First, do no harm

All the medics out there will be familiar with the third stanza of the Hippocratic oath: ‘I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone’. The rest of us don’t have such an oath but I think we might need one.

In the last three weeks, I have seen eight people with chronic, disabling and distressing back pain. They were all rather ‘typical’ with regards to radiology reports; the usual lack of evidence of major medical or structural risk; the usual run of failed treatments. They included a middle aged lady on 20 years of disability benefits and a former world champion rower still trying to make a comeback. They were also rather typical in their view that their back was in substantial danger. Usually in such situations my first treatment objective is to help them reconceptualise both their impression of their back and their impression of their pain. As part of this process, I normally try to identify where their current conceptualisation is grounded – are there key chunks of information that might be easily addressed? It is remarkable, although no longer surprising, how often I discover the smoking gun in the hands of a well meaning health professional.

Every one of these eight patients attributed their understanding of their back, at least in part, to information they had been given. This was not about ‘slipped discs’ – I sense we may now have reached the tipping point when it comes to the social unacceptability of that term amongst health professionals. No this was the now more common fare –  ‘You have no core stability; Your this or that is out of alignment and needs realigning; You have an upslip; a downslip; an unresolved problem in some far-flung anatomical location that everyone else has missed; You have no closure on this joint or that; Your this or that is impinging your that or this – or my favourite this week – ‘your top rib is getting stuck’ (although the exact terms used to describe this dysfunction are unutterably catastrophic). I have a rather pendular response to such discoveries – I swing from quiet acceptance of the naivety of the clinician that planted this falsehood and the belief that we all act from our own insecurities and agenda, to marked annoyance and frustration at the harm the clinician has brought upon this person by planting this falsehood; the clinician who has, in my view, radically changed not just the patient’s behaviour, but also some of the fundamentals that drive their biology.

Where do these pathophysiological models come from? Well there is clearly a thriving industry of ‘paradigm products’ – pathophysiological quasi-theories, most of which seem pretty dodgy to me and nearly all of which are untested.  Indeed, many of the inventors of these ‘paradigm products’ appear to have no intent of putting their ideas through any kind of interrogation at all. Instead, the proof of the pudding seems to lie in the profile of their patients, or the loosely related research they borrow to fit their idea. To top it off, our community seems to endorse such paradigm products, by including them in ‘scientific’ meetings and professional magazines. What a responsibility it is to stand at the podium with the ear of well meaning clinicians who, tomorrow, will use the message to give hope to people in trouble. What a responsibility indeed.

Am I being too precious about this? Too harsh? Perhaps. But think of the victims here. The victims are, in my view, those people in pain. People such as the last eight I have seen, terrified, deep in the belly of their nervous system, that they are about to break in two.

So to whom are we in the ‘physical therapies’ accountable for the things we do?  Treatments that don’t work aside of their non-specific effects, are still endorsed, sometimes officially, on the grounds that they are ‘risk and side-effect free’. Really? In my view, my last eight patients were harmed by the treatment they received. They were harmed by the significant contribution their clinician made to their understanding of their problem. For those eight patients, I believe that the clinician triggered a neural process that ended up entrenched in the everyday workings of the patient’s brain. A couple of them became reliant on that clinician or that treatment approach, sometimes  ‘because it was ‘discovered’ (note that the patient never sees these things as ‘invented’) by someone who speaks on it at conferences and teaches it around the world’.  For a few, I think the clinician set them up to never recover at all.

Sure, there are many patients for whom these treatments seem to work. I too have seen and heard the case studies. But what sort of a marketer presents the ‘before and afters’ that suck?

I think it is time for a fundamental shift here. There is no doubt that chronic pain is a serious health issue. There is also no doubt that an individual’s understanding of their problem modulates their pain. I believe we should no longer avoid what our medical colleagues hold sacrosanct – to first and foremost DO NO HARM. We should hold accountable ourselves and our colleagues. We should hold accountable our professional societies in whose magazines some A-grade therapeutic trollop is advertised, and we should hold accountable our conference committees who ‘give the people what they want’ even if what they want is a con – a con that leaves some people waiting for their back to blow, crumble, crush or pop. We can do better and I think we should.

About Lorimer Moseley

Lorimer is Professor of Clinical Neurosciences & Foundation Chair in Physiotherapy at the University of South Australia. He is also Senior Principal Research Fellow at Neuroscience Research Australia and an NHMRC Principal Research Fellow. He has twenty years of clinical experience working with people in pain. After positions at the University of Sydney and The University of Oxford, Lorimer returned to Australia in 2009. He has written 150 articles, written four books and given over 100 keynote lectures in over 30 countries. He has won the most prestigious project prize for Medical and Health Innovation in Australia and the inaugural Clinical Science Prize from the International Association for the Study of Pain. He leads the Body in Mind research group.

Link to Lorimer’s published research hereDownloadable PDFs here.

Comments

  1. Jennifer Gait says:

    I have read the above with interest, though I can’t say that I understood it all. I also just finished listening to Lorimer Mosely’s interview on Smart Drug Smarts, and as I could not find anywhere else to leave a comment, came here.
    In the interview Lorimer said that in order to experience pain, the brain must investigate every piece of evidence, and implied that that evidence was coming to the brain from the nociceptors. But what about the messages in the brain that do not necessarily come from the body – thoughts, beliefs and emotions. Could they not also cause pain that is interpreted as physical pain?
    In the interview, Lorimer mentioned that in the laboratory, pain thresholds tend to be consistent with little variability, and it’s only when you get out into the real world that variability emerges. Why is this? It appears to indicate that there is more than physical nociception affecting the pain levels. Pain being caused, or at least increased, by thoughts, beliefs and emotions, could help account for this finding, since it is unlikely that people would volunteer for pain experiments if they were afraid of pain or were having a difficult time emotionally. Also, it is known that people who were sexually abused as children, and who therefore are carrying a lot of emotional pain, are more likely to have chronic pain. Lorimer hinted that emotions , and beliefs about the self, were likely involved when he said in the interview “if we could convince everyone that they are loved and loving, we could drastically reduce chronic pain.”
    So, I would like to suggest that clinicians talk to their patients about the link between emotions and pain, and that for some people who find it difficult to recognize their emotions, pain may be the expression of an emotion. Mindfulness meditation can help, as can help from a psychologist, either one or one or in a group. Art therapy, with a therapist skilled in working with chronic pain patients, can also help patients connect to their feelings and gradually come to accept parts of themselves they may have cut off.
    I am not a therapist, just a sometime chronic pain sufferer who after two bouts of chronic pain, the last one lasting 8 years, managed to let go of it – helped by therapy. I still sometimes get pain, but I respond completely differently, so it does not bother me.

  2. Nicely put Ralph – we are in a dilemma.
    I am on the side that feels that we cannot ethically be complicit in duplicity. Informed consent underpins treatment. We cannot actively enhance our placebo input without consent. And to get consent we have to explain away most of the ‘magic’.
    So I find myself often in the role of the small boy pointing at the emporer who is wearing nothing at all. I don’t drive as nice a car as the tailors though my conscience feels pretty good.
    Kind thoughts,
    Steve

  3. Ralph Samwell says:

    I’m also struggling with this, I tend to sit on the fence and get splinters up me bum. Do I dance around my pt beating them with feathers because they know it will and has got them out of their perceived pain or do I listen to my scientific brain that refuses to pass on “Bad Science”? I certainly wont stop giving my two year old magic kisses for her scraps. It seems humans can only cope with a certain amount of reality and I therefore side with Prof John Gray and that “progress is a myth but a life without myth, is a myth in its self”, miracles and mysteries. But I keep the dream alive whether I know not yet its truth or not. I suspect things are changing but it seems reasonable that it should be at the pace of natural evolution. I believe in you guys because I have seen the improved changes in my perception and approach that to, in no small part belongs to BiM.
    I see David Quinter as Quality over quantity.
    By the way, if you’ve not read What do you care what other people think? By R. Feynman, I’d highly recommend it. It’s a causal entropic universe, and that’s the truth.
    How can we restore confidence that pain science is science? We don’t have too because for me the fundamental difference between the two principles are, gurus make it about themselves whereas we are making it about the savvy pt perceptions. Pt are only temporarily happy with mystery as long as the miracle happens, eventually the happiness will fade (fad) and they will want to know how it happened and demystify it, there wouldn’t be any science if they didn’t. We are all curious as to how the magician did that trick and what to know. The answer is simple, show how the guru did his trick and it’s not about working with energy.
    Stating, “people are not rational” is an irrational statement, if people aren’t rational, then that statement also can’t be rational as it came from a person. Truth is, people are both rational and irrational and pts err on the side of whatever is currently happening and it’s our job to guide them through this.
    They want to ‘give their back’ to someone with authority, someone looking intelligent (possibly a mix between a priest and a doctor) , self-confident, able to communicate insane theories without moving a eyelid using the tone of a family man, someone to worship and with conference certificates hung on every wall………… because the pt defines that as the truth, the qualified expert truth and they are usually happy to hand over their fate. What other choice do they have?

  4. Thought so – I’m a matador who lost his driving licence, work in an abatoir now (but am actually qualified).

    EG Reply:

    That’s an old fashioned attitude deano. I graduated dux of 100 students in both 3rd and 4th year in Physiotherapy, in both practical and theory subjects. And it did me not one scrap of good in the clinic, because I was taught some old fashioned model focussed on tissue damage. I was foolish to entrust a university with my education. Nowadays I educate myself and do my own (clinical) research if I want to know something. Open a book, read some research and see what you can learn.

    EG.

