Physiotherapy Education: a Reflection

Physiotherapy Education Perspectives

A little bit of snow, Christmas mood is in the air and I’ve just started counting down the days left going back to Greece! But first, we have to talk about a “reconstruction” of Physiotherapy Education, which can probably lead to better-qualified physiotherapy professionals. Besides, that was the main purpose of the creation of this blog!

In my previous post, there was a comparison of the effectiveness of electrotherapy and therapeutic exercise in the treatment of MSK conditions based on the latest evidence available. Based on my little experience as a physio, I was expecting that exercise therapy will be much more effective than electrotherapy. And it’s true! However, it was a surprise to see that electrotherapy modalities have always shown little evidence to support their efficacy in regards to the management of musculoskeletal disorders. The question is, why we devote so much time learning electrotherapy since it has been…

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The End of the Journey…

It has been previously described that chronic pain is like the alarm system in the house. This annoying tune/noise keeps ringing for a long period of time. The alarm sound misinforms you about burglars entering the house. It turns on in every sound or light movement. You don’t have the ability to turn it off when you push the turn-off button on your keys anymore, or when you try the deactivation code on the panel. As a result, you are afraid to get in or out of the house because you don’t want to hear this noise again. You have even stopped inviting your friends or your kids’ friends to your house. Perhaps you think that  not activating the alarm would be the best solution. Can you see the half of the puzzle yet? It’s like your brain. The sensitivity increases even though there is no more danger. Your whole life is disturbed by this. Emotions, feelings, beliefs and memory. Your beliefs about pain are increased; the fear increases every time you move. You may think or you’re sure that the alarm/pain will start the annoying noise. In addition, your family’s and friends’ involvement is inevitable . You had to give up all your hobbies because of this pain. Sometimes you had to take a sick leave from your work because you could not turn off the alarm the night before. All your emotions, feelings and memories are strongly connected to your pain. Maybe is time to try something new and different. It’s obvious that you don’t wanna sell your house. For a long period of your life the pain defined you. It’s time for you to define your pain.  You have already known why this is happening. It’s time to desensitize the alarm/pain.

Remember what was the initial reason for setting up the alarm? To protect you-even though it became over protecting. Now have in mind that when the alarm gets sensitize does NOT mean that there is a burglar in your house. If you can understand this you will already know that hurt does not always equal harm. To simplify this, if you are performing a movement and you have a new pain does not mean that you have injured or damaged a new tissue. This is due to sensitivity of your brain. Do not panic or get stressed.

 The final pieces of the puzzle

 It is totally acceptable that you had to give up your hobbies or your favorite activities because of your pain. Once you have understood why the pain persists you would like to return back to your activities and social life. Be careful though this transition should be made smoothly. At first, choose your favorite activity, the one you used to do before you were in pain. I will use the dog example! (Love dogs:))  Let’s assume that before your pain you used to take the dog for a half an hour walk.  At the moment the dog is a bit disappointed by you as you no longer take it for a walk. You think that you can’t do that because if you walk the dog for 30 minutes you will be in pain. Well, actually you are able to walk the dog! If you know that the duration will cause you pain then you don’t have to push your limits.Ask yourselves, what is the most likely duration that I can do these activities without pain? Is that duration 10 or 15 minutes? If you think that with 10 minutes you will be pain free then go for it! But remember this is your first attempt. Don’t push your limits. You can gradually increase this duration by adding 1 or 2 minutes each time. It is the same as if you were going for shopping or for a drink with your friends.  Plan your progression!!

Connect the final piece of the puzzle

As a consequence of your pain, you are afraid to perform specific movements. It is normal. You know that if you do a particular movement you will be in pain. What if you try to achieve the movement with an alternative way? Your brain knows that if you bend forward or if you turn your head you will encounter pain. As a consequence you avoid this particular movement. You can trick your brain by performing the movement in a more different and pain free way. In this way, your brain will not recognize the movements as painful, plus it would be a new safe, pain free movement for the brain. For this reason we will use some of Lorimer’s suggestions.  

