In 2014 I attended a course held by Peter O'Sullivan titled Cognitive Functional Approach to Management of Low Back Pain Disorders. Peter is Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia. In addition to his teaching and research at Curtin University, he works in clinical practice as a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2005) in Perth, Australia. He is recognised internationally as a leading clinician, researcher and educator in the management of complex musculoskeletal pain disorders. Peter is at the forefront of research in chronic low back pain and one of his main goals is to reduce the gap between what science tells us and what clinicians and patients know. Along with his team from Western Australia, he continues to drive the revolution of changing how we view and manage back pain, from a pathological model to a conceptual model.
For those who have had the pleasure of meeting Peter and observing his style, they would all agree he has a gift for communication. His interview techniques are fascinating to watch and learn from. When I left masters I had this feeling that only there was particular information I needed to receive from my clients in order to assist with my understanding of their problem, and the words they choose significantly directed my thinking. For example the words they chose to describe pain helped me decipher the pain was nociceptive or neurogenic. Sometimes the questions would indirectly question about 24 hour behaviour, red and yellow flags. At times it seemed like a game or a masquerade and I never felt comfortable just asking client's a direct question.
Then I met Peter who is brilliant, honest, genuine, straight forward and he simply talks to his patients. He chooses his words carefully, he clarifies what they mean by something, what something means to them and what they have learnt. And from what I've seen, it leads to a far better outcome, better rapport and better results with patient recovery.
I learnt so many tips to make my communication skills better. The aim of this blog is to share with you the key messages I took away from this course. I've broken the messages that really impacted me into sections which reflect the topic of discussion.
The most important thing for me was learning to ask
"What do our patients understand from what we tell them?"
"What does this mean to them?"
- When it comes to discussing the diagnosis of low back pain there are times when it is really hard to put a specific label on pain because it is hard to say it is one particular structure or thing.
- 'Blurry diagnosis' is common. In fact 85% of people with low back pain are labelled as non-specific chronic low back pain. So a blurry diagnosis is used in the majority of diagnoses.
- For some reason, clinicians don't feel comfortable with this conceptual framework and we are always looking to label something. Its almost a way to blame a structure. But really ask yourself.... does naming it change how you manage it?
- There are often central and peripheral causes of LBP and PGP and it is very difficult to know the exact contribution of the CNS, path-anatomy, the PNS and cognitive/emotional factors which impact on the overall problem.
Predictors of disability
- The number one predictor of disability is Fear
- Disability is effected by our thoughts about a problem and fear leads to:
- Heightened CNS arousal,
- Altered endocrine and immune system functioning,
- Hypervigilance, doctor shopping, tensing up and other altered movement and behavioural patterns, and
- High levels of pain is another strong predictor of disability.
- Beliefs about pain
- Beliefs about pain, injury, prognosis etc can become a thought virus.
- What do our patients understand from what we tell them?
- What does this mean to them?
- These are two invaluable points I took away from the course and try to incorporate into my clinical practice.
- Low self efficacy is also a strong predictive of disability. Self efficacy is the confidence a person has in their ability to achieve a desired outcome (Costa et al, 2003).
Interpretation of radiology
- When looking at a scan ... first decide if there is something wrong i.e normal morphology or pathology.
- Be careful about language used and lamens terms which can lead to unhelpful phrases.
- Some very unhelpful phrases have been developed from miscommunicating the results of radiology e.g bone on bone, arthritis is everywhere, the disc is completely collapsed... these are phrases associated with very negative outcomes and catastrophisation. They leave people feeling helpless.
- What we choose to say contributes to the belief system of people.
- Can we change our communication into helpful, safe, positive, empowering phrases?
Is disc degeneration painful?
There is a small percentage of people with severe disc degeneration who have persistent and high levels of pain (Takatalo ESJ et al, 2011). There is on the other hand, and large percentage of people (35%) who have disc degenerative changes and no pain. Disc degeneration is an aged related process and not a disease process and therefore does not have to be a painful problem.
A study by McCullough et al (2012) explored the prevalence of MRI findings in people without back pain. 237 reports were taken and 30% of these reports were accompanied with the statement about normal morphological changes seen on scans. The results found that when patients/clinicians were provided with epidemiological data on the normal spinal changes seen on MRI, they were less likely to receive narcotic prescription. Disc degeneration was seen in 91% of people, disc height loss 56%, disc bulges 64%, disc protrusion 32%, and annular tears 38%. The findings of these studies reinforce to clinicians that MRI results for the spine must be viewed with caution and related to the clinical presentation.
So what does all this information mean for physiotherapists? Don't be anti-scanning…. we often find useful and valuable information from scan. It is not the scan or the radiologist that leads to poorer outcomes or the nocebo effect, it is the way we educate patients and given them information about the results. Take time to carefully educate and ensure they understand correctly.
Predictors of recovery
- We need to be aware not only of the belief set people hold but also their mindset.
- For those with a fixed mindset opportunity to change is not within their control.
- For those with a growth mindset opportunity to change is within their control and they are open to adapting.
- Ask your patient "What do you think you need to get better?"
