Warning: This blog may cause offence!!!
You might be thinking this blog will be about some recent online events where some physios took offence at a word I used at the end of a tweet. And in a way, it is as some physios are way too easily offended at things they choose to read. But this is actually more about how too many physios are too soft, too scared, and too afraid of pain. This is about how I think many physios need to toughen up both professionally and personally.
Recent online events around one of my tweets have again highlighted to me how many in this profession have very little resilience and are triggered by the slightest thing that irks, annoys, or upsets them. The same events have also highlighted to me how this profession is full of hypocrisy, contradiction, and nasty two faced sycophants. It seems those who claim to be compassionate and understanding clinicians, are quick to publicly accuse and chastise those who make genuine mistakes. It appears those who claim to be intelligent and rational thinkers often fall foul of many fallacies and errors in critical thinking. It also appears that those who claim to be keen for progress and change are often quick to attack and shut down anyone who questions them or their ideas. And finally, it appears that those who bang on about disliking online self-promotion and egos promote themselves and their courses more than anyone else I know.
However, the biggest contradiction with many physios is how they manage people in pain. Many physios say they now understand and recognise how pain and structural issues are poorly correlated and how pain doesn’t equal damage, hurt doesn’t mean harm, and sore can be safe. Yet despite saying this, they act the opposite by constantly trying to reduce or remove pain in patients with manual therapy, tapes, machines, and other crap. They also tell patients to stop or reduce tasks or activities that cause some pain, and many won’t even contemplate the idea of getting a patient to do an exercise that hurts.
What is it with physios and pain?
Why do so many physios say pain is OK and safe one second, then in the next breath act the exact opposite, telling patients to avoid things that hurt or reducing pain with treatments? Well I believe that despite talking a good game many physios don’t actually believe that it is OK to ask patients to do things that hurt, nor do I believe that many feel confident or comfortable to not treat those they see and let pain continue or even increase in a session. To put it bluntly many physios are shit scared of pain existing or increasing in their patients and to paraphrase Pete O’Sullivan on his recent workshop in London…
if physios are scared of pain, how can they expect their patients not to be!
In my opinion, pain doesn’t always need to be reduced in those we see, and at times it doesn’t matter if it increases. I believe that if we as a profession are to play any role in trying to reduce the chronic pain epidemic that our society has got itself into due to its constant demand for quick fixes and avoidance of things that are difficult, hard, and uncomfortable, we need to start believing that getting people to do things that hurt isn’t bad. I do recognise this is challenging, alien, almost unthinkable for many healthcare professionals due to their training, personal traits, and instincts that tends to give them an inherent desire to help not hurt patients. Some even think that its unethical and harmful to let pain countine or increase and that it breaks our first rule of healthcare…
but ‘do no harm’ doesn’t mean ‘do not hurt’.
Trying to convince physios and other healthcare professionals that it is OK to let pain exsist and not always reduce it and even perhaps increase it is hard. But its even harder to convince those who are experiencing it. Pain is an unpleasant sensation, it demands attention, it creates changes in behavior, and no one really wants it. But we need to start looking at pain differently. Pain is a fundamental part of our existence and without it we would be in a lot of trouble. Just think for a minute how it would be to live with NO pain all the time. At first you may think it would be fantastic to go through life living comfortably, easily, and like a super hero tolerating things others couldn’t.
Well its not like that at all. Living without pain is a curse. Those who suffer with the rare genetic condition called congenital insensitivity to pain go through life without feeling pain, but they cause themselves severe injuries and live in in constant fear and threat of having a serious illness going undetected until its too late. Just imagine what would happen if you didn’t get any pain when you bite your tongue whilst eating? You would most likely carry on chewing but now with a bit of extra tongue! What about when you lean on a hot cooker top, or cut yourself, or get an infection or some other disease and not know about it until you see flesh melting, bones sticking out, or pass out? Simply put, pain is a remarkable process that protects us and keeps us safe, and without it we are extremely vulnerable.
Not experiencing pain is not good, and in my opinion this is what’s happening to our society. We are not experiencing pain as much or as often as we used to. We reduce and avoid pain all the time with our easy lifestyles, modern technology, accessible medications, and constant molly coddling and over protecting. We have lowered our tolerance to pain and now feel pain quicker, faster, and easier than before with lower and lower stimulus. The human race is becoming more vulnerable, more hypersensitive and more intolerant to pain through its avoidance, and this is in part the fault of physios and all healthcare professionals .