Bending forward is painful. Alternatively you can sit on a chair and bend forward. Is the same movement but your legs and half of your body are not in tension; they are relaxed on the chair. You can also do this in front of a mirror-the visual input will deceive your brain that this movement is no longer painful. You can also use other parts of your body to perform a movement. When standing up you can use the legs first, by moving forward one leg each time or if you want to turn your head, try to rotate your body while you’re looking at a particular object. Finally you can use these techniques in your everyday life. Once you have understood that pain does not equal harm you can gradually return to your activities. Congratulations, you have made a new friend. Your friend can be tough sometimes but with the appropriate manipulations he can be your best friend.

What you  will gain if you understand why the pain persists

• Learning the naked truth about your pain will improve your attitudes and perceptions around pain

• Your quality of life will be revised

• You will experience less pain

• By learning about pain you can reduce your disability

• Your physical performance will be better

• If you decrease your fears you will boost your activity

• Your coping skills will raise

References 

1. Butler, D.S. and Moseley, L.G. (2013) Explain pain. 2nd edn. Melbourne, Australia: Noigroup Publications.
2. Moseley, L. (2002) ‘Combined physiotherapy and education is efficacious for chronic low back pain’, Australian Journal of Physiotherapy, 48(4), pp. 297–302. doi: 10.1016/s0004-9514(14)60169-0.
3. Waddell, G., Newton, M., Henderson, I., Somerville, D. and Main, C.J. (1993) ‘A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability’, Pain, 52(2), pp. 157–168. doi: 10.1016/0304-3959(93)90127-b.

Pictures 

Figure 1. puzzle :   https://www.pinterest.com/gingerdoll123/fibromyalgia-3/ 
Figure 2.bending forward : http://www.cgcube.ir/tutorial-article/animation-basics/408-understanding-the-12-principles-of-animation
Figure 3.sit to stand : http://blog.digitaltutors.com/animation-body-mechanics-ease-in-and-ease-out/
Figure 4.exit pain : http://www.nationalelfservice.net/musculoskeletal/musculoskeletal-pain/cost-effectiveness-of-self-management-for-chronic-pain-in-an-aging-population/

 

 

The story behind the “Understanding pain” concept

As mentioned before understanding pain and the complexity behind it is not easy. The input is the physiotherapists and the output is the patients. I was questioning myself about what qualities should the input hold in order to achieve the maximum output, and how physiotherapists achieve this knowledge?  Is there a model that we can follow?

The answer is really complicated. I started this blog as an advice and education for patients with persistent pain. But who will educate us in order to educate the patient? Is it the University? Maybe a course? Or will the answer be found in literature? In my case it is a combination of literature and University. Whatever the case, I am still thinking what about the other physios? What are their perceptions and beliefs about pain? Does this perceptions derived from literature or not? And finally what is the impact on our patient’s treatment? Well I think there was a transformation in my head from the “inflammatory soup” into the more questioning stage! Let’s hope that the final stage will be the answer, understanding and enlightenment stage.

Thoughts regarding the past, present and future evidence

Present

Having a look at today’s evidence, one can find quite good evidence about the effects of Explaining Pain (EP)(Moseley and Butler, 2015)1 and Pain Neuroscience Education (PNE)(Louw et al., 2011)2 on the overall patients’ treatment outcome.

Past

(Overmeer et al., 2011) 3A Randomized Controlled Trial testing if teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes?  Well the results were that “Pain and disability outcomes in all patients of physical therapists who had participated in the course or in patients at risk of developing long-term disability who had higher levels of catastrophizing or depression were not significantly different from those outcomes in patients of physical therapists who had not participated in the course. Pain and disability outcomes in patients with a low risk of developing long-term disability—and pain outcomes in patients with a high risk of developing long-term disability—were not dependent upon whether the attitudes and beliefs of their physical therapists changed during the course. However, disability outcomes in patients with a high risk of developing long-term disability may have been influenced by whether the attitudes and beliefs of their physical therapists changed”.

