Confronting with Strength. Reconceptualizing our assessment to make changes in behaviour and pain

Catch phrase:  CONFRONT WITH STRENGTH

The point: How are patient's view their pain or injury influences both their behaviours and their sensitivity.  Finding ways to change this narrative can be helpful. It might also be relevant the idea of expectancy violation to change pain but I'll stay away from that topic for now.

The challenge

Sometimes treating pain or disability is like trying to change your patients' favourite colour.  They tell you they like Blue and you are convinced that they should start liking Red.

Changing opinions is tough and since "Pain is the opinion of the Brain" we have to change that opinion.  But how do we change opinions?  Just tell someone that they now like red?  That doesn't usually work and can even lead to the backfire effect. (more reading here and some nice podcasts too).  

As therapists we are often trying to change the false beliefs that our patients have about their body, their pain and what they think they can and can not do.  Movement behaviours might be sensitizing the patient and those movement behaviours might be predicated upon a number of other factors.  Addressing those factors allows those sensitizing movements to change.  More specifically, finding those beliefs, especially ones that might be continuing to sensitize the patient, informs our choices of what type of pain education Key Messages you might want to deliver which in turn allows an enhancement of the other treatment options.

For example, the idea behind confronting with strength might be especially relevant for those who choose avoidance strategies for their pain.  People may feel that they are weak and frail and that they have the most "messed up shoulder their doctor has ever seen".   I believe that we should start with the assumption that our patients are strong, stable, robust and capable of adaptation.

How do you know your patient's can adapt?  There are two criteria:

1. Human

and

2. Not dead.

So now we can look for things to challenge their beliefs about their predicament.  We are looking for things specific to the person that might lead them to reconsider their views of themselves.  Two options are below (but there are certainly others):

1. From their history

Finding something in their history that might challenge their beliefs.  Do they have good days on vacation? Was their pain better when they slept better?  Have they had a couple of days where the pain was much less? Have they been forced to be physically active yet didn't really feel a lot of pain? Did their pain start without any physical trauma?  Variations in pain or success with physical activity all lead to the notion that pain is different from damage or that pain might be more about sensitivity than injury.  Or these anomalies in their history leads to the idea that physical activity and doing things that are meaningful to them are not only not damaging but can be helpful.  We are almost trying to find something the patient might already know but we now "allow" them to believe it.

2. From their physical exam

Physical exams typically suck...for finding a structural source of nociception that is.  We should totally try to rule out red flags and any tissue that requires healing or repair but after that they are pretty poor.  Essentially, the tests just tell us what movement hurts.  So how can we flip these tests?  Lets find all things that are great about the exam.  Like..."That is one sweet Neer's test you have there" or "You're SI joint is wonderfully stable"..."that is one luscious ACL"   Or if you do a quick symptom modification test like a Scapular Assistance Test you point out how a subtle change means that their pain is certainly more about sensitivity than pain since there is no way they healed in 2 minutes.

There are certainly other ways to do this but in summary the steps might look like this:

1. Find the contributors or beliefs the patient has that might be sensitizing them

2. Consider what pain science key message might be relevant to reconceptualize their predicament

3. Consider what factors in their history or in their current abilities that reinforce that key message

This is essentially the biopsychosocial approach.  Those three areas are addressed together and they each reinforce one another.  No one ignores the bio here.  We just amplify the mechanical components of our therapy with the other spheres.