  5. Hi Lorimer.
    I love your blog.
    I note even cheery old you sounds a little frustrated.
    I recall having a minor discussion along these lines at NOI conference in Melbourne this year. I asked a similar question and you said we should have a discussion over ? cab sav about it. Name your time.
    More thoughts for you:
    My concept of interest in relation to EP is that of ‘Nocebo, placebo and how placebo transforms into nocebo …”
    Hopefully I have your interest.

    Nocebo = easy and is simply what you describe above with scary misinformation and speculation provided under the particularly problematic guise of (drum roll ….) – EXPERT OPINION !!!!! Even the courts accept this rubbish.

    Placebo: wow is this interesting – measuring neurotransmitter changes and similar after a ”sugar tablet’ – very cool (and explained by EP).
    Marketing people manipulate this well.

    Placebo = Nocebo: this is esoteric so bear with me.
    Most, if not all, msk / orth interventions trials are based on the concept of comparison different treatments. Then, interventionists start touting the treatment (often very early even before these poorly structured trials are in; ? financial influence or are we really always just wanting to help people ??). These snake oil, oops placebo treatments then reinforce the entrenched mentality in treaters and patients alike that the problem is (another drum roll please …) STRUCTURAL !!!! The rest is repeated history.
    Pretty much all of msk treatment trials can be viewed from the perspective of comparison of crap placebo with good placebo, with very good placebo with excellent placebo (surgery).
    Interestingly most trials just satisfy statistical requirements (the magic “70%” success rate). I was particularly bored at a conference one year hearing this repeated statistic from various treatment studies and it suddenly dawned on me that all were almost identical. Go figure. Coincidence? I think not.
    Recent trials on vertebroplasty, arthroscopy prove my point.
    Patients then go from practitioner to practitioner seeking different treatments and when it works, the practitioner and the patient become even more entrenched in this paradigm which is epidemiologically bankrupt (NB: past decades of increased sophistication, treatments, technology etc…. coincide uneasily with significant increase in chronic pain).
    This is all good for the patients who obtain the placebo response at whatever stage (probably because they are simply subconsciously ‘ready’ to get better), but not so good for the ever increasing ones that don’t, and particularly bad when a placebo treatment / surgery results in a complication, OR continued similar treatment without pain understanding focus results in another problem eg: opiate addiction etc… (have you ever noticed how the very clever pain management ‘experts’ (not all) keep upping the doses when patients are non-responsive. Some end up on doses fit for elephants or small towns).

    Hence placebo in msk treatment –> nocebo QED.

    PS: I am particularly bitter and twisted this week as a worker I did a review on > 1year ago and attempted to coerce her ‘expert’ treaters regarding the necessity of cessation opiates just died at 36 years old. She was still on ridiculous doses of opiates and getting repeated aspiration pneumonia episodes; eventually died in her sleep. Phx included back injury and surgery after a relatively minor workplace injury etc, etc, ETC …

    Thanks, I feel better now.

  6. John Quintner says:

    Readers of this discussion need to know that the innovative and successful programmes developed by Stephanie Davies and her team in the Pain Medicine unit at Fremantle Hospital will cease to exist at the end of the year when the new Fiona Stanley Hospital hits its straps. Half of the unit were offered positions at the new hospital but this did not include the administrative staff, without which the programmes cannot be run. Dr Davies and some of her colleagues have resigned in protest. This is a tragedy of major proportions for Pain Medicine in our State. A valuable community service will be lost, as well as an accredited pain medicine unit. Yes, harm can also be done by bureaucrats whose actions are beyond our control.

  7. Wow!!! This seems to be an impassioned plea to our profession
    Fortunate that we have you Lorimer but your story is our experience and we are not “professors” so the ability to help people accept the paradigm is ever a challenge!

  8. Idealogically I would challenge beliefs every time they are wrong. When I know the evidence and trust it I will say so.
    But it always depends on the patient – if they are sandstone then they are just going to blunt my chisels and I am wasting our time to try and effect change so I will often fall back to a CBT skills based approach of ‘sound advice’. However if they are flexible in their outlook on life and willing to allow me to change their mind and if by doing so they will live well with their experience of their body then I will have a discussion with them about how manual therapy is unlikely to be the answer and why.
    I stood up at a ‘Back Care’ night with a local charity and went through the Cochrane evidence base for treatments with them. It needs to be done. Some had the wind taken from their sails but most nodded sagely and had their determination to take control of their own lifes re-affirmed.
    Kind thoughts,
    Steve

  9. john Quintner says:

    Thanks Mark, I do recall the impact that listening to Murray Banks had upon me. Yes, the messages still ring true today. In his words, we can at least help our patients to “learn how to live” again. I do not see this as an exercise in psychoanalysis, which has largely fallen out of fashion, or so I am told. How about offering them a coherent and understandable explanation of their biological predicament? This act, which I admit is easier said than done, would validate their narrative and provide them with the chance of making better sense of their lives in pain.

    EG Reply:

    How does your pain education validate the client’s narrative?

    example:

    client: my lumbar joints have advanced wear and tear
    doctor: yes but…

    Where’s the validation of the wear and tear? Where and how do you do this? Or is the aim to replace and invalidate the client’s experience?

    EG

    john Quintner Reply:

    Generally people feel validated when they are listened to and when their own explanations are taken seriously. The explanation may be open to discussion and negotiation, whereas the person’s lived experience must not be challenged by the clinician.

    Soula Reply:

    Bingo!

    Mark Quittner Reply:

    Hello John,
    Agreed, I try to educate without the use of terms that may create guilt or validate fear responses in patients. It is true that my ‘truth’ may not be the patients ‘truth’, possibly causing a loss of trust within the interaction.
    I am sure we have all experienced a situation where we have provided our best considered explanation to a patient, walking on egg shells to maintain our integrity and beliefs, thinking we have achieved this outcome given the patient feedback at the time, only to hear the patient using the very same ingrained language / beliefs at the next session with us.
    Do we then persist, give-up or moderate our views hoping to eventually influence the patient. Does it matter either way, especially if the patient’s health is improving?
    A whole new kettle of fish is involved to answer that question – are we being self delusional that improvement occurs because of our intervention or in spite of it? Cause and effect argument.
    Ultimately, we really do not know.
    An educated guess SHOULD be better than an uneducated guess, however even this statement is fraught.
    MrPhysio+

    EG Reply:

    Let’s keep this discussion going, because I don’t think it exists elsewhere online.

    If a client arrives and says “my chiro says I have a twisted pelvis and it probably needs life long treatment”… is there a deep visceral reaction in the you as his therapist/doctor? Judging by the responses on this thread, I’d say anger or hatred would be fairly common, directed either at the chiro or the client or both. Who can admit to feeling angry when they hear this sort of statement?

    Now the crucial question – if I feel anger as the therapist, what do I do with this?

    If I hide it, then I’m not congruent. If I’m not congruent, then there will be no trust. Without trust and rapport, the client will not integrate anything I say regarding pain education. Game over. Ineffective treatment.

    If on the other hand I express my anger, I will at least be congruent, but depending on the strength of the emotion, this will frighten the client and he will close off. Game over. Ineffective treatment.

    So the anger simply cannot be there if we’re to be effective with pain education. Consider this if your explain pain sessions ever fail. Nowadays, I rarely feel angry about other clinicians saying things like “twisted pelvis requiring life long treatment”, but I’m not sure how I got here. I know I used to get very angry, and I remember how that would destroy any ability I had to win the client over.

    Maybe I just gave up and accepted that other clinicians are pretty uneducated on average, and just accepted them as they are. I was once where they are. Not only that, but there will be people who look at what I write here and say the same about me – “I used to be like that”!

    EG

    John Quintner Reply:

    It is well to remember that the patient may also be angry for any number of valid reasons. A meaningful engagement in the “third space” allows for both parties to acknowledge their feelings and work through them together. How to set up such an encounter within our “production line” health-care system remains a formidable challenge.

  10. Our discussions sometimes become very serious and introspective. To lighten the mood but hopefully stay on topic I have included a blast from the past.

    The following links are to old recordings of Dr Murray Banks Psychologist comedian from the 1950’s. Simple observations of life, some relevant to our understanding of human behaviour commented upon in our posts. There are many other recording links available.

    In one recording, Dr Banks speaks about nervous breakdowns, going on to explain that no nerve has ever been shown to break down when a nervous breakdown occurs. The person has simply chosen a course of behaviour as a coping mechanism. Is chronic pain a similar choice? – not necessarily conscious decisions.

    I find the thought processes expressed by Dr Banks of interest, both in content and in expression – especially given the 60 year year gap to todays world.

