Can potentially harmful pain explanations ever be helpful?
WARNING
I’m not sure you want to go down this road with me dear reader so consider this your warning. There are some messy potentially uncomfortable truths in this blog.
I like finding common threads between different treatment styles. I like to consider why someone gets better. And I’m pretty aware false attribution. For example, I like to prescribe heavy loads for many painful conditions. I note that people often get better and it would be very easy to conclude that they got better because they got stronger or we built up the tissue’s structural strength. But, there are other potential reasons why heavy loads help and we can’t conclude causation or mechanisms based on these anecdotes.
So, for the past few years I’ve been doing the same type of reflection when it comes to our explanations of why people hurt (aka how we help people in pain make sense of their pain). Like many others I’ve been pretty tired of therapists making their patients feel like fragile stack of blocks ready to give way at any point. Or therapists who tell their patients that their glutes are shut off, they have faulty movement patterns, their discs are 37 bends away from herniating and they need to correct all these things before they resume their life.
I hate these narratives and have certainly seen the harm they can cause but…
…what if they are accidentally helpful for some people and I just don’t see those people? Or the narratives are part of treatment program that ends up being helpful. I know these responders exist. I know therapists who practice in this style and I know that have helped people. We even have some pragmatic research where interventions with questionable narratives (i.e the Kinesiopathological model) lead to favourable outcomes.
So assuming there are occasions where these interventions and negative narratives are helpful I think we should then ask why are they doing OK? And can we learn anything from this? So bear with me as we explore this simple question. How can false and potentially harmful narratives actually be helpful?
What do people want and need to recover?
People in pain need to make sense of their pain. And this explanation for their pain needs to resonate with them. Good explanations weave components of the patient’s story into a cohesive narrative that explains (makes sense) the entire experience of someone in pain.
But that’s not all!
That narrative needs to be followed by a plan that also makes sense. It’s the treatment “glove” that fits the problem’s “hand”. We help our patient’s make sense of their problem which then follows logically into our solution. When the solution resonates with both the pain explanation and the person it gives people hope. We can’t just throw out a bunch of contributors to pain and not provide a means to address them.
To me, good explanations are only good clinically when they can be met with an achievable solution (our patient centred treatment plan). Which leads me to ask…
Can that explanation be false? Or does it have to be true?
Take these two scenarios.
#1 Biomedical kinesiopathological Therapist (BKT) and person in pain
The BKT performs a ridiculously thorough, redundant and largely unnecessary physical examination of the person’s spine, hips, knees and feet with a particular emphasis on recreating their pain and understanding the mechanical contributions to the painful movements. The therapist listens to their entire history of physical activity, explores previous injuries, understands how frustrated they are with years of low back pain and commiserates with how angry they are that no one can help them strength train, play baseball and fish without this pain.
After 90 minutes the BKT explains:
Your back pain makes sense. Just like when you had that disc herniation in your neck 8 years ago you probably have a small one at L4/5 right now. Its not a full blown herniation but the outer layers of the disc (pulls out spine model to show patient) have started to delaminate. And we can have delamination for years and not have problems because there aren’t nerves on the inside of the disc. But after a while the nucleus starts to push its way through the outer parts of the disc and then our body starts to grow nerves into this injury and we start having pain. What you’ve been doing accidentally for years is pushing out this nuclear material and slowly over time you are causing those nerves to get more and more sensitive. You do this because of your spine flexion. Spine flexion causes this disc damage and you’ve been damaging your spine with all the flexion that you do. You sit in flexion all day at work, they way you do your squats, deadlifts, sits ups and most exercise involve a lot of flexion and the sports you play all have you flexing your back. Its just wearing out because of the movements you do. You don’t use your hips and your back is just getting overloaded. Its a wonder you didn’t have pain years ago and unless you do something about this flexion its just going to get worse.
You don’t have a lot of hip mobility so when you golf you rotate at your spine a lot. All of these repetitive movements are just irritating that really sensitive disc and its probably causing some central sensitization now. You probably also have some microinstability so that the spinal parts are moving around more than they should and that aggravating the disc too.
Person in Pain: Sounds bad. What can I do?
