Buying some time
Most people know how hard it is to explain pain to patients especially … well … when they have ongoing pain! The endless touring of different clinicians and specialist clinics in pursuit of a cure is common. Ingrained belief systems mean that hunting for the source of the pain is often a driving force. Explaining pain can be tricky and from time to time can lead to a patient heading for the hills never to be seen again. You can nearly see yourself losing them in slow motion. Anything which makes it easier to explain pain is always welcome. On occasion you may come up with something which resonates with the patient and buys you time so you can gradually introduce new concepts which may challenge/change the patient’s belief systems.
The other day, one happened by chance. A patient and I were chatting. He has ongoing pain. I can never say the word chronic to the patient. It seems like the ultimate nocebo. Did anything good ever get paired with the word chronic? Did you even hear of chronic success or chronic romance or being a chronic winner? No! Seemingly endlessly negative things are paired with the word “chronic” like anxiety, debt or disease. So, ongoing pain it is.
Finding a metaphor
Anyway, over time, this patient’s pain was being triggered by less and less stimulus. Naturally he felt that this meant his disc disease was worsening. As we were chatting, something came to me which was surprisingly useful. I asked him whether he had a burglar alarm at home. Having confirmed he did indeed have an alarm, we spoke about the merits of a good burglar alarm, principally the safety in knowing your valuables are protected and your personal safety is assured. Obviously you want the alarm to go off when you are being burgled … but what if the alarm is so finely tuned that it goes off when it is windy or if there is thunder and lightning or when Man United are beaten ? Then, its a pure nuisance and of no benefit to you.
Explaining that his brain was continuously evaluating the threat level and was a little too sensitive was a surprise to him. Comparing his brain’s current response to the perceived threat level with a too-finely tuned burglar alarm really hit home. Finding ways of reducing the sensitivity of the alarm in a wide variety of ways now seems to make sense to him . Sometimes you get it right. So often you don’t. There is a long way to go but perhaps changing things one patient at a time is not too bad.
Blanaid Coveney is a practicing physiotherapist in Dublin, Ireland. Her professional interests are around epidemiology, pain and all things brain related.
Nice one Blanaid, already stolen it 😎😘
Reblogged this on Neil Wise Physio and commented:
Sometimes some of the simplest explanations are the best. As the late, great Robin McKenzie would often say, just listen to the patient, they will always give the cues! Thanks Blanaid
I have become metaphor man.Funnily I have used the same burglar alarm metaphor myself.I find I get attached to certain ones for a while (currently using the Frankenstein metaphor from ACT literature) and then find new ones.I think this keeps things fresh and the patient will be (subliminally) aware if you keep churning out the same old thing.
What I find interesting and I would like to know if others observe this ,but when a patient really gets the benefit of a metaphor you can see them go a bit absent,staring into the distance,probably whilst they embody the metaphor,before returning to the room with the cognitive change instilled and a look of child who got the racing bike they wanted for christmas!.
“but when a patient really gets the benefit of a metaphor you can see them go a bit absent, staring into the distance..”
Yes. Staring, absence, exaggerated swallowing, slowed voluntary movements, flushed face, waxy features, etc. All signs of mild trance and/or unconscious processing.
“…and a look of child who got the racing bike they wanted for christmas!”.
Nice. The suggestion has been accepted.
Good old Robin had another bit of wisdom that became a critical component of my care whether I was treating a patient with a mechanical nociceptive trigger or a non-nociceptive behavioral trigger for the pain. That bit of wisdom is ” if you can reliably reproduce and abolish the patient’s pain with specific movements that make mechanical sense, they are much more likely to be compliant and successful”. Given the bombardment of danger messages that patients get from the news, advertising, and their providers reinforcing the belief that something terrible is physically happening to their bodies, it would be only be human nature for any patient to find it difficult to conceptualize that their brain, mediated through their beliefs, could be causing the pain in their body. One of the greatest clinical tools that I learned from Robin was to be unafraid of producing a patient’s pain. Once I have completed my evaluation and have clarified or eliminated any mechanical nociceptive triggers, my focus turns to “can I provoke the discomfort in a non-mechanical way”. That is where listening to the patient and picking up their overt and subtle messages can lead you to activities that have the potential to provoke an increase in the level of the discomfort in a way that could not be mechanically based. When I can not find that good behavioral trigger, I find that the mirror, Recognise, and a cash of horrific videos can be tremendously valuable in provoking that pain response in a non mechanical way. Provoking the pain in a non-mechanical nociceptive way can become an extremely important teaching tool that makes the educational program “real” to them. Often we become so focused on relieving pain, that we forget that the process of producing pain can be the key to achieving the patient’s ultimate goal.
Meant to say waxy *flexibility.
Sometimes it can be difficult to know if someone is receptive to suggestion, especially if they are lying face down on the plinth. However we can easily test for suggestibility before delivering our metaphors.
Gently take hold of the client’s wrist and move his arm up and away from the body. Feel for ‘waxiness’, (the limb moves in a soft way where it feels like melted wax). To the degree that the client’s arm stays in the position created, so is he open to your suggestion.
If the client continues to resist falling into a suggestible state, the most effective method is to ‘punish’ him by withdrawing your attention quickly and completely. The degree of withdrawal required will depend on the client and you need to be extremely perceptive and sensitive here. The aim is to get the client to open up to relaxing, not hurt him. The more chronic the client, the more he will resist, so you really need to have this skill otherwise I don’t know how the treatment will work.
From the client’s perspective, it should feel like one moment the therapist is there with you in attendance, fully open… and then the next moment the attention and openness is gone. When you (the therapist) reintroduce attention, make it full-on… and if necessary, withdraw it again. All this can be done rapidly and without the client being consciously aware of what’s going on. Eventually the client gives in and relaxes.
It’s important to know that the harder you have to work to help someone open up, the more vulnerable they become. And you really must speak with great confidence and respect at this point. Every word must be chosen with great care. THEN, make sure you end the session by re-establishing normal consciousness.
‘Punish’ is a harsh sounding word. I couldn’t really find the right word to describe how in some instances, behaviour modification might be necessary. Just a gentle, non-verbal ‘snub’ can be used to help the client move towards an attitude which will ultimately benefit him. It’s subtle.
A much better approach is for the therapist to be so skilled at gaining rapport that the client just naturally falls into an open and trusting frame of mind. But even with that skill, sometimes a little extra is needed.
I wanted to add that as a paediatric chronic pain physio, our team has a variety of metaphors and analogies that we use. There is a wonderful article that was published in 2013 that summarizes a number of metaphors that are used to explain chronic (ongoing! persistent!) pain:
Coakley, Rachael and Schechter, Neil. “Chronic pain is like… The clinical use of analogy and metaphor in the treatment of chronic pain in children”. Pediatric Pain Letter. April 2013. 15:1.
Thanks you Kathleen. Its a really nice paper with lots of useful analogies and metaphors. Highly recommend it.