    Part 1 https://www.youtube.com/watch?v=eSD1gBdMksc

    Part 2 https://www.youtube.com/watch?v=OCD_fodHvyc 4.07 minute

    https://www.youtube.com/watch?v=C5P3TG6mIs8 8.20 minute

    http://en.wikipedia.org/wiki/Murray_Banks

    Enjoy
    Mark Quittner MrPhysio+ Healesville

  11. John Barbis says:

    I applaud the energy of all those seeking a different paradigm for the treatment of pain. I have been on that path for a long time. I have started in Maitland, became quite good at Mechanical Diagnosis and Therapy, integrated David B’s concepts of neuromobility and neuropathic nociception management into that system, and came to appreciate the behavioral importance in making components of CBT and Mindfulness training important elements of my care when needed. I have made Pain education and GMI an integral component of my care in one form or another for the past 6 years. I have found it to be extremely valuable but also found that it isn’t the “answer”. In my practice which deals with some of the most difficult pain patients in the Philadelphia area, I have found “the Pain-Brain Stuff” to be extremely helpful in some patients who did not respond to interventions for mechanical or neuropathic nociceptive generators of the pain. I also found it to be of moderate to limited help in most patients with what appear to be pain from the more profound structural changes within the central nervous system (severe CRPS, RSD’s, cord type syndromes). I have to my astonishment found it to be dangerous in some patients with significant psychological co –morbidities. I have had multiple-personality patients decompensate. I have had two patients with suicidal histories redevelop suicidal ideations. I have had patients with anxiety disorders and depression regress in both of their conditions. I had to stop the program in all of the cases. As a very wise psychiatrist with whom I work said, “When you open or work in someone’s brain, you never know what you will uncover or will come out”. Sometimes pain is a safety behavior that controls much more significant pathology below it. I do not propose these as common problems that are to be expected. I just state these examples of potential warning labels that should go with this health care intervention. It is in the spirit of “Do No Harm” that we need to be aware of potential harm from those things that we do not see as dangerous. Sometimes seemingly safe techniques in different environments surprise us.
    In addition I ask all of us to apply the same critical eye to the literature that both supports and does not support these concepts. We need to apply as critical an eye to those things we believe in as we apply to other techniques we degrade or in some cases almost slander. Given the volume and quality of the literature on GMI and Pain Education, do we have solid legs on which to stand? I ask you to apply the criteria in the article on BIM Facebook’s page to the research supporting your beliefs: http://theconversation.com/the-10-stuff-ups-we-all-make-when-interpreting-research-30816
    I do not think that the literature is worse than some (except the more robust literature looking at the use of Pacing, CBI, PGAP, and Mindfulness training in the management of pain which have been in process for longer periods of time) but it is also no better than a lot of it. We owe it to our patients that we not be cheerleaders for specific interventions but clear-eyed, practioners who try to weigh evidence as best as we can and dispassionately recommend what appears to be the most appropriate interventions for them. I have not found nor have I seen evidence for a grouping of defined clinical signs and symptoms that would be indicative of high probability for a successful outcome for the application of GMI or pain education. I have not seen the number of RCT’s necessary to say that these techniques have a high probability of producing both robust statistical significant and clinically relevant improvements. The evidence is not there to inform my patients about the probability of their having a good outcome from my use of this type of treatment. I do not mean to be harsh here and will I use the GMI/Pain education concepts with the patient I will see in an hour? Absolutely. I make that decision not because of any allegiance, but because from my evaluation I have made a clinical judgment that it will help in his management. He will gain from that knowledge and given his psychometric testing has no potential warning signs.

    Kieran Reply:

    a thoughtful and reasonable post John. and definitely worth reminding us that we need to be as critical of all interventions.
    Just 2 thoughts;
    1. haven’t heard too many describe the harms you describe with GMI, though am open to that happening with any cognitive intervention.
    2. i wouldn’t say the evidence for thiings like pacing, mindfulness or PGAP is all the super-impressive either – for example, i really like elements of the PGAP approach but (i) i haven’t seen an RCT using the approach published yet and (ii) the “helpful hints” section of PGAP booklet are about as biomedical as it gets when it comes to LBP. equally, pacing looks better than rest, but as a mass intervention for chronic pain, i am a little underwhelmed by the strength of the evidence too. but to go back to the topic of this post, none of them gave been linked to much harm (though patients regularly explain pacing as “don’t overdo it”)

    ad any scary situation like you describe

  12. Hi EG- I have to disagree with your comments “truths” suitable to the patient. If we don’t know the facts-accept it – move on. What is point in sugarcoating something and potentially misleading some one? . I think as clinicians we have an overriding moral responsibility to our patients- no matter whether if it is a free treatment or paid treatment and no matter how the unpleasant the ‘truth’ is. If i ever become a patient – i want my clinician to tell the ‘full story’ the whole thing- not the edited version and I as an individual takes the decision. I am afraid not many people are the whole story!!
    P.S. all of the above depends on the intellect and the personality of the person who is sitting in front of you.

    EG Reply:

    Hi Naveen,

    If you think I am misleading clients, I want to know how you think that happens – specifically, with examples.

    Can you give me an example of an ‘unpleasant truth’ that you would feel morally obliged to convey to a client?

    Can you give an example of how you think I might ‘sugar-coat’ something that I would present to a client?

    You say if you became a patient you would want to know the whole story and then make a decision. What would be an example of ‘the whole story’? What decision is it that you are making?

    EG

  13. As a patient who’s been through it almost 8 years now, and being someone who’s work was to communicate creatively, who’s been able to advocate a patient’s perspective and ultimately who has been able to make progress and leave the full’time ‘chronic pain’ state behind I think the patient needs to be given a little more of the part in this show. If a patient doesn’t understand or is ever told they actually have a huge role to play in their journey, neither practitioner or patient will see results in chronic issues. Well that’s what I believe and that’s the pain management program I’m working on at the moment with my fab WA team (AKA JQ and Mel Galbraith). As with anything in life, if you don’t involve the consumer you very rarely get anywhere. They are just as much a part of a solution as is the research, diagnosis and treatment.
    Well that’s my experience and view anyway.

    KW Reply:

    It’s interesting though to see the reaction of patients when you try to explain to them the reason they have pain. It is totally foreign to their preconceived notions/biases/misinformation fed to them by health care providers, media, friends, family in the past. Many folks I see already “know” whats wrong with them and “know” what they need and want. For example, If they want a narcotic pain pill (which most do) and you say that there is no evidence that there is any long term benefit from that treatment and in fact there is harm, they get disappointed and angry. I have had a few storm out of the office saying “I thought this was pain management.” I have had folks walk into my office for an “opinion” only to be upset when that opinion (based on up to date evidence and neuroscience) doesn’t jive with their beliefs however wrong they are. The job in chronic pain management now appears to be the act of “persuasion”….changing peoples opinion about firmly entrenched beliefs and biases…firmly rooted neurotags. How do we change the chronic pain habit/addiction/neurotag? It’s like trying to change a persons view on politics or religion. But of course we should First Do No Harm, whether a patient likes it or not.

    dianna howell Reply:

    I agree 100%.

    Soula Reply:

    KW if you all stand united in that consult process then you’ll be contributing to the change of perception of pain which as we all know is out of date now. You are in the position to educate and there’s only one way to do it. A patient being upset is them expressing their frustration when no easy fix is offered to them. Ultimately that’s what we all want with any problem in life, espcecially a health one. You’re in a tough position but it’s not until patients understand their issue is a long term, invisible one and that they need to do most of the work, they will huff and puff. I guess you need the right resources to back you up and obviously this is a brilliant one. No one wants to go to a practitioner who’s not learning. We all know now that ends up in drug dependence… you must share your education with the patient. And the patient needs to be handed their task, ‘they need to better themselves’. Harsh but there’s no easy way through chronic pain.

  14. John Quintner says:

    All I can tell you is that my approach has changed radically over the last 5 years and the patients who attend our STEPS programme do “get it”.

  15. John Quintner says:

    @ John Ware. It occurs to me that by replacing what we consider to be a patients “erroneous” beliefs with our own, we are assuming that the latter will stand the test of time. Do you see this as potentially problematic?

    EG Reply:

    Hi John Q,

    I know you’re question is to John W, but I’ve been thinking a lot about this aspect too. Overall I think it’s quite ok if done the right way.

    Erickson (Milton) was an extremely manipulative guy. He’d spend hours devising very tricky scripts and ways to talking to clients. And yet he was extremely effective, extremely helpful to them. He could turn a client’s mind around 180 degrees with ease it seems, and that was all for the good. But he always had very strong rapport as a first and essential step. Without that, none of it would have worked. Bandler and co. have confirmed this.

    Rogers on the other hand was so incredibly respectful of the client that he was almost totally non-directive. He felt that if he offered suggestions that this was a denial of the client’s own in-built abilities. When you see some of his old videos, you can see the look of love in his client’s eyes and it’s just wonderful that he can do this. But it’s possible in my view that he *may* have been able to speed up the process significantly had he perhaps been slightly more directive at times. Those times would be when deep rapport has been established, not before.

    The common link is rapport; both were experts at achieving this.

    EG

    EG Reply:

    your*

    John Ware Reply:

    John Q. says: “It occurs to me that by replacing what we consider to be a patients “erroneous” beliefs with our own, we are assuming that the latter will stand the test of time. Do you see this as potentially problematic?”

    I’m sorry I missed this from a couple of weeks ago. For some reason I’m not getting comment feeds consistently from this thread.

    To answer your question, I think there are “less wrong” explanations available to us that we should be using, as a colleague recently described it, to “alter the trajectory” of a patient with a pain problem. For instance, would you agree that getting a patients to believe that their myofascial trigger point doesn’t exist in their muscle but is probably a sensitized cutaneous peripheral nerve?

    I’ve always considered pain neurophysiology education a method of shifting focus from discrete peripheral connective tissue “dysfunction” to a more defensible, and perhaps holistic, focus on the signaling tissue. Any way we can get patients to improve their understanding of the why and how of their pain, the better as far as I’m concerned.

  16. Hi Loz
    A brave post thank you – we need more of them from leaders like yourself – to help change the current narrative and practice around pain. It strikes me from reading many of the replies that what we often lack as clinicians is a confident and convincing alternative narrative for our patients – that makes sense to us and them. We need more effective skills and strategies to empower people in pain to better cope and manage pain their lives. Maybe only then can we do away with simplistic defaults like ‘your rib is out’ and ‘let me put it back in for you’. Maybe as clinicians we also need to control our ego’s too – by not being the ‘master clinician’ trying to ‘fix’ the problem – but to walk on a journey with our clients and help empower them with the tools to manage their pain for themselves. Not a great ‘return’ business model – but a great ‘new’ business model. We all have a huge challenge to help stop this train wreck of disabling pain further evolving – where the health care system itself acts as the engine driving the carnage.