Future

I was wondering what would be the outcomes of a new RCT teaching Physiotherapist a combination of EP/PNE with the 5 steps approach of Jo Nijs?(Nijs et al., 2013)4( have a look below for the 5 steps ) Will the beliefs and perceptions  of Physiotherapists change? What will be the overall outcome regarding our patients? Well taking into account the todays evidence I think the outcomes will surprise us!

The reason that I support this is because in my case as mentioned in the first post I was a bit confused regarding chronic pain and how to approach it. My beliefs back then were much different than now. Of course the University is a contributor factor but with the evidence on my side I can now understand and apply better the pain complexity approach.

Most of us –including me- use to use a more biomedical approach to treat our patients suffering chronic pain. As a result we fail to treat them in the most effective way. As the evidence suggest a more biopsychosocial approach can be more effective. Let’s see some steps that as physiotherapists can undertake in order to achieve a holistic approach when treating chronic patients.

A significant and effective approach is the one that Jo.Nijs(Nijs et al., 2013) 4 suggests which includes both Therapist and Patients.

Steps to undertake in order to achieve a maximum output

Step 1. Understand the background and the complexity of chronic pain (have a look in the previous post)

Step 2. Combine Pain Education/Pain Neuroscience Education with the psychosocial approach

Step 3. Apply it to the patients

1. Self-reflection→ a clinicians starting point

• Self-assessment by the use of questionnaires(The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) -self-reported measure that discriminates between a biomedical and a biopsychosocial orientation of therapists with regard to low back pain management,

• In addition advice literature addressing the biopsychosocial nature of chronic musculoskeletal pain ( have a look at references section)

2. Assessment of patients attitudes and beliefs with chronic musculoskeletal pain

• Detailed interview of the patient with the use of questionnaires

•  You can use Tampa Scale Kinesiophobia(Vlaeyen et al., 1995)5 or the Fear Avoidance Beliefs Questionnaire(Waddell et al., 1993)6
• Illness Perception Questionnaire(Broadbent et al., 2006)7

In addition to these a recent study of Wijma et al.,2016,8 suggests that a clinical biopsychosocial assessment is recommended prior to PE/PNE as an interaction between patient, pain and biopsychosocial manner. The use of Pain – Somatic factors – Cognitive factors –Emotional factors – Behavioral factors – Social factors – Motivation – model (PSCEBSM-model).”This model attempts to clearly establish what the dominant pain mechanism is (predominant nociceptive, neuropathic, or non-neuropathic central sensitization pain), as well as to assess the provoking and perpetuating biopsychosocial factors in patients with chronic pain. Using this approach allows the clinician to specifically classify patients and tailor the plan of care, including PNE, to individual patients ”

Click here to have a look in PSCEBSM-model

3. Clinical Reasoning including reconceptualizations and Education

• reconceptualize pain before initiating the treatment, try to educate the patient about pain- Have a look at my friends/colleague recent post regarding Pain Education(PE)

5. Therapy

• Therapy should be based on patients’ individual needs and goals.
• Treatment should lead to lead to improve self-efficacy (Milesl et al., 2011)9

The above models and steps suggest a perfect way for physiotherapists’ to understand this complexity and enables them to apply it efficiently. Of course this is something that one cannot learn in the blink of an eye. It takes time and experience…

