{"id":147,"date":"2017-09-27T13:34:10","date_gmt":"2017-09-27T03:34:10","guid":{"rendered":"http:\/\/blog.amt.org.au\/?p=147"},"modified":"2017-11-27T15:35:09","modified_gmt":"2017-11-27T04:35:09","slug":"pain-versus-pain-a-clinical-experience","status":"publish","type":"post","link":"https:\/\/blog.amt.org.au\/index.php\/2017\/09\/27\/pain-versus-pain-a-clinical-experience\/","title":{"rendered":"Pain versus Pain (a clinical experience)"},"content":{"rendered":"
by Clyde Andrews<\/h6>\n
\"\"

Girl in the Mirror, by Pablo Picasso<\/p><\/div>\n

Yes, you read that title correctly: pain versus pain. But let me clarify.<\/p>\n

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.<\/p>\n

\u201cI\u2019ve 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.\u201d<\/p>\n

Let\u2019s mull that over for a moment.<\/p>\n

Obviously, the physiotherapist would have done an assessment to reach that conclusion. So what does the physio mean by \u201cassociated pain\u201d?<\/p>\n

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<\/em> to do will cause pain (what the physio means by associated pain)?<\/p>\n

Now, being a supreme fanboy of the work of Lorimer Moseley<\/a> and David Butler<\/a>, especially their \u201cExplain Pain\u201d books, the idea that the client\u2019s brain was playing a significant role in generating pain during this activity was pretty compelling to me.<\/p>\n

Butler and Moseley coined the term DIM (Danger in Me) to describe the brain\u2019s capacity to alert the body to a potential threat or danger. They explore the concept of DIMs at length in Explain Pain<\/a> and\u00a0The Explain Pain Handbook: Protectometer<\/a> but for a handy overview of how DIMs might be implicated in producing pain, this edition of noi notes<\/a> is useful.<\/p>\n

\"\"

The Explain Pain Handbook: Protectometer, page 17<\/p><\/div>\n

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.<\/p>\n

But then the client said another really profound thing:<\/p>\n

\u201cThe physio didn\u2019t 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\u2014and it cost me 80 bucks too!\u201d<\/p>\n

The problem is that she might have tripped herself up due to her expectations and beliefs (ahoy, there\u2019s another DIM rearing its ugly head) so the message from the physio clearly missed the mark. There\u2019s 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<\/em><\/strong>, as a therapist, to do something<\/strong>! And when you do something, it helps to ease the client\u2019s mind, which in turn can generate fantastic SIMs (Safeties in Me), another essential element of Butler and Moseley\u2019s Protectometer.<\/p>\n

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.<\/p>\n

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 \u2018syndrome\u2019 and \u2018condition\u2019 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\u2014it\u2019s what clients react to best.<\/p>\n

So how did I approach this situation, knowing that there was probably a deeper reason for the pain as the physiotherapist suggested and <\/strong>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: \u201cCan you think of anything that has happened to you recently that has upset you or left you feeling angry\/sad?\u201d \u201cHave you been doing anything different lately?\u201d<\/p>\n

My client delivered yet another knockout punch during my gentle \u201cinterrogation\u201d.<\/p>\n

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.<\/p>\n

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\u2019t provide a \u201ctreatment\u201d that met her expectations \u2026<\/p>\n

Two DIMs right there!<\/p>\n

This all added up to an experience that, in the words of the client, \u2018ruined my holiday\u2019, even though she\u2019d had a great time up until the massage.<\/p>\n

Perhaps her brain was guarding her from further perceived ruination. <\/em>The box jumps became the trigger for one of those flashy-light warnings: “do not proceed with this activity, you\u2019ll experience bad things and you don\u2019t want that to happen again, do you?\u201d.<\/p>\n

Getting over the client\u2019s preconceived ideas of what a treatment should be was the first and biggest hurdle here. If the physiotherapist had done a little<\/em> more (perhaps even a bit of massage!) to support the \u2018lecture\u2019 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.<\/p>\n

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 \u201cOh wow, I can move my back again. It\u2019s such a relief, let me tell you.\u201d<\/p>\n

A couple of days later, she sent me a text \u201cBox jumping like a boss now thanks to you. \u201d<\/p>\n

Job done!<\/p>\n","protected":false},"excerpt":{"rendered":"

Massage therapist Clyde Andrews takes us through a clinical experience of integrating pain science into practice.<\/p>\n","protected":false},"author":1,"featured_media":149,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[2],"tags":[12,7,8,6,10,5,9,11,4],"class_list":["post-147","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-professional-practice","tag-back-pain","tag-david-butler","tag-explain-pain","tag-lorimer-moseley","tag-massage-therapy","tag-pain-science","tag-protectometer","tag-remedial-massage","tag-treatment"],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2017\/09\/girlinthemirror.jpg?fit=1280%2C720&ssl=1","jetpack_likes_enabled":true,"jetpack_sharing_enabled":true,"jetpack-related-posts":[{"id":596,"url":"https:\/\/blog.amt.org.au\/index.php\/2018\/03\/07\/podcasts-and-facebook-and-twitter-oh-my\/","url_meta":{"origin":147,"position":0},"title":"Podcasts and Facebook and Twitter, Oh My!","author":"admin","date":"07\/03\/2018","format":false,"excerpt":"A list of industry relevant podcasters, podcast episodes, Facebook pages to \"like\" and Twitter people to follow all in one handy location.","rel":"","context":"In "Continuing education"","block_context":{"text":"Continuing education","link":"https:\/\/blog.amt.org.au\/index.php\/category\/continuing-education\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/03\/Podcasts-Facebook-Twitter.png?fit=560%2C315&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/03\/Podcasts-Facebook-Twitter.png?fit=560%2C315&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/03\/Podcasts-Facebook-Twitter.png?fit=560%2C315&ssl=1&resize=525%2C300 1.5x"},"classes":[]},{"id":1471,"url":"https:\/\/blog.amt.org.au\/index.php\/2019\/03\/13\/improving-quality-of-care\/","url_meta":{"origin":147,"position":1},"title":"Improving Quality of Care","author":"admin","date":"13\/03\/2019","format":false,"excerpt":"Massage therapy struggles with the baggage of outdated ideas. 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