  17. John Ware, PT says:

    Who said anything about questionnaires? The methods that I’ve learned to explain pain don’t rely on questionnaires, and they seem to fall in line with what you describe as “Rogerian” and “Ericksonian” approaches. The patient’s beliefs about the role of degenerating discs is validated. The case in point is a nurse with biomedical training. She has likely been hearing half-truths and inaccuracies about degenerative discs for decades. It would be stupid to attempt to directly challenge those beliefs. By focusing on the signalling system of the body, and using story and metaphor to impart the message of pain being a perception, like vision, or a need state like hunger and thirst, you begin to gently shift the patient away from erroneous beliefs about the role of pathoanatomy and towards a more accurate understanding of why they hurt.

    I’ve never spent a cent on learning the principles of motivation interviewing, unless you include the small amount I spent on Louis Giffords’ Topical Issues in Pain series. Steve Goldingay wrote eloquently about how to apply these principles in TiP-5. It’s not rocket science, it’s just sound concepts about how to communicate effectively in the role as a therapist.

    Perhaps the reason you’re hearing PTs mis-apply this information is because they’ve had such little exposure to effective communication skills in PT school. There’s that and the all of the cognitive dissonance that they have to overcome in order to unlearn all the nonsensical biomechanical assessments they were taught.

  18. “The careless word does more harm than the careless scalpel”

    We rage on the margins of our professions about the fraudulent toss that passes itself off as EBM and is practiced as therapy in our name as PTs. We are defeated in our endeavours by the empirical fact that it takes an order of magnitude more effort to disprove bullshit than to invent it. And there seems less of us than them that are dipping their snouts into the trough of human misery. Dipping into it and making it deeper, wider more pervasive. Perpetuating the memes of misery. The bastards!

    How do we change this? Go public and they will get all legal on our asses and we have to get the science to beyond reasonable doubt in a court of law or face financial destruction and even if we win we have to sacrifice years of our lives doing it.

    Me, I think there will be a tipping point. Something will happen and we will be called to account for our practices. There will be those that can demonstrate that they did no harm – in body or mind – and those that did in their ignorance and those that did with their exploitation.

    A private PT on the High Street in my town advertises that they can sort out 96% of back pain. He does not say that 97% of it sorts itself out whether he does anything or not. First against the wall when the revolution comes.

    Lets get angry about this. Lets make some noise. Lets not go quiet into that dark night!
    Kind thoughts,
    Steve

  19. Ronald Kan says:

    Thank you Lorimer for paying attention to this nocebo driven sickening behavior of health professionals. Working in an outpatient center for rehabilitation of patients with chronic pain, it is our everyday work to redeem patients with chronic pain from these detrimental beliefs about the integrity and vulnerability of their moving body. Last month we published an article of equivalent scope in the Dutch journal for Phyisical Therapy.
    Thanks again!
    Ronald.

  20. A really interesting read – I have come across this several times with patients. We may have moved forwards from ‘crumbling spine’ and ‘glass back’ but I assure you there are still some medical professionals who use similar phrases! I think the latest one I heard was ‘my GP told me I had the spine of an eighty year old’. The patients was 31!

  21. Kory Zimney, PT says:

    Thanks Lorimer for a frank, yet well deserved, wake up call to all of us attempting to provide care for those in pain.

    I look at my past efforts (and probably some of my current efforts) and realize that Voltaire was speaking to me. “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”

    With that in mind I have tried to change my practice keeping this Voltaire thought in mind: “The art of medicine consists of amusing the patient while nature cures the disease.” My amusement techniques have changed from talking about rib thingies, slipped discs, weak cores, stuck fascia, and many other silly things to trying to enter into the third space as Dr. Quinter and his colleagues have referred to in their 2008 article with the use of our current understanding of pain and treatments that are congruent.

  22. Thanks for sparking up an interesting debate lorimer. I appreciate the fact that you are actually treating these tricky chronic pain conditions and hve a clinicians perspective and not just a researchers. I do find BiM is strong on telling us clinicians what’s not working but there does not seem to be strong evidence telling us why to do with the patients you encountered above . Or is there ?

    ste5e Reply:

    There is plenty to do.

    Prove that the majority of pain is not related to damage. Identify thoughts and beliefs which are part of the patients pain history – that undermine at every twist and bend – accept that they are there and we cannot shift them but teach mindfulness to be aware of them, defusion techniques to not let them intrude as much, offer truth and balance and offer alternative healthful, helpful concepts (does not help so much), prove pain is not damage and use that experience of the patient to challenge their other assumptions, grade up their activities back to CV engagement, retrain their rescue dog, get them back into their life, guided by their values, now. If at all possible hands off so the patient is sure that they are doing all the good stuff themselves and we can take no credit for them getting themselves sorted.

    Therapeutic neuroscience, ACT and graded exposure. Delivered with hutzpah to maximise any descending help we can get. As part of an integrated team of PT, OT, psych and medic.

    If they engage we do well but we cannot catch them all when the purveyors of lies and honeyed words drip poison in their ears from all around.
    Kind thoughts,
    Steve

  23. Superb piece – again! Thought provoking as ever.

    We often spend much time debating the many technical aspects of pain which are not fully understood (e.g. what are the specific mechanisms through which a specific treatment or patient interaction helps). However our patients are held back from recovery by a lack of much more basic knowledge such as you have described – their body structures (bones, ligs, discs….) are not utterly disfigured/deformed/damaged/misaligned etc…..

    I have no doubt that some of this junk information is provided in a manner that suits the privatised nature of much modern healthcare. However, some of it is provided with the best of intentions by a very nice, well intentioned therapist! I have heard Peter O’Sullivan say that if a patient is being told their body is basically damaged/ruined, they would be better off to hear this from a person with a poor interpersonal manner with patients, as the patient may ignore them!

    and some of this harm will have been provided by all of us at different times – even without realising we were harming people – how many of us actually ask patients what they think we have said about their condition, or ask whether they feel their situation is more or less dangerous than they thought before the examination? Words I sued to think were benign include “wear and tear” and “chronic” which we now realise can be interpreted as dangerous by many patients

    Yes, there is an element of preaching to the choir about excellent sites such as BiM. And I agree there is little evidence that these discussions in themselves will change healthcare. But this could also motivate people/groups to work together.

    It is for this reason that public health campaigns are needed – as unfortunately the middle man (or woman) (i.e. treating therapist) can “interpret” a patient’s presentation in a wide variety of ways. As you touched on, the “disc out” story is getting a little bit less air time more. But there is always a new “pathology” or deformity in town – problematic ribs and feet as the source of LBP are all the rage at the moment. As you point out in your reply, the cost of public health campaigns can be prohibitive, and the payback could be slow to achieve. However, I see very few alternatives which could make a real dent in public/societal/healthcare beliefs. now getting someone to pay for those kind of campaigns……..thats another matter

  24. thanks for the great post lorimer. here’s a cartoon i penned recently on the topic https://www.facebook.com/806281386060487/photos/a.824678490887443.1073741828.806281386060487/825524694136156/?type=1

  25. touche L,
    Loeser described iatrogenic risk decades ago.
    J

  26. This is a great discussion! As a teacher of Alexander technique I believe there are plenty of simple and effective behavioural, educational and neuroplastic approaches to working with a person in pain.
    The starting point is working with the whole person and not on a part of a person. Yes, in most cases pain is a response.

  27. Zara Hansen says:

    I seem to have clicked on the wrong reply, my comment was meant for the mini debate earlier between John and EG. Sorry, seems out of context after all the other thoughtful reflections!

  28. Zara Hansen says:

    Good debate John and EG, hope you don’t mind if I jump in. I am happy to give confident, assuring messages on the things I can be really confident about: ‘based on x, y, and z, I think it is highly unlikely that there is anything going on in your back that we need to worry about’ etc. However, if we are getting into the realms of reassurance, I.e repeatedly having to say the same things, then we could be part of the problem. Using a Cognitive behavioural model of health anxiety (See Salkovskis) then reassurance is conceptualised as a safety seeking behaviour and actually can maintain the anxiety or fear. The person with the anxious belief about their back, such as ‘my back is crumbling’ needs help to work out that this is unlikely, although not impossible. And that living their life according to unlikely outcomes has downsides. I suppose it comes down to: can we be certain about anything.

    EG Reply:

    Hi Zara,

    I like your comments.

    I use a Rogerian approach with some Ericksonian elements. In the first part of the treatment, I am attempting to see and feel the client’s inner world as accurately and intimately as possible. So if a client is telling me “my back is crumbling”, my immediate response is not one of negation. I don’t say “no, your back is fine”. That would be harmful because it is a denial of his experience. His experience is vitally important to him.

    Instead I would imagine what he is feeling in regards to the statement “my back is crumbling”. Once his view has been fully validated and understood, then I have rapport. Now the second part of the treatment is the Ericksonian stuff. I utilize his words and expressions and subtly turn them around. ‘Crumbling’ becomes ‘strong and solid’ for example.

    This is a highly abbreviated version. But I agree with you – there’s no point denying or contradicting a client’s world view off the bat. This has not been integrated into the Explain Pain work, and yet it is crucially important. I see and hear physios launching into pain education which totally upsets the clients understandings, and it’s disastrous. No effect.

    EG

    John Ware, PT Reply:

    EG says: “there’s no point denying or contradicting a client’s world view off the bat. This has not been integrated into the Explain Pain work, and yet it is crucially important. I see and hear physios launching into pain education which totally upsets the clients understandings, and it’s disastrous. No effect.”
    I disagree that the Explain Pain approach that is presented in the literature fails to incorporate what has broadly been referred to as “motivational interviewing” techniques. Although, I have no doubt that this has been dumbed down by some isolated purveyors of “pain science education”.

