change in back pain beliefs and behaviors: When public education is not enough. Spine Journal: Official Journal of the North American Spine Society, 12(11), 979-988.
Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 92(12), 2041-2056. doi:http://dx.doi.org/10.1016/j.apmr.2011.07.198
Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy Theory and Practice, 29(3), 175-194.
Louw, A., Puentedura, E. L., & Mintken, P. (2012). Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiotherapy Theory and Practice, 28(1), 50-62.
Moseley, G., Nicholas, M. K., & Hodges, P. W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi:http://dx.doi.org/10.1097/00002508-200409000-00007