References

1. Moseley, G.L. and Butler, D.S. (2015) ‘Fifteen years of explaining pain: The past, present, and future’, The Journal of Pain, 16(9), pp. 807–813. doi: 10.1016/j.jpain.2015.05.005.
2. Louw, A., Diener, I., Butler, D.S. and Puentedura, E.J. (2011) ‘The effect of Neuroscience education on pain, disability, anxiety, and stress in chronic Musculoskeletal pain’, Archives of Physical Medicine and Rehabilitation, 92(12), pp. 2041–2056. doi: 10.1016/j.apmr.2011.07.198.
3. Overmeer, T., Boersma, K., Denison, E. and Linton, S.J. (2011) ‘Does teaching physical therapists to deliver a Biopsychosocial treatment program result in better patient outcomes? A Randomized controlled trial’, Physical Therapy, 91(5), pp. 804–819. doi: 10.2522/ptj.20100079.
4. Nijs, J., Roussel, N., Paul van Wilgen, C., Köke, A. and Smeets, R. (2013) ‘Thinking beyond muscles and joints: Therapists“ and patients” attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment’, Manual Therapy, 18(2), pp. 96–102. doi: 10.1016/j.math.2012.11.001.
5. Vlaeyen, J.W.S., Kole-Snijders, A.M.J., Boeren, R.G.B. and van Eek, H. (1995) ‘Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance’, Pain, 62(3), pp. 363–372. doi: 10.1016/0304-3959(94)00279-n.
6. Waddell, G., Newton, M., Henderson, I., Somerville, D. and Main, C.J. (1993) ‘A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability’, Pain, 52(2), pp. 157–168. doi: 10.1016/0304-3959(93)90127-b.
7. Broadbent, E., Petrie, K.J., Main, J. and Weinman, J. (2006) ‘The brief illness perception questionnaire’, Journal of Psychosomatic Research, 60(6), pp. 631–637. doi: 10.1016/j.jpsychores.2005.10.020.
8. Wijma, A.J., van Wilgen, C.P., Meeus, M. and Nijs, J. (2016) ‘Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education’, Physiotherapy Theory and Practice, 32(5), pp. 368–384. doi: 10.1080/09593985.2016.1194651.
9. Milesl, C.L., Pincusl, T., Carnesl, D., Homerl, K.E., Taylorl, S.J.C., Bremnerl, S.A., Rahmanl, A. and Underwoodl, M. (2011) ‘Review: Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs’, European Journal of Pain, 15(8), p. 775.e1–775.e11. doi: 10.1016/j.ejpain.2011.01.016.

References for  addressing the biopsychosocial nature of chronic musculoskeletal pain

1. Leeuw, M., Goossens, M.E.J.B., Linton, S.J., Crombez, G., Boersma, K. and Vlaeyen, J.W.S. (2006) ‘The fear-avoidance model of Musculoskeletal pain: Current state of scientific evidence’, Journal of Behavioral Medicine, 30(1), pp. 77–94. doi: 10.1007/s10865-006-9085-0.
2. Hollander, M. den, de Jong, J.R., Volders, S., Goossens, M.E., Smeets, R.J. and Vlaeyen, J.W. (2010) ‘Fear reduction in patients with chronic pain: A learning theory perspective’, Expert Review of Neurotherapeutics, 10(11), pp. 1733–1745. doi: 10.1586/ern.10.115.
3. Hassett, A.L. and Williams, D.A. (2011) ‘Non-pharmacological treatment of chronic widespread musculoskeletal pain’, Best Practice & Research Clinical Rheumatology, 25(2), pp. 299–309. doi: 10.1016/j.berh.2011.01.005.

Pictures

Figure 1 Brain : http://de.123rf.com/photo_17628517_human-head-with-question-mark-symbol.html

Figure 2. Evidence : http://es.123rf.com/photo_17957703_illustration-depicting-cutout-printed-letters-arranged-to-form-the-word-evidence.html

Figure 3 . 5 steps approach : Wijma, A.J., van Wilgen, C.P., Meeus, M. and Nijs, J. (2016) ‘Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education’, Physiotherapy Theory and Practice, 32(5), pp. 368–384. doi: 10.1080/09593985.2016.1194651.

Figure 4:.Knowledge and Experience : http://www.azquotes.com/quote/843832

Pain journey- Part 1

Pain, Acute and Chronic

Since the last post I have been reading a lot about pain in both of its’ stages, acute and chronic. I think I have created an “inflammatory soup” in my brain!  I wanted to make sure that I understand every aspect of pain and especially chronic pain. My dear Roger it took me almost 2 weeks of reading and searching about chronic pain. But I can now say I know what you meant by the phrase “is all in the mind”!!