    An excellent example is the case report by Louw et al (2011). The authors don’t directly confront the patient’s beliefs regarding the presence of “bulging discs” and “degenerative disc disease”; rather, they provide a positive message through the use of metaphor and detailed neuroscience concepts followed by asking the patient to reflect back her understanding of the information. They also make a point of avoiding using the term “pain” when instructing the patient to move during the examination. The instructions are to “bend forward while keeping your knees straight and to stop whenever you feel like you need to stop.” And then the patient is asked to elaborate further on why her movement was limited. This method of communicating is not only compassionate, but demonstrates the importance of acknowledging the over-riding influence of psychosocial factors- in this case anxiety about movement- in patients’ pain experience.

    I don’t know any therapists who have a firm understanding of providing therapeutic neuroscience education who will routinely “launch in” to this by challenging firmly held attitudes and beliefs. In my view, that’s not consistent at all with this approach.

    EG Reply:

    “The authors don’t directly confront the patient’s beliefs regarding the presence of “bulging discs” and “degenerative disc disease”; rather, they provide a positive message through the use of metaphor and detailed neuroscience concepts followed by asking the patient to reflect back her understanding of the information”.

    And where is the deep understanding of the patient’s own internal representations of the pain *as it is right now, with all its faults and errors*? There is none. Questionnaires don’t achieve this depth of understanding – they don’t even come close.

    Motivational interviewing is just one man’s attempt to repackage and re-brand Rogers’ work, then re-sell it for a profit. I don’t like that. It’s fine, but there is much better available from the originator.

    EG.

    John Ware, PT Reply:

    [I clicked on the wrong “reply” link the first time, so I’m going to copy and paste my response to EG in the appropriate sub-thread. Perhaps someone can delete the copy at the bottom of the thread.]

    Who said anything about questionnaires? The methods that I’ve learned to explain pain don’t rely on questionnaires, and they seem to fall in line with what you describe as “Rogerian” and “Ericksonian” approaches. The patient’s beliefs about the role of degenerating discs are validated. The case in point is a nurse with biomedical training. She has likely been hearing half-truths and inaccuracies about degenerative discs for decades. It would be stupid to attempt to directly challenge those beliefs. By focusing on the signalling system of the body (nervous system physiology), and using story and metaphor to impart the message of pain being a perception, like vision, or a need state like hunger and thirst, you begin to gently shift the patient away from erroneous beliefs about the role of pathoanatomy and towards a more accurate understanding of why they hurt.

    I’ve never spent a cent on learning the principles of motivational interviewing, unless you include the small amount I spent on Louis Giffords’ Topical Issues in Pain series. In TiP-5, Steve Goldingay wrote eloquently about how to apply these principles. It’s not rocket science, it’s just sound concepts about how to communicate effectively in the role as a therapist with a patient suffering a persistent pain problem.

    Perhaps the reason you’re hearing PTs mis-apply this information is because they’ve had such little exposure to effective communication skills in PT school. There’s that and all of the cognitive dissonance that they have to overcome in order to unlearn all the nonsensical biomechanical assessments they were taught.

  29. john Quintner says:

    Were we prophetic in our 2008 paper?

    “Despite the best of intentions, the proposals arising out of the biopsychosocial framework have imposed the world view of the clinician-observer at the ethical and clinical expense of the patient.

    Much knowledge is communicated through narrative, but the de facto narrative of the observer historically has dominated, thereby ignoring that the observer is part of the very system being observed.

    As a result, the body–mind dichotomy has been perpetuated arbitrarily and wilfully upon the person in persistent pain. All the different approaches essentially apprehend a default of responsibility to the patient’s “mind” and invite a clinical judgement of psychosocial susceptibility.

    Ironically, culturally trapped as we are in the format of linear (biomedical) and body-or-mind (biopsychosocial) thinking, we have succeeded only in developing a series of circular arguments.

    No matter what line of enquiry we pursue, we come up against questions that defy our accessibility to answers. The lived experience of being human is not linear and indeed is beyond body–mind monism or dualism.

    We have to accept that some things are likely to be insuperable, too
    complex to apprehend from an embedded linear determinism or from an either/or desire to make sense of pain. That is to say, our attempts to
    develop explanatory models bounce off a metaphysical brick wall, which constitutes the aporia of pain.”

    After reading the many insightful comments posted so far on Body in Mind, it occurred to me that perhaps we have indeed hit that brick wall. Quo vadis?

    Quintner et al. Pain medicine & its models: helping or hindering? Pain Medicine 2008; 9: 824-834.

    KW Reply:

    Dr Quintner,
    I think I have an understanding of what Dr Moseley describes as the mechanism involved in chronic pain or basically pain in general. Essentially information from sensors (be it integumentary, visual, olfactory, auditory, position, etc) is transmitted to the spinal cord and then to the brain. The brain then determines whether the information is a danger or a threat and then decides to produce the pain experience or not. This occurs whether there is tissue threat/damage or not. So the pain experience is generated by “the brain.” The brain is merely taking in information, monitoring the situation, and then if it feels it is appropriate will produce the pain. This makes sense to me but I continue to want to learn as much as possible. If I have it wrong then I apologize. What would be interesting would be to get an overview of what you believe the pain process to be. I’ll try to read your writings but it would be interesting to get an overview from you if possible. Then how does one approach treating these often difficult patients?
    Thanks in advance!
    KW

    John Quintner Reply:

    We have to first accept that the linear cause/effect approaches that we have been taught to apply in the clinic don’t help many of those with chronic pain who come to us for help.

    A new paradigm is emerging that embodies what we might call the wHOPE (whole person engagement) model of care.

    The series of papers that we have published in Pain Medicine since our 2008 contribution were written in an attempt to move pain theory in this direction. There may well be other approaches.

    But from what I have been hearing for some time on Body in Mind, I think we have indeed hit the metaphorical brick wall.

    KW Reply:

    I will read the papers. Have you had any clinical success implementing your theory/model? It is amazing how difficult it is to move in a positive direction with chronic pain patients…… Very complicated and very challenging. In fact quite tiring unfortunately.

  30. John Barbis says:

    Great comment. I agree, but change does happen glacially. After all the APTA has stated that hot packs should no longer be used for back pain. This seems simplistic and long overdue, but the conceptual model is changing. I will probably be long dead before major changes occur. when I think back to PT in 1976 when I started and now. the change is remarkable.

  31. There are some advantages to having worked in pain management for a while, one of them is to have seen treatment fads come and go. I have lived through the leg length discrepancy, the muscle imbalance, the core stability and others! But the messages I’ve been giving in all that time are the very same messages that Lorimer and others have been giving (but you guys do it in a more sexy way!).

    This message is deceptively simple. Non-nocebic language, clear explanation, guided experiments to increase movement confidence, and being aware of thoughts, beliefs and other psychosocial factors.

    The problems I’ve had are that this isn’t very sexy in practice. It’s not a cool and groovy new technique. It doesn’t draw on some mythical insight. It is all about listening, hearing, thinking before speaking, and taking the time to check whether the person has heard what you’re saying.

    And unfortunately these things look superficially easy but in reality are very hard to do. Perhaps it’s those mirror neurones, clinicians trying very hard to protect themselves from developing too much empathy by avoiding listening too closely and instead using habitual responses that roll off the tongue without actually hearing what is being said by the person in pain. Listening puts people, clinicians, in a more vulnerable place where they begin to recognise themselves in the distress of their patients.

    John Barbis I am not convinced research evidence will shake these systems. I think people are not rational, and both systems and individuals err on the side of whatever is currently happening. Inertia.

    After all, the evidence that psychosocial factors are one of the strongest influences on disability from acute low back pain has been assembled and promulgated since the early 1990’s, and most clearly from 1997 in NZ with the Psychosocial yellow flags document. And still, as I review the recent literature looking at patient and clinician responses to a holistic model (biopsychosocial, or whatever you call it) the overwhelming response is to remain in stasis. Most GP’s don’t follow the guidelines for acute low back pain (I can give you refs galore to support this). Many patients don’t want to consider psychosocial factors because they believe this denigrates their experience, makes their pain “psychological” instead of real (refs available).

    It’s HARD for a clinician to shift from a simple explanation (your core muscles are weak) to a complex explanation (your brain is over-representing the threat because of …). Patients are often not ready to hear it (they translate this to “so you’re saying it’s in my head”), they also hear multiple different explanations for their problem and find it tricky to let go of sticky back beliefs. Clinicians find it difficult to explain, to check for understanding, to re-explain.
    And our systems pay for throughput rather than output.

    I’ve been asked by medical practitioners “why can’t you just give us a checklist or a couple of questions we can ask” when I’ve been teaching psychosocial and neurophysiological concepts of pain. This is because they perceive they have little time, they’re not fully understanding why these concepts are important, and perhaps their mindset remains stuck in the “psychosocial factors are why our treatments don’t work” rather than taking the time to see how fundamental these factors are.

    As Bill Fordyce said “Information is to behaviour change as spaghetti is to a brick”. It’s not just about providing information – we all know smoking is unhealthy yet people start smoking every day. It’s also about systems, reinforcement, social norms, policy development, and shifts in power. What changes behaviour? And what changes behaviour of a system?

