Could health care finally be getting it when it comes to care for people in pain? The recent report that the US Department of Health and Human Services revealed its “National Pain Strategy” would lead us to think, maybe we need to rethink how pain is cared for here in the US. This is not new news as the Institute of Medicine told us this back in 2011 with the “Relieving Pain in America” report. Dr. Patrick Wall reminded us long before those reports: “If we are so good, how come our patients are so bad.” We need to do better in health care when it comes to treating people in pain.
In order for us to do this I think we need to improve our pain competence. Not just our knowledge of pain, but true competence. Sure knowledge of pain neuroscience is an important component. But just teaching neuro anatomy and physiology of pain is about as helpful to treating a person in pain as the anatomy and physiology of the knee is for fully rehabilitating a person with a torn ACL. I liken it too cultural competence which has been defined as: a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations. When it comes to care for those in pain do we have a set of congruent behaviors, attitudes and policies that come together? Or do we go off on our own belief systems and think we have the answers? Do we work effectively with patients in pain? Or do we do what we think “works” and fool ourselves because of self-justification, confirmation bias and cognitive dissonance (Mistakes Were Made (but not by me), is a great read if you don’t think you are victim to your own self-justification and biases).
We look above the surface and think – “I got this, it’s just a little pain to treat.” (We know how well that turned out for the Titanic when it was faced with a little bit of ice in its way.)
I think pain competence can be seen in similar light as cultural competence especially when looking at the cultural competence continuum. The Iceberg Model creates such a great visual for us to see our limitations when it comes to competence, we need to recognize it is a bit deeper and complex than what we see on the surface. We look above the surface and think – “I got this, it’s just a little pain to treat.” (We know how well that turned out for the Titanic when it was faced with a little bit of ice in its way.) The cultural competence continuum gives us a road map to maybe becoming more proficient in our care for the patient in pain. How many clinicians are still working in a fashion that shows signs of pain destructiveness and pain incapacity? Providers still seeing pain in a Cartesian fashion as physical (real pain) or psychological (fake pain). Holding onto untrue beliefs and practices when providing care for those that are in pain. There are those in the pain blindness category. Treating all patients, the same because we see the body purely as a biomechanical structure and all we ever need to do is fix the biomechanical fault (posture, core strength, trigger point, bound fascia, etc.). The challenge with these early levels of the competence continuum is that you have no idea what you are even missing. Some clinicians have moved into pain pre-competence. They have gone to a lecture on pain science maybe read an article and thought it was interesting, but haven’t really changed anything in their practice. A few are deep into trying to understand their patient from a pain perspective and have achieved some level of pain competence with the continual striving toward pain proficiency but this I am afraid is a very small minority.
Cognitive dissonance is so difficult to overcome when you are unaware of it.
So how do you develop your pain competence? First is awareness. This is the hardest for those that are in pain blindness or below phase of the continuum because they are in the pre-contemplative stage of the transtheoretical change model. Cognitive dissonance is so difficult to overcome when you are unaware of it. We have spent years explaining to patients that their back pain is due to their SI joint being out of place and having confirmation bias when we do a muscle energy technique. That technique “fixed” their “pain”, so that must mean that our assumptions were correct that we fixed their SI joint thus fixing their pain. Letting in a counter thought that maybe the SI joint out-flare has nothing to do with their “pain” and the treatment that worked maybe nothing more than some novel movement provided in a safe environment for the brain to not be as fearful and thus produce less pain. Potentially those exercises instead of correcting a biomechanical fault refreshed a homunculus that was a bit smudged. Maybe even a little regression to the mean was part of why they got better or the natural course of recovery from a disorder and our treatment had little or nothing to do with it. But when you’re convinced it is their SI joint and MET puts it back into place and you don’t see a need to change your explanation to the patient because it works (most of the time) you will most likely not change until your awareness changes to how much you might be blind too. After we improve our awareness we can look at our attitude. We need to look at our own beliefs and values. This is not just about caring more for the person in pain and showing empathy, while that is important, it is much deeper. We have to change our behavior, which is a true reflection of our attitude and beliefs. Do we give lip service to our superficial change in attitude and beliefs? Do we say we understand and use pain neuroscience yet revert back to the same biomechanical explanations and treatments because we are convinced they work and cover them up with some artificial neuroscience reason? While third element, knowledge, alone cannot change your attitude it is an important part of the development through the continuum. I am amazed at people that report how they understand pain neuroscience because they went to a course or read a blog post on it once. I teach our pain neuroscience courses and spend hours every weekend trying to teach as much as I can about pain and recognize it is just a tiny fraction of what I know let alone how much more is out there to know. For me personally for the last 10 years I have been trying to understand pain at a deeper level and just like anything as you begin to understand it more you recognize how little, if anything, we really know. The last element is skill development. It is the continual practice and refinement of skills from subjective evaluation, clinical examination tests, patient education, treatment skills, verbal and non-verbal skills, motivation, behavior change techniques and all the things that go into a being an expert clinician.
So where do you think you lie on the pain competency continuum, really? Be honest with yourself, your patients would like you to be honest because they are hurting and so few health care providers can provide them with care that involves pain competency. The good news is the therapy professions may be the most suited to care for those in pain. As Dr. Patrick Wall stated: “Therapy is the sleeping giant in the treatment of pain.” The problem is if your still asleep, you are not very competent.
Okay your turn: – What say you?
Via Kory Zimney, PT, DPT, CSMT, CAFS
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Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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