But this is not enough. The most important thing is to help our patients to finally see the light in the tunnel of pain. But really, how easy is to explain this to our patients? Is it easy to start explaining about synapses, action potential, C fibers, A-δ fibers and danger messenger?  Well I don’t think so!! Probably we will completely confuse them with all this terminology and neuroscience.

As you already know this post will be a journey through pain. A journey to understand what is acute and chronic pain and the differences between them.

In order to understand what chronic pain is first we have to know how we define pain. Let’s first have a look in the literature regarding pain and the differences between acute and chronic pain. An internationally recognized definition is by the International Association for the Study of Pain (IASP)  “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Merskey 1994; IASP 2014) 1.

Before we move on in the differences between acute and chronic pain, I will tell you about a debate I had with some of my friends regarding acute and chronic pain.

I was having a discussion the other day with my friends in Cyprus about acute and chronic pain. Our main discussion was; “ok Pana we know what acute pain is but really what you mean with the term chronic and the long-term effect on the patient’s body?” Actually one of them is a physio and the other is a Vet. Of course the physio could understand, but the problem was with the Vet. You see, animals cannot explain their pain. So I was facing a big question. In a way the Vet was the patient who could not understand how chronic pain develops and the difference from acute pain.

Vet: “I know that in order to feel pain there must be tissue damage or an underlying pathology.  Ok let’s say Femoroacetabular Impingement Syndrome (FAI) – yes animals can have this condition too. We know the underlying pathology of that, and we also know why the pain exists.  And we also know that when we treat it the pain will no longer exist. So what are you talking about, when you say you can have pain but with no identifiable cause or tissue damage? And how this interferes with your patients’ beliefs and feelings?” BANG!!!

Of course his point was clear and he was absolutely right. He is like our patients. From the moment that something is happening –tissue damage or pathology- the pain is because of that. But what happens after the tissue has healed? Why is the pain still there? What happens when the X-Ray or MRI is clear? A really tricky question! Well how do we answer this question? Why is the pain still there if there is no tissue damage?

Before we answer the big question, let’s have a look on the differences between Acute and Chronic pain.

ACUTE    vs     CHRONIC PAIN

Acute pain

• short term, recent onset, limited duration 2
• tends to link with body damage 3
• usually has an identifiable temporal and casual relationship to injury or disease 3

Chronic pain

• lasts longer than acute, persists beyond the time of healing of an injury 2
• does not necessary mean that there is an ongoing damage 3
• frequently there may not be any clearly identifiable cause 3

It is clear that acute pain has specifiable duration and most importantly a cause! For example a minor injury as a paper cut or something more severe as an ankle sprain. As soon as the tissue heals the pain will go away. But what happens when the tissue has healed but the pain is still there? And most importantly WHY is it still there?  

Welcome to chronic pain!

Chronic pain is not so simple. Is far more complex as we think. Yet, the mechanisms responsible for its transition from the acute to chronic stage are unclear and their functions remain a mystery. Because if we knew the reasons behind that transition we could manage it. Persistent pain not only affects a specific body part but rather has an impact in other areas as well.  We know that during chronic pain several areas of the brain are also involved. These areas have connections with our patients’ beliefs and feelings. ( Melzack, 1999,2001)4,5.Feelings and memories influence the life and physical symptoms to all individuals. You see, this is a multidimensional problem. But this is another story to be discussed later on another post.

How to understand chronic pain? And the reason that is “in the head”

It is really important for our patients to understand what is happening during chronic pain and it is much more important to help them cope with it in order to continue their lives and return back to their activities and social life.