  32. John Barbis says:

    Dear Sir,
    As a therapist there is no technique or concept within our profession that I would be willing to go to the mat about. I have been in this profession long enough that I realize that time brings about changes in knowledge and thinking. As a result, what I do today with my patients is very different from what I did 5, 10, 20 or 35 years ago. Concepts that I taught back then, I realize now were incorrect. When presented with facts, logic and research, I am willing to change. The things that I am willing to go to the mat about are my core values. One of my core values is the dignity that is to be given to each patient. Since these individuals are under my care, I automatically assume a higher standard in dealing with them than I would for just someone I meet on the street. A very important component of the dignity that I honor with my patients is forthright honesty. The patient needs to make an informed decision about whether they are willing to accept my care and follow my instruction. A very important part of their ability to make that informed decision is having accurate information on which they can honestly make their own risk/benefit decision. If I am not accurate in my explanation of my assessment and plans, how can they make an informed decision? If I present a falsehood, saying that I know that I can help them when I have doubt, have I not abrogated my contract with that patient and shown them less dignity than they deserve?
    I have had patients refuse care because of my doubt and THAT IS THEIR RIGHT IN MAKING AN INFORMED DECISION. I have no difficulty with that. The vast majority of the time, however, I have had patients thank me for my honesty and it has actually strengthened the therapeutic bond. As a result, it permitted me to have patients accept interventions and concepts that they would not have accepted without the recognition of my respect for them. In my years of dealing with pain patients, I cannot say that I have returned a great percentage of them back to their pristine, premorbid state. I have helped the vast majority back to a more productive life. Realistic expectations are an important component of pain care. Realistic expectations come about through an honest and open relationship between therapist and patient. When we begin to scrap honesty for supposed outcomes, professionally we lose. We need to find ways of providing both honesty and outcomes. If I think of the really good role models that I have had in my career, all of then have found the way to use the two to enhance the quality of their care, not diminish it. That to me is the art and the science of an expert clinician. It is a goal to which I aspire- not always achieve, but I make the attempt. It is a core of my professional being and I will go to the mat for it.

    EG Reply:

    Hi John,

    I think this is directed at me…yes? I’ll reply anyway.

    “If I present a falsehood, saying that I know that I can help them when I have doubt, have I not abrogated my contract with that patient and shown them less dignity than they deserve?”

    I agree with that you say here. If you have personal doubt and yet you say otherwise, then you are incongruent, and there will be no trust. The trick is to eliminate your *own* doubt to the extent that you can say “I can help you” and be congruent with that statement.

    “Realistic expectations are an important component of pain care”.

    If you do the work of 1) eliminating doubt in yourself and 2) enhancing your ability to create empathy and rapport, then this idea of “realistic” becomes quite plastic. Anything is possible.

    EG

  33. John Barbis says:

    Why haven’t the more behavioral, education, and Neuroplastic approaches to managing pain have not taken off and become more accepted? As a big proponent and supporter of these approaches, not just for chronic pain but all pain, I believe that there are several. The three that I perceive as most important are:
    1. Research and human behavior- although the research supporting the use of these approaches is interesting, trending in a positive direction, and generally well done (thanks L and the rest of you out there), it is still not sufficiently compelling to justify the investment in training, skill development, and resources for most providers. Often the single biggest argument for the use of these methods is one of “acceptance by default”. “ The others don’t work”. I have found that developing the skills and knowledge base to do these techniques takes time and concentrated effort. Some of the biggest challenges that practioners who are seeking to change their practice patterns face are the same ones that confront our patients: unlearning years of behaviors, beliefs, and reflexive practice that are hardwired into our brains. It is ironic that the more skilled that you had become in the past, the more difficult it will be to change to something new like this. Given the lack of compelling findings and costs of training, I find it frustrating but not all that surprising that these concepts are not being accepted more aggressively.
    2. Focus on naming of pathologies and nociception- All of health care, no matter what the profession, has been oriented around naming the pathology and then matching the appropriate intervention (protocol- how I hate that word) to the name. A “systems approach” involving a resilient, logical, adaptable process is not one in which most of our colleagues are trained. Let alone a system that is significantly based in the use of language. The treatment of mechanical nociceptive and, for the most part, neuropathic nociceptive entities lend themselves easily to naming and defined physical treatment pathways. They have clear ICD-9 codes. Their management, especially in the early stages, is relatively predictable, easy, and successful (if for no other reason than the natural self resolving history). Their management only becomes complicated when that nociceptive problem becomes involved with that complex mechanism called the nervous system that is constantly trying to protect us. By the way, what code do we use for “central pain syndrome” that is not immediately kicked out by an insurance company for payment?
    3. How do we prove the absence of nociception to ourselves, our colleagues, and, most importantly, the patient? It is by definition very difficult to prove a negative. There is an automatic assumption that any health care provider makes when implementing of one of these approaches. That assumption is: “there is nothing causing your symptoms that is dangerous or, if there is, it is relatively minor in relation to your behavioral response”. To me it is not sufficient to say to a patient “trust me” when it comes to that assumption. I feel that I have to have evidence (and not just in the negative as stated in 1) justifying that trust. I wish that I had a satisfactory answer to this question for this section. The best that I can come with is that I am required to prove that those nociceptive elements that the patient most fears are not present. That is difficult and often time consuming, but I found that negative process to be essential to the success of the care.
    In mentoring colleagues and presenting these concepts of management to other therapists, psychologists, nurses, and physicians, these are the three main issues, in one form or another, that are raised in resistance to the implementation of this type of care. There are other administrative issues that are often raised, but those really have their basis in these three. In time I think the progression of the research and improvement in our application of these techniques will solve these issues. Most likely in 10 years, what we propose now as being valuable with be changed substantially. Wouldn’t be ironic, but probable, that the concepts we hold now will be accepted but those that have progressed on the conceptual backs of these will be seen as “out there”. I do believe that we have to be aware that there are some very definite problems confronting a more widespread implementation of this type of biopyschosocial intervention that are deeper than just getting our information out there to the public. That is the normal process. If we apply these concepts of managing chronic pain to the fixing of the chronic dysfunction of our health care systems in treating pain, the Neuroplastic interventions of knowledge acquisition, training/education, persistence/patience, focus, and reward will succeed in the end.

  34. Everyday I thank BiM for existing and shifting the way I was taught to understand chronic pain. The more I read about pain science, the more I am convinced that ‘input’ therapies has a limited role in solving chronic pain with faulty conceptualizations and pronounced threat perception.
    However, everyday I struggle with myself to be truly convinced about this new chronic pain paradigm and how to integrate it into our models of care – based primarily on input therapies. How can I explain my patient why I am performing Manual Therapy? I confess that it is easier to talk about hypomobilities (and “little movement restrictions” – I like to empashize “little” in order to reduce threat) than to integrante manual Therapy on the context of pain neuroscience. However, everyday I try to shift the way I think.

    Here in Brazil, PT are educated with a model in which structure and biomechanics prevail over pain understanding. Quite often, biomechanics is deemed to be more important than pain itself (really????).

    I thank Professor Lorimer Moseley for his effort to dissemine this science-based way to look at chronic pain patients. BiM has spread to Brazil and I’ll do my best to dissemine evidence-based, rational information with the potential to improves patient’s lives.

    Cheers from BR

    EG Reply:

    Hi Giovanni,

    “However, everyday I struggle with myself to be truly convinced about this new chronic pain paradigm and how to integrate it into our models of care – based primarily on input therapies. How can I explain my patient why I am performing Manual Therapy? I confess that it is easier to talk about hypomobilities….”.

    Input therapies do actually work in chronic situations, it’s just that the effect is very short lived (maybe 20 minutes, and the same is true for acute injuries). So like yourself, I do use inputs with chronic clients. I explain to the client that what I’m doing gives the nervous system a break, a respite, where the body can just forget about everything for a while. They like this idea of a complete break from the pain. I’m in charge, I’m confident, and they are the passive recipients of this respite…. it’s a big relief.

    If the treatment ended there, a high risk of dependency would arise. But during the input-style treatment, I am doing the *real* and lasting work. I am applying a bunch of Rogerian and Ericksonian psychotherapeutic principles. See my response to Zara below.

    EG

    Andrew Reply:

    Yes I agree input therapies are useful ! The albeit temporary relief experiences can give the pt the real belief that their condition can and will improve. Sometimes that is the proof they need to truly believe and belief is the crucial ingredient

    Deano Reply:

    So EG, I’m interested – are you a psychologist, psychotherapist or psychiatrist too?

    EG Reply:

    Hi Deano,

    Yes, I’m all of those… and a philosopher. How about yourself?

    EG

  35. Jimmy Picard says:

    Thanks Lorimer! This article really hits home with me. I often wonder how many PT’s consider the impact of the language they use with patients. Really, how helpful can it be to tell your patient that their back has been hurting for X number of years because (bring out the skeleton) this facet joint is not “opening” or because something is “out of position”……

  36. Agreed, this is a serious problem. My clinic regularly, daily, has presentations from patients negatively impacted by negative health concepts fed by ‘those in the know’ and often confirmed in the patients mind after internet searching the terminology pushed at them.

    There is often a swim against the relentless tide sensation for me as the patient listens to my positive alternate view of their previously diagnosed impending functional demise, then rattles off a list of all the ‘evidence’ provided to them by others contradicting my view.

    A local Doctor has told some of my patients that he feels I am overly positive and proactive in my views. Is the reverse true of this Doctors views?

    Recently a patient consulted me for a problem, after seeing a number of other therapists described by the patient as useless. This patient sees me when others are unable to address problems effectively, in their view. I was somewhat taken aback when told that the patient also consulted with another health professional on a weekly basis for ‘adjustments’ of the spine.

    The ‘adjustments’ have been undertaken for a prolonged period and there was no indication of an end point. The patient appeared to believe this was normal. It is beyond my comprehension that such ongoing treatments can be permitted by the relevant professional body nor the regulating authorities.

    And yet the public perceptions are constantly being moulded by such behaviours, making lone voices of sanity difficult to be heard above the hype.

    My secret weapon against the onslaught is to retain my integrity. Anxiety reduction techniques coupled with verifiable new explanations for the patients condition derail false information.
    When presented as a way to move toward positive outcomes, we can undermine the self serving and self deluding therapists fleecing patients due to the fostered idea of ‘irreversible damage’ to parts of their body requiring ongoing treatment.

    The patient can become more self reliant with a new outlook on life, reducing the depression/anxiety that often magnifies pain perception. And, they begin to save money – always a good motivator.