Phrases which are unhelpful provide messages which will
- Promote beliefs about structural damage e.g. arthritis, slipped disc, wear and tear.
- Promote fear beyond the acute phase e.g. you need to be careful, never bend or lift, you have a weak back.
- Promote a negative outlook on recovery e.g. your back will only wear out more as you get older, and this will be with you for the rest of your life.
- Hurt equals Harm e.g. stop if you feel any pain, let pain guide you.
Phrases which are helpful provide messages which will
- Promote normal movement e.g. your back gets stronger and heals with movement, motion is lotion, guarding your back and avoiding movements can make it worse.
- Promote biopsychosocial beliefs about pain e.g. back pain doesn't mean structures are damaged, often it means you are sensitised. Your back may be sensitised from awkward postures, poor hygiene, poor dietary and exercise habits, and stress. Your brain is an amplifier, if you're worried about your pain it will increase.
- Promote resilience e.g. your back is one of the strongest structures in your body and very few injuries cause permanent damage.
- Promote self-management e.g. let's try work out a plan to help you help yourself.
- Promote better insight about imaging results e.g. your imaging results are a normal part of ageing like grey hair, and the movements in your back might be painful at first like a sprained ankle but moving normally helps them to heal it doesn't cause more damage.
Stage of the disorder (acute, subacute, chronic, recurrent)
- Is it a specific disorder, non-specific disorder or red flag?
- Is there a mechanical or non-mechanical pain behaviour?
- What is the pain type? Nociceptive, inflammatory, dysfunctional, neuropathic, or mixed.
- We need to decide if the tissue is damaged or if it is highly sensitised?
Mechanical pain has a clear mechanical behaviour to the disorder, clear anatomical origin to the disorder, movement hypersensitivity, and is linked to posture, loading, movement control, activity, sleep problems and stress.
Non-mechanical pain is disproportionate in its behaviour to mechanical stress, with no clear anatomical origin to the disorder, widespread hypersensitivity to cold and pressure hyperalgesia, increased anxiety, depression, catastrophising, stress and sleep problems.
Cognitive & psychological factors
- How much do yellow flags matter? I think it all comes down to context.
- Cognitive & psychological factors you might need to take into consideration are deprivation of sleep, altered mood, and altered immunity, as can all lower the threshold of the nervous system and lead to increased levels of pain.
- The brain has a huge role to play in catastrophisation and interpretation of noxious stimuli. A good example is cultural context eg. african tribes pierces hooks through skin, walking on coals, while others would find that too painful to bear.
- Social factors may included socio-economic status, financial status, work, seeking compensation, poor family functioning, life stress events and cultural stress.
- Lifestyle factors and individual considerations (sleep hygiene, work-life balance).
- Why do you need to know about these? Because pain relates to functional behaviours.
- Let's talk about Stress
- Stress can be positive!
- Stress makes us resilient.
- But if stress is sustained, even if it is positive, breaks us down.
- Stress load and pain is carefully balance through the immune, endocrine, nervous system.
- Pain leads to a stress response, altered motor control and health behaviours.
The backfire effect describes a cognitive reaction where our deepest convictions are challenged by contradictory evidence, and this challenge results in the beliefs being enhance and made stronger. It is not when your beliefs are challenged by facts and you alter your opinion and incorporate the new information into your thinking.
The placebo effect is related to the perceptions and expectations of the patient. If the substance is viewed as helpful, it can heal.
The nocebo effect is a cognitive reaction related to perceptions and expectations. If it is viewed as harmful, it can cause negative effects. Medical scanning can often have a nocebo effect.
This is not a complete outline of the course but more a highlight of the areas where my thinking changed and developed. After attending Peter's course I realised that the words we choose to use are so powerful and can send very strong messages to those listening. But if we don't take the time to check what people interpret from what we say, the messages can change from being powerful and empowering, to disabling.
It fascinates me now to chat with friends, family and clients when they describe their injuries and diagnosis and often I ask myself "what does that word mean to you?". If I am going to ask them this questions I only do it when I have the time to chat to them, understand whats going on in their head, and educate them with better information if they need it. If I can't do that, I don't start the conversation because it can just leave them questioning their own understanding and feeling unable to find the answers.
"Words are singularly the most powerful force available to humanity. We can choose to use this force constructively with words of encouragement, or destructively using words of despair. Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate and to humble." Yehuda Berg
Take the time to clarify by asking "what have you understand from that?" Just like me, you'll be surprised how easily misconceptions start & how easy they can be prevented through education.
Choose to take your clients on the journey to recovery.
References & further reading
For further information www.pain-ed.com is an open sourced website for both patients and clinicians, with the goal of closing the gap between research and practice.
I'd also recommend the following articles relating to this blog.
McCullough, B. J., Johnson, G. R., Martin, B. I., & Jarvik, J. G. (2012). Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management?. Radiology, 262(3), 941-946.
O'Sullivan, P. (2012). It's time for change with the management of non-specific chronic low back pain. British journal of sports medicine, 46(4), 224-227.
O’Sullivan, P. (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), 242-255.