BKT: We have to change your movement patterns and stop putting that stress on the disc. I’ve looked at how you deadlift and squat and we can modify your technique to be more upright and switch out your squats with lunges. We are also going to change the weights you lift. You are lifting too much right now for your back so we have switch from doing 3x8 to 4 sets of 3 with less load and our new technique. You can still play hockey but you are going to play defence with a longer stick and only pick-up and not in your competitive league. I’d advise a sit to stand desk as well. You also need to walk more or get some more Zone 2 aerobic exercise - but nothing where you have a lot of spine flexion. If we can improve the blood flow to the area and avoid that damaging pattern the disc can start to heal. You still get to weight train but we will add some spine stability exercises that build up the stability of your spine and won’t damage it further. I’ve seen countless people just like you and it takes time but you can do great.
Person in Pain: Makes sense. Lets’ go!!!!
3 months later: feeling better, less pain, engaged in hockey and all sports but knows that they need to protect their spine with their movement modifications and regularly doing exercise to keep it robust
This is the classic kinesiopathological model. You can see it tested in a paper like this (Van Dillen 2021) where the clinical improvements are pretty good and comparable to the CFT approach that I prefer (link here). I don’t agree with the kinesiopathological explanation but I hope you can see how this will make sense to a lot of people, shape their expectations and give them a program that could be helpful (regardless of the explanation). The treatment program in many of these scenarios could be helpful because they manage loads (e.g backed off of doing the things that were aggravating them), kept and gets people active, do symptom modification, help them control their pain and give them permission to keep doing the things they love. The mechanism could have nothing to do with disc nociception or spine instability. That explanation just motivated or lead to a potentially helpful approach. The people in these instances probably didn’t get better because of some change in the disc but because they had hope, optimism, had an explanation that made sense to them and then did a pretty general intervention that was helpful for a number of reasons that have nothing to do with spine stability or disc herniations.
Scenario 2: Potential accurate explanation but unhelpful execution
The problematic BioPsychoSocial therapist (PBPST) - After a 90 minute in depth history taking and exam
PBPST: After doing the assessment, examining your scans and hearing your story we can be assured that your pain is not due to damage. We know that a lot of people have changes on their scan and they don’t have pain. Your back is totally fine. This is really a problem with your neuroimmune system. You definitely have nociplastic pain and have structural and functional changes through out your nervous system that both create and perpetuate this persistent pain problem and your obvious suffering. You have traits of catastrophizing and rumination (potentially a manifestation of your OCD) which makes it worse and you have a 30 year history of anxiety and depression. Depression is regularly linked with pain and can absolutely cause it and make it worse. You have history of trauma and your work stress right now is off the charts. Your job is unstable, causing a lot of financial stress and you seem to be getting tired of seeing therapists, spending money on them and not getting any results. This clinical uncertainty can absolutely make our pain worse. You seem really stuck and pain has become one helluva a habit for you.
Person in Pain: Yes, that sounds like me. What can we do?
PBPST: Ummm, have you tried Yoga?
Obviously, no one would do this. Its taken to the extreme but I think you get my point. And those points are:
1. I’m not going to give out inaccurate and potentially harmful beliefs about pain. I personally think a strong biomedical/KPM approach is wrong and much prefer a CFT approach (link here) But, as therapists I think its useful to understand why people still recover when exposed to a kinesiopathological approach. What can we learn about these approaches? Where is the good in them and what is potentially bad. Find the good, save that and avoid the bad. Easy-peasy
2. Our explanations must not only make sense to the person and resonate but they must be followed with a plan that makes sense and resonates with the pain explanation. Find the glove that fits the hand. This paper compares a BPS pain explanation versus a biomedical pain explanation and they found no differences in outcomes I think they may have stumbled upon this conclusion (link here) where they write:
”Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT”.
3. We don’t need to totally ignore interventions we see in the kinesiopathological model. The approach needs a reframing not extinction. Much of the KPM success is probably due to optimism, building pain self-efficacy, general physical activity, load/symptom management, the resumption of meaningful activities and a supportive and caring therapist. Its the classic calm shit down, build shit back up approach.
Caveat
The big problem with the first scenario is not so much that it will help some people (that’s great) but there are probably a subset people that it won’t help and then the explanation becomes harmful. They have heard that their spine is fragile and unstable and now things have gotten worse. Because the contributors to their pain problem were never addressed and now we have added fear,rumination and avoidance to the mix with our shitty explanation. And I would guess these are the people we all see that the kinesiopathological model failed. These might be a tiny portion of all people who have had low back pain but since so many people have low back pain a tiny portion is still a significant amount.
Thoughts? Should I delete this blog?