    The above presents a problem for the therapist – the better I become at achieving patient understanding and self management, the less money I make (as I live in a low population area). To survive, I must see more patients, yet the purveyors of misinformation have much stronger networks and constantly divert relevant patients before reaching my clinic. Referrers with negative and archaic ideas can facilitate the tidal flow toward misinformation.

    Patients that truly believe, incorrectly as it happens, that they have something seriously wrong with them are unlikely to give up the proffered treatment from the presenting expert. To do so would be counter intuitive. The destructive therapy cycle continues – cycling with no lycra or exercise benefit can’t be good!

    I agree with Lorimer that something needs to change, and quickly. A Government public education program highlighting the need to seek out positive therapists would be beneficial, backed by legislative muscle behind registration authorities to weed out problem therapists. Along with this, the community requires all therapists to be on an even footing in relation to advertising claims and practices.

    The current multi tiered arrangement permitting alternative therapists to claim whatever they like as well as other therapists outside the AHPRA jurisdiction being able to advertise, use testimonials etc is confusing to the public.

    However, there is a danger having agencies increase power, as we may have experienced. A level playing field for all therapists would be a good start, along with improved public education regarding realistic expectations for therapeutic interventions.

    Humour and analogy is what I use to communicate with my patients.

  37. Great discussion everyone. Yes the new paradigm for solving pain is slowly emerging and yes it comes from the patient not the clinician. I have been lucky enough recently to wok with children and by handing them back the control of their pain they can solve it easily. Years of headaches gone in a week as well as abdominal and face pain. As others have commented that by changing their perception and belief around their awareness of pain the glitches in the database are removed and the body will function normaly again. Obviously this could take longer in adults who have more software discrepancies !

  38. Thanks for putting this out there. It is so refreshing. I am one of those people on the fringe, over the edge and outside the square. I do ‘healing’ work, working with energy and empathic intuitive awareness. I guide others into a state of grace in the present moment. I have spent many years ‘healing’ myself… and traveled through huge amounts of pain (including neuralgia) the origin of which was from painful trauma as an infant. In some way I feel fortunate to have not been supported by the current system and taken on their views and beliefs… it seemed pointless to me to be filled with knowledge and negativity and hopelessness. What I have found in my own journey of more than 25 years (including my own research) is that pain and perception are deeply linked. Perception affects experience and experience affects perception. seen particularly in chronic situations. The greatest value I have found is transcending normal perceptual reality (and all the beliefs included in it). That what the world seems truly afraid of is ‘not knowing’… yet when we surrender everything we know, into a perceptual reality of not knowing… well healing happens and pain dissolves. There’s alot more to it, beyond this sharing… but for me that has been one of the main keys to unlock the potential behind the pain and integrate the self back into heart-centered wholeness. Thanks for the work you do Lorimer.

  39. As a massage therapist, I can certainly say that I have been guilty of informing clients that they have pelvic rotations, leg length discrepancies, rotated vertebrae and plenty of other pseudo-scientific nonsense. But hey, that was only because that’s what I was told to do!

    It is really embarrassing to realise that information about the neuromatrix and the poor reliability of lumbar imaging goes back as far as the mid 90’s. Twenty years later we are only just starting to catch on.

    Unfortunately, we still have chiro university level courses teaching subluxation theory, osteo courses teaching sacral torsions and massage therapists sprouting all plethora of nonsense.

    At least we now have professors leading the charge to a much more enlightened approach to pain, that surprisingly enough takes into account the “whole” person.

    The truth is out there now, it will just take time for people to realise it, and I am sure critical mass is just about achieved.

    Aran

  40. Dear Lorimer,

    “There are three powers, three powers alone, able to conquer and to hold captive for ever the conscience of these impotent rebels for their happiness those forces are miracle, mystery and authority.” Dostoevsky – The Brothers Karamazov

    I find this applicable both to patients and physiotherapists and it seems we fight against something superior than their nervous system such has their philosophy, religion, upbringing and health education. They want to ‘give their back’ to someone with authority, someone looking intelligent (possibly a mix between a priest and a doctor) , self-confident, able to communicate insane theories without moving a eyelid using the tone of a family man, someone to worship and with conference certificates hung on every wall. They do not even look for the truth, they are happy with the mystery as long as the miracle happens. ‘Spatially defined disruption’ talking, they don’t want their spine back until fixed.

    “when man rejects miracle he rejects God too; for man seeks not so much God as the miraculous. And as man cannot bear to be without the miraculous, he will create new miracles of his own for himself, and will worship deeds of sorcery and witchcraft” Dostoevsky – The Brothers Karamazov

    We see the creation of a new witchcraft every month (needles, devices, something called Pilates, methods of pushing here and there, etc.) and physiotherapists still look for the miracles too, worshipping the authority of the speaker/lecturer. They create groups and they aggregate in the name of the “witchcraft of the moment”. Isn’t this philosophy/education/religion? They can’t reject it. When it works for them, who cares about the truth?

  41. Dr. Moseley,
    I can sense your frustration in this post. And I can easily appreciate it.

    I do suspect things are changing, but agree that it appears this is happening at a very slow rate. I would attribute this, partially, to “pain science” being viewed by many, mistakenly, as a camp or movement (I recently wrote about here: http://forwardthinkingpt.com/2014/09/26/pain-science-is-not-a-movement-pain-science-is-not-a-camp-pain-science-is-science/).

    But in this labeling, I am not sure we can solely blame the clinicians. Historically, the field of PT has been flooded with guru’s and concepts that have not been substantiated by sufficient evidence or sustainable plausibility. I suspect many view “pain science” as just the “next concept”, to be soon added into the “fad” library next to myofascial release and craniosacral therapy. The difference, which is unfortunately overlooked, is the scientific plausibility, and adherence to Occam’s Razor, of many concepts within pain science.

    So this stated, it is easy for us to say we must hold our colleagues accountable for not adopting some of these basic scientific principles within pain science, but is it truly their fault for being resistant?

    How can we restore confidence that pain science is science?

    John Quintner Reply:

    Joseph, perhaps “nerve flossing” could be added to the list on the “fad library”. This “therapy” is being administered by well-meaning health care practitioners who have been led to believe that it is evidence-based. Bring out the evidence!

  42. A passionate piece indeed, Loz!

    Thanks John for the Richard Feynman quote: “… you must not fool yourself, and you are the easiest person to fool.”

    This is true for both novice and experienced clinicians. The novice who is looking for simplicity and safety and the expert at risk of ignoring what doesn’t fit her/his favoured paradigm.

    We could talk about reflective practice and the need for effective mechanisms for regular review of what we do clinically – but getting back to Lorimer’s key point – ‘we’ need to ensure that we are not propagating concepts, ideas and interventions that cause harm. This requires diligence in the preparation of our own work for dissemination and the preparedness to hold to account those amongst our professions who threaten such a standard.

    And thanks to BiM for providing the ‘space’ and the intellectual stimulation needed to develop an informed opinion. I go away much better prepared to share wisdom through mumblings, mutterings, chatterings and campaigning!

  43. Awesome.

    I just gave a CE webinar on the same topic and am giving a talk at a conference this weekend on the EXACT same topic. I give a case study on how a belief in “shifted rings” has lead a patient to believe her triathlon winning body is weak, unstable and in need of correction whenever she squats. Wow, talk about Discover Catastrophizing.

    So thanks for this. I will lose my powerpoint and just read out this blog post.

    Greg

  44. Hi Lorimer,

    I read a lot of blogs and forums similar to this one (similar tone), and I’ve noticed that nothing is changing. If these forums were researched for their effectiveness in changing ideas about healthcare, I think they have perhaps failed. I enjoy reading and contributing, but progress is deadly slow.

    I don’t know anything about marketing, but maybe this is where some significant alterations need to be made. Things need to be sped up, a lot. And effectiveness needs to be measured (if that’s the aim… is it?).

    For example, if BiM was my baby, I would give up trying to convince therapists and doctors, since they don’t seem ready or receptive to the idea that the mind is the key to unraveling chronic pain. I would go direct to the public and test the waters there. I would employ the most brilliant marketing professionals money can buy and start a media campaign. Flood social media, TV, radio. Identify the most watched public opinion shows and set up interviews and clinical examples. Ads would be aired in prime time slots. Drive it from the “bottom up”. Easy to say I know…

    Where does all the money come from? Government. You tell them how much this campaign is going to save the country.

    We’re just talking to ourselves here. A *tiny* group of physios who see things differently. It’s always the same faces.

    I’d appreciate a response. Thanks. 🙂

    EG.

