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I sometimes feel like my brain is a bit like my linen cupboard. It’s a bit small for the amount of linen I have acquired over my lifetime and sometimes when I try and squeeze another towel or three into it, the door doesn’t quite shut and it pops open and something falls out. As I read pain articles and books, listen to podcasts on pain science and education and attend new workshops and conferences on pain and absorb more pearls and nuggets of information, I feel my brain has reached its limit and something has to give- my big worry is what? What has now morphed out of my memory and potentially gone for good?

After attending the AGES Conference 2018 in Brisbane over the weekend, it is definitely face and name matching. You see a face and know it well but can’t quite think of the name quickly enough… embarrassing dilemma. I have said it before and will say it again- we should all wear name tags all the time.

What I am writing tonight is a little prompter for some great listening and some key words that I am going to slip into many future conversations- whether they be with pain patients, when doing talks or maybe even a dinner conversation (I will sound very intellectual in the last scenario).

Therapeutic alliance

Control the controllables

Learned helplessness

‘Therapeutic alliance’ and the fabulous statement  ‘Control the controllables’ come from attending a recent workshop on Pudendal Neuralgia conducted by the wonderful Michelle Lyons, an Irish Women’s and Men’s physiotherapist who conducts workshops around the world (and when in America for the Herman and Wallace Institute).

Therapeutic alliance is so important- for me the first part is engaging with the patient from the get-go, listening to their story, assessing and instituting a management programme and then encouraging adherence to the programme from the patient. It is also important to make the programme interesting for the patient, relevant for their needs and one that is achievable. Therefore any goal setting must include relevant goals from the patient – they must be the patient’s goals not the therapist’s.

‘Control the controllables’ – if only everyone approached their day, their week, their life, with that statement frolicking around in their head – it would make the days more productive and more goals would be achieved. It is particularly relevant for pain management (pain cure – start brainwashing yourself -say it over and over again – we want cure not management! This sets a new conversation in your brain.)

First deal with what you can – reduce your work hours if work is high on the stress producing scale; go to bed early if a lack of sleep is contributing to increasing your pain; eat healthily – we know a good diet is an essential platform on which to build a good outcome; discuss with your partner what he/she can do to assist in achieving any set goals. Once those controllables are locked in, then you may have the opportunity to focus on some of the harder issues that seemed insurmountable when you were working ridiculous hours, sleeping 4-5 hours a night and eating lots of inflammatory foods such as sugars and fast foods with a lower nutritional value.

Learned hopelessness – I heard this in Dr Joe Tatta’s podcast Episode 92 with Dr Tim Salomons on the Pain Neuromatrix and it was such a light bulb moment for me. I totally recommend that you try and listen to this podcast in full and I have directly transcribed (it is pretty much word for word from this podcast if it is in italics) some of the salient points that resonated with me.

When you go from provider to provider trying to get help with a persistent pain problem (or any pelvic floor dysfunction for that matter) and you have numerous investigations, assessments and treatment strategies and nothing seems to work, then you begin to have a belief that nothing can help and you get into this state of learned helplessness/ hopelessness and this affects your motivation (essential to exercise), your affect (your emotion, you feel depressed, sad, hopeless) and your ability to learn (and we have said many times that good pain education is a fundamental part of starting on that road to cure).

There are a series of experiments describing learned helplessness- two groups of animals with exactly the same stresses (such as shocks) but one set of animals has the ability to escape the shocks and one doesn’t- what happens is that even though the animals have exactly the same degree of shocks or stresses, the group that has no way to control their outcome stops trying, they become demotivated they show signs of anxiety and depression and most importantly they fail to learn in the next instance so when you put them in a setting when they can control the stress they don’t bother – they stop trying altogether. 

An example of this is when patients are scheduled for back surgery and they have a lot of hope and expectation about the new surgery (or strategy)- so when it fails they are then skeptical about any other new surgery/treatment strategy and they demonstrate features of learned hopelessness. There is a loss of the link between your actions having any effect on what happens to you- a lot of chronic pain patients have tried many different drugs, many physios, psychologists, GPs pain specialists and they have still have pain. They have tried and tried and tried and they have failed and failed and failed and we wonder they are all depressed- why are they not trying at the next treatment with your suggestions. They have become examples of learned helplessness patients. Essentially they believe that nothing they can do is going to lead to a positive outcome and if they get better it is by blind luck.

This is problematic and so Dr Salomons has been studying this at a brain level and across the brain matrix there is far greater activation (central sensitisation) if they perceive their pain as uncontrollable. The people who do well when their pain is uncontrollable seem to switch strategies. There are two kinds of coping strategies – an action strategy (based on taking away the stressor) and an emotion-focussed strategy one where they concentrate on dealing with the stressor at an emotional level. This is relevant because in life- somethings are controllable and some things are uncontrollable and working out what strategy to choose at which time is why some people cope with tumultuous events and others don’t.  This is the ultimate perceived control

Dr Salomons believes it is essential to try and intervene earlier with pain patients- to break this cycle of protracted times between when the patient is first experiencing the pain and finally discovering someone who can effectively treat and cure this pain. So a key point maybe working out through a good assessment tool (maybe the Pain Catastrophising Outcome Measure) who is potentially at more risk and particularly getting those people in and treating their persistent pain early enough. (An example maybe someone who suffers an injury at the same time as losing a partner or parent or even their job- this is a high risk situation which would benefit from early effective intervention to prevent persistent pain developing.)

He talks about the importance of becoming aware of the emotions in the body and their interplay with a persistent pain condition. If a patient has a degenerative condition and the physiotherapist decides they need to do a specific exercise for 45 minutes every day to help slow the  degenerative process, but if they do that exercise it will do nothing (ie except just prevent the degenerative process) but it could make their pain worse, the patient is unlikely to do the exercise. The patient is learning if I do a whole lot of work, nothing is going to happen- in fact my pain may get worse.  People (and animals -google Pavlov’s dogs) learn by being rewarded and managing their expectations. If there is no reward there is unlikely to be continuation of the exercise.

One of the biggest problems in pain management is poor expectation management- patients scheduled for back surgery- invest a lot of hope in the surgery ” Finally this is going to be cured say with back surgery – more often than not the surgery fails- imagine how that feels-they have poured lots of hope and expectation into this surgery that person is now much worse than they were before because they will no longer believe you – they are skeptical they are no longer buying in to what you are saying. 

So what do I see as the take-home messages?

  • Use psychology to get them to exercise and use exercise to help them with the psychology- it helps them feel good.
  • We therapists many times have created this hopelessness by repeatedly doing things to patients and not empowering them with self-help strategies.
  • Discourage learned helplessness with patients -inspire them with good education, positivity and empower them with the belief that they can in fact change the course they are repeatedly traveling along.
  • Reinstate perceived control- the extent to which patients feel that they have control.

And yes my brain has imploded!