Pain versus Pain (a clinical experience)
by Clyde Andrews
Yes, you read that title correctly: pain versus pain. But let me clarify.
I recently treated a client who had been to a physiotherapist prior to seeing me. During the initial assessment, the client said something that resonated profoundly.
“I’ve had some back pain. It now hurts when I do my box jumps and the physio said that the pain I get from doing that activity is associated pain.”
Let’s mull that over for a moment.
Obviously, the physiotherapist would have done an assessment to reach that conclusion. So what does the physio mean by “associated pain”?
One significant consideration in teasing this out is that the client is a personal trainer so she does a fair amount of physical activity daily, including said box jumps. This opens up a whole new can of worms. Is the cause of her pain a physical result of doing the box jumps or is it her brain issuing an early warning system and telling her that the activity she is about to do will cause pain (what the physio means by associated pain)?
Now, being a supreme fanboy of the work of Lorimer Moseley and David Butler, especially their “Explain Pain” books, the idea that the client’s brain was playing a significant role in generating pain during this activity was pretty compelling to me.
Butler and Moseley coined the term DIM (Danger in Me) to describe the brain’s capacity to alert the body to a potential threat or danger. They explore the concept of DIMs at length in Explain Pain and The Explain Pain Handbook: Protectometer but for a handy overview of how DIMs might be implicated in producing pain, this edition of noi notes is useful.
My working theory with this client was that, when she box jumped, some lurking DIM caused the pain to manifest itself like a big ugly manifesting-type monster. My mission (should I choose to accept it) was to discover the reason for that manifestation. This is when I found myself reaching for the clinical reasoning skills from my toolbox.
But then the client said another really profound thing:
“The physio didn’t do anything. He just seemed to lecture me. I zoned out after the first five minutes because I knew this was going to be a waste of my time—and it cost me 80 bucks too!”
The problem is that she might have tripped herself up due to her expectations and beliefs (ahoy, there’s another DIM rearing its ugly head) so the message from the physio clearly missed the mark. There’s probably some learning here for therapists of all stripes: when it comes to treating pain, in my experience people want something to HAPPEN! They want you, as a therapist, to do something! And when you do something, it helps to ease the client’s mind, which in turn can generate fantastic SIMs (Safeties in Me), another essential element of Butler and Moseley’s Protectometer.
A lecture on pain association for an entire consultation could be a DIM or a SIM for a client, depending on a whole range of highly individual factors. This is where clinical judgement and effective listening really come to the fore.
The client often wants actions as well as words, not just a lecture. A treatment can involve giving a lot of information but this needs to be framed in a positive way, using reassuring words. Remember, words like ‘syndrome’ and ‘condition’ carry heavy baggage and can get those DIMs popping up quicker than weeds during spring. Positivity is key, both with what we do and the language we use—it’s what clients react to best.
So how did I approach this situation, knowing that there was probably a deeper reason for the pain as the physiotherapist suggested and with a few apparent DIMs to address? I used subjective and objective investigation, physical touch, comprehensive questioning and careful listening. (The questions I ask are often broader than just physical presentation: “Can you think of anything that has happened to you recently that has upset you or left you feeling angry/sad?” “Have you been doing anything different lately?”
My client delivered yet another knockout punch during my gentle “interrogation”.
The week before the visit to the physiotherapist, she had been on holiday in Thailand (lucky thing!). However, on the last day of the holiday, she decided to indulge in one of those beachside massages. Everything was going swimmingly until the massage therapist decided to get on top of her back and walk across her spine. Yikes! DIM anyone? Her back was sore for the flight home and for a few days after that.
So, the client returned to work with a sore back. At some point, her brain started associating the activity of box jumping with pain because of the incident on holiday that caused the initial pain. Then the physiotherapist didn’t provide a “treatment” that met her expectations …
Two DIMs right there!
This all added up to an experience that, in the words of the client, ‘ruined my holiday’, even though she’d had a great time up until the massage.
Perhaps her brain was guarding her from further perceived ruination. The box jumps became the trigger for one of those flashy-light warnings: “do not proceed with this activity, you’ll experience bad things and you don’t want that to happen again, do you?”.
Getting over the client’s preconceived ideas of what a treatment should be was the first and biggest hurdle here. If the physiotherapist had done a little more (perhaps even a bit of massage!) to support the ‘lecture’ on pain association then the client may have been happy. And when the client is happy with the way a treatment goes, the brain releases all sorts of lovely SIMs and pain tends to ameliorate.
After I gave the client a remedial massage and loads of reassuring chit chat about pain and how it affects us, she got up and said “Oh wow, I can move my back again. It’s such a relief, let me tell you.”
A couple of days later, she sent me a text “Box jumping like a boss now thanks to you. ”