    Lorimer Reply:

    Thanks all for comments. I appreciate your candour one and all. In particular response to EG – yours is a really important point and one that we at BiM have been throwing around since the beginning. How do we measure what we do? This site has been researched (and actually is being researched as we speak) and, on a formal level, we have established that we do change behaviours insofar as getting people to look at research, with an effect size that is worth publishing. However, do we change how people treat? I don’t know. I too feel that we are a tiny group of researchers and clinicians (from several professional groups not just Physiotherapy), but I have been told many times that there is a much larger group who read and ponder things like BiM without ever commenting or ‘being seen’. Our metrics suggest our messages infiltrate a very large, international and reasonably diverse community and reverberate through other fora and media perhaps like the ones you mention, even trickling up to grant applications and industry reports. I share your skepticism however, as to whether this really means anything at all, but at the moment I am unconvinced that it doesn’t.
    We would like to think we are reasonably unique in the space, although I agree we are not alone in the things we say – we just try to make it about more than just one person or research group, and we have truly outstanding members of the research community driving what we write about (see Section Editors). It IS costly – we spend over $60,000 a year on BiM – the equivalent of two PhD scholarships – we do this without any industry or community support because we think BiM plays an important role.
    I don’t share your view that nothing is changing. Nor do I think the progress is so slow as to be deadly. It is slow however. I agree wholeheartedly on that front. Sometimes I fall back to the question of doing something in order to get an outcome versus doing something because it is the right thing to do. I am more convinced that BiM is the right thing to do than I am that it will achieve our lofty goals of changing the world.
    Regarding your suggestion on going straight to the public – the keys here are, as you have implied, money, time and will. I can tell you, from first hand knowledge, that most governments do not actually see it as a good way to spend their money, although I agree that they are the key stakeholders. The delay to return on investment is an immediate turn off. Time is, unfortunately, not limitless and we must all make decisions about how we want to spend ours – most weeks I will wish I had three full lives – one I would dedicate to time with family and friends, one i would dedicate just to my current work, which I love, and one in which I would do the sorts of things you are suggesting. And learn how to draw. And swim properly – I suck at swimming. As regards to Will – there are champions for this cause but I agree, we need more.
    Some of what you desire is actually happening in small ways all over the planet and, from the decent vantage point I have, I can see that there are mumblings turning into mutterings, chatterings into organised campaigns. There are organisation such as the IASP, its NeuPSIG and Education SIGs, who are engaging with government and industry. This is indeed a Grand Challenge, but those of us taking it on are not nearly as lonely as we were. It wasn’t that long ago that offering a course on Explaining Pain would attract friends, enemies and no one else. I think we need to keep the dream alive (and gaining strength slowly but surely!) and I appreciate each of you who do this in whatever way you do.

    EG Reply:

    Thanks Lorimer.

    I understand what you’re saying here. Other than going direct to the public, I think the only other way to create broad change is to let our clinical results speak for themselves and let word of mouth do the rest.

    The public are very savvy, and if there’s a guy in town who can cure 10 years of back pain with one treatment, word will spread. I’m not that guy (not yet!), but that’s my continuous challenge to myself – “How can I make this chronic pain disappear more completely and more rapidly?” If I can’t produce better outcomes than other practitioners, then I can’t really complain about how they go about their work, even if it’s out of step with current research.

    EG.

  45. John Barbis says:

    Yo L,
    Excellent blog. I actually start off the objective component of all of my evaluations with that statement. It is amazing how most patients find that comment very comforting since many have experienced a significant increase in their symptoms after their health care exams. I also tell each of my patients that they are in control of the examination and they can tell me to stop at any time. I also tell them that I may try to negotiate with them at that point since it may be information that I need to find a “nociceptive trigger”, i.e. a trigger that actually may indicate tissue threat. (It starts the conversation on pain). However, when I do that they know clearly why I am doing it and have control.
    My concern about “doing no harm” has often left me conflicted about the correct clinical course. I often find myself facing the following questions with no clear objective evidence to provide the clinical certainty of a safe, appropriate pathway:
    Have I found and identified those nociceptive triggers that could be potentially dangerous? (Non-recognized mechanical and neurogenic nociceptive triggers sometimes do exist in persistent pain patients! Shit and nociception do happen! Even a broken clock is right twice per day. Etc.)
    Will I actually cause harm if I start the patient on an educational, behavioral, or Neuroplastic intervention if the identity and extent of a true nociceptive generator has not been clarified?
    If I focus on clarifying my clinical concerns about the presence of a nociceptive generator, will I just become one of another long line of clinicians reinforcing an iatrogenic problem?
    How can I ask a patient to believe my line that “this is all in your head”, if I am not convinced that I have cleared or identified potential sources of physical harm?
    Do I place myself in legal, professional, and potentially financial (referrals and potential legal fees) danger (my definition of professional nociception) if I tell the patient to ignore all of the other information (past tests, advice from other professionals, media information, etc.) that they have been exposed to over the history of their pain?
    How do I deal with these questions?
    I want that patient to believe that I have done a very thorough clinical examination to come to my conclusion. This, plus being aware of the Biopsychosocial totality of the pain experience for that patient, has forced me into modifying, focusing, and developing a much more disciplined subjective, psychometric, and objective evaluation. Both the patient and I have to be convinced that together we have identified those conditions that are dangerous and have adapted the program to address them. I truly wish that there were a cadre of clinical tests that were shown to be highly reliable to come to the security about “danger” that we would want. There are not. Often, in patients with persistent pain, our clinical findings come down to a group of conflicting signs that leave us totally puzzled. “There are signs of.., but really not conclusive, but again it could indicate…”
    How do I proceed? It comes down to that line again “Do no harm”. I do some pain education but the first several visits may be devoted to trial exercises or activities that better clarify the presence and, more importantly, absence of any nociceptive sources. At that point my line often becomes: “I have bad news for you- I do not know what is causing your pain. I have good news for you, I do not know what is causing your pain, but I can tell you what is not!” We generally go from there.

    EG Reply:

    Hi John,

    “There are signs of.., but really not conclusive, but again it could indicate…”
    This sentence creates anxiety. Creating anxiety is doing harm.

    “I have bad news for you- I do not know what is causing your pain…”. This causes more anxiety again. More harm.

    It matters not whether your statements are “true” or “untrue”, fear has been shown to be the single most potent factor to maintain pain.

    As an alternative, if you said “I know what’s going on here, and I’m confident I can help you”, you would reduce anxiety and improve outcomes. Whether you end up helping or not will come down to your skills in relating to the client, but at least start off on the right foot.

    EG.

    John Barbis Reply:

    “It matters not whether your statements are “true” or “untrue”, fear has been shown to be the single most potent factor to maintain pain.”
    Truth means everything to me. When I do not know, I am honest about it. The honesty of my expressions are part of the presentation. Do you think that the patient is not thinking what I am?
    “if you said “I know what’s going on here, and I’m confident I can help you”, How can I make that statement if it is not true. I would not stoop to saying anything that I could not back up. Dishonest presentations are in same class of statements that are made from over reading MRI’s. Why should we or patients be afraid of ambiguities? The sign of a good clinician is one who is able to deal with those ambiguities is a forthright way and try to solve them. If I were a patient and a clinician said what you propose to me and I knew it, I would break his nose.

    EG Reply:

    Hi John,

    “The sign of a good clinician is one who is able to deal with those ambiguities is a forthright way and try to solve them”.

    You’re speaking from your own point of view. I instead take the client’s perspective and say a good clinician is someone who can reduce or eliminate my pain. As the client, that’s all I care about and I don’t care too much how we get there, so long as it’s safe and reasonably quick. And I certainly don’t care about how my therapist’s anxieties. I’m paying for a solution.

    Truth is important to me too, but what is truth? One particular truth is that fear is the main contributing factor in creating/maintaining pain. So I don’t add to the client’s existing burden of fear. I choose my “truths” according to what helps the client, not according to what helps me feel ok about my morality. He is paying me to help him, so that’s what I do in the most direct way I know how. Truth is relative anyway, but that’s a different topic.

    I challenge you and you want to break my nose! That’s fine, but there’s a huge impediment to learning built into that mindset. I know I didn’t challenge you gently, but I didn’t feel like doing it gently. You’re a therapist.

    EG.

  46. Michael Ingle says:

    Thanks Lorimer. I have heard these messages from various speakers such as yourself and Peter O’Sullivan a few times over the last couple of years. Sadly there seems to be a large section of the profession resistant to these ideas. When talking to these clinicians, a typical response is “we don’t see those sort of patients.” I am quick to make the point that all chronic disabling back pain starts as acute [simple?] pain.

    Peter recently opened a speech in Sydney with a video clip that suggested we can’t recognise something if we don’t know what we are looking for. Chronic disabling low back pain is not a rare problem. It is the number one cause of disability in Australia. It costs our government $4.8 billion annually. Statistically alone, there must be plenty of physiotherapists seeing people with this nature of back pain. Hopefully with our collective efforts to improve the management of back pain these people will be recognised and managed in the best possible way.

    Andrew McMullan Reply:

    “When talking to these clinicians, a typical response is “we don’t see those sort of patients.” I am quick to make the point that all chronic disabling back pain starts as acute [simple?] pain.”

    It also reflects a fundamental failure to understand that all patient/clincian interactions are by there nature psycho-social as the seeking of help from another party is a psycho-social admission of not coping. Far too many times rather than providing reassurance peoples non-coping is used as a means to exploit their help for financial gain. What a conflict of interest.

    ANdy

  47. For every treatment, and every interaction, there are good and not-so-good effects. While “slipped discs” don’t get mentioned as often, the language of “core instability” and the need to move in special ways to “avoid harm” is instilled even in 5th year medical students. I recently talked to a class about the lack of evidence for so-called safe manual handling: they did not believe me. The not-so-good effects of language are beautifully described by Benedetti in his book The Patient’s Brain: The neuroscience behind the doctor-patient relationship. Perhaps this should be mandatory reading for anyone entering a health profession?

  48. Great blog! Very recognizable as i often “struggle” with patients that are convinced that their problems are caused by slipped vertebra’s, leg length differences or other structural problems.
    Convincing these patients that often want the “quick fix” is even more of a struggle sometimes.
    I’ll be definitely following this blog for more inspiration!

    Sarah Compton Reply:

    Hi Herman, I’m very interested in how you persuade such patients that their pain is not structural as this is an area of work I’m exploring. And what is your main form of treatment for such people?

  49. john Quintner says:

    Lorimer, in his 1972 Caltech lecture (Cargo Cult Science), the physicist Richard Feynman explains the first principle for maintaining one’s scientific integrity: “… you must not fool yourself, and you are the easiest person to fool. So you have to be very careful about that. After you’ve not fooled yourself, it’s easy not to fool other scientists. You just have to be honest in a conventional way after that.”

    If I had to hazard a guess as to our main source of error in the context of this discussion, it would be our glib practice of imparting our conjectures to our patients and colleagues in the guise of established knowledge.