It is like a puzzle, you need to connect the pieces and voila! The picture is clear and understandable! One way to understand chronic pain is to think a house alarm! I had this conversation with my Dad. He was asking me about the MSc and what I study at the moment. I started explaining to him about chronic pain, synapses and impulses! Of course he lost his interest a minute later. But then I thought that my Dad is a house Electrician, so if I try to give him an example relating with houses or panels he might find it easier to follow! And he did actually! So let’s come again to the house alarm example. First you set up the alarm to prevent any burglar from breaking in the house. The burglar enters
the house and the alarm is on, the annoying noise starts, the lights flash and you wake up. This is a really a good house alarm system! But what happens when this alarm becomes over sensitive? It’s easy! The kids try to enter the house, or you try to enter the house yourself but the alarm sirens and lights are still on and the annoying noise becomes persistent for no reason.

 This is what is happening in the brain. It keeps firing faulty information when there is no damage or injury.

Yeap it is all in the brain-but it is 100% real!! And as Professor Lorimer said the pain is the output of the brain, it does not exist until is exists. It is a production of your brain!!!

That was only a small piece of the puzzle. Just think about that until the next post…

 

P.S. I have uploaded a video-I find it really good actually the way she explains chronic pain. Have a look at it!

 

 

References

1. “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994. In: http://www.iasp-pain.org/Taxonomy. 
2. Understanding Persistent Pain, How to Turn Down the Volume On Persistent Pain, Department of Health and Human Services, Tasmanian Health Organization South, (2014), (p. 2)
3. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2015), Acute Pain Management: Scientific Evidence (4th edition) (p. 1), ANZCA & FPM, Melbourne
4. Melzack , R., Pain and stress: a new perspective, in Psychosocial factors in pain, R.J. Gatchel and D.C. Turk, Editors. 1999, Guildford Press: New York
5. Melzack,R.,( 2001) Pain and the neuromatrix in the brain. J Dent Educ. 65(12): 1378-82

Fig 1: Puzzle In:  https://www.google.co.uk/searchq=pain+%26+puzzle&espv=2&biw=1159&bih=554&source=lnms&tbm=isch&sa=X&ved=0ahUKEwijmWy4r_QAhVQ2WMKHeRlB58Q_AUIBigB&dpr=1.65#imgrc=I9sRo7_TzTVBnM%3A

Fig 2: Brain. In: www.spine-health.com

The beginning…

My first own blog!!! I still don’t believe it that I am about to write a blog expressing my thoughts and my patients’ concerns. Let me first introduce my self- Panayiota or Pana it’s easier for the people here because they can’t pronounce my full name 😉. A physiotherapist from Cyprus who has just begun this amazing journey into MSc at University of Nottingham! After 5 years of practicing, I felt that I had more questions than answers especially questions regarding pain, so I decided to explore this by taking this Master journey! I thought that I knew a lot of things about physiotherapy but this MSc changed my mind, and the way I was thinking! Well Socrates was absolutely right when he said “The more I learn, the less I realize I know” this is exactly how I am feeling at the moment, and this is how my journey begins!!   

I think it was the first week in the lecture room, sitting in the class hearing Roger talking about pain and chronic pain– I was so focus on what he was explaining, because  chronic pain was always something that I couldn’t fully understand, and suddenly  Roger  blew my mind with  an explanation that pain is in the head!!! What? Wait Roger what do you mean? Are you sure about this? (Of course Pana he is sure, he is a University Professor!!) I thought that my patients were in pain because of prolonged tissue damage and now you just messed up with my brain! Socrates was so right! So I then realized that this is my opportunity to learn and understand more about pain and chronic pain.

Keeping that in mind I can now understand why some of my patients were in continuous pain. I am not saying that I am a pain expert now but at least I can understand the background of it.  I am thinking of my patients asking me, why me? What is wrong with me? Why I’m I still in pain? Can you do something else for me? Back then I couldn’t understand much and most of the times I couldn’t give them specific answers because I didn’t know much about it. But thanks to Roger,Heather and Dr. Paul I can now say that I am able to understand more than before!

After all these I decided that my blog will provide information about pain, pain understanding and pain education! Well let’s make this journey pain free, and make your pain your best friend!!!