What’s the solution?
If you’re intolerant to something the best way to become tolerant is through exposure, gradual, graded exposure. We know this works for exercise, allergies, phobias, even alcohol, and its no different for pain. In my opinion many who experience pain doing things that shouldn’t hurt such as bending over, getting out of chair, walking, lifting their arms above their head need exposure to these painful things to develop resistance to it, what they don’t need is further avoidance, analgesia, or even bloody symptom modification procedures.
I was taught as a physio to always try and reduce pain in my patients and I used to try my hardest. But I wasn’t always successful, in fact I was rarely successful. This used to really dishearten me and made me feel that I wasnt a good physio and a failure, and I thought about quitting this job many, many times. However, over the years I slowly began to realise that it didn’t matter if I did or didn’t reduce patients pain when I saw them. Patients who I didn’t reduce their pain got better, and patients who I did reduce their pain didn’t always get better, in fact sometimes they got worse. It seemed that many other factors determine if patients are going to improve or not other than just creating changes in their pain when they come to see me.
I now find I get more and more patients doing stuff that hurts and cause them some discomfort in sessions, rather than trying to reduce their pain for a number of reasons. First is because those I see have been told to rest, reduce, remove, avoid the pain for many weeks and/or months and this hasn’t helped, in fact its made them worse. I often find myself having to be the harsh, mean, bad guy telling patients to reverse this and to suck it up, crack on, and get going as no other bugger does. Doctors, therapists, family, friends often tell people in pain to NOT do things that hurt, and I do understand this is good advice in some certain situations, but only ever for short periods, not 3, 6, 12 months after an episode of non specific low back, knee, shoulder pain.
Getting patients to do things that hurt tends to be a shock for them and so I find it often confronts and violates expectations which can be hugely beneficial (ref). Many patients come to see me expecting a massage or something easy to do due to previous experiences or preconceptions of physio, many don’t expect to be asked to something that is challenging or that will hurt. Now don’t misunderstand or jump to conclusions about how I do this. I am not advocating a gung ho, macho, no pain no gain approach, screaming at patients like some demented US Marine Drill Sargent. Getting patients to do things they don’t want to do is not as aggressive or as hard nosed as you may think, but it is hard work, really hard work.
To get patients to do things that hurt is difficult, most are reluctant and some flatly refuse. But with rationale compassion, robust encouragement, and confident reassurance most will do what I ask of them eventually. The key I find is to develop a good rapport with the patient early on, and this is easier said than done, but once established be persistent and confident, and don’t promise things you cant, like it wont be as bad as you think, as it usually is, to begin with.
Another key point I find is to not let them do the painful task or exercise just once, but many, many times in succession. Most eventually do realise that it wasn’t as bad as they expected and/or pain levels are reducing, this then starts to produce the confidence that they can expose themselves to more and more things that hurt on their own and they have control over their pain.
What tasks or exercises I get patients to do varies from patient to patient based on what they tell me they can not, or do not want to do. Sometimes its getting them to pick something off the floor, sometimes its getting them to reach up high, sometimes it involves me knocking them around a bit giving them some sudden unexpected movements. My most special orthopaedic test in my physcial examinations is asking the patient to show me the things they can’t or don’t want to do, and thats what I tend to get them to do!
Another reason I get my patients doing things that hurt a bit is I like to give exercises and tasks with higher loads and dosages. Anyone who has exercised will know that heavier, faster, more frequent exercises/tasks tend hurt more than lighter, slower, less frequent ones, but they do create physiological and psychological changes sooner, faster, better.
What’s the evidence?
Despite common belief and assumption by many physios getting patients to do exercises and tasks that are painful doesn’t have detrimental effects, in fact it may have significant advantages over non painful exercises in the short term. A recent and important systematic review by Ben Smith and colleagues just published in the British Journal of Sports Medicine here has shown that exercises that cause pain up to around 5 out of 10 on the visual pain scale have no harmful or detrimental effects.
Source: BJSM, Smith et al (2017)
However, as with most things getting some people to do painful exercises or tasks is not a panacea or suitable for everyone, and so some caution is warranted in some populations. Repeated exposure to painful stimuli can be great in developing habituation to pain, but it can also create increased sensitisation to it (ref, ref, ref). It appears that some populations do not get the same top down inhibiting central responses with painful stimulus and so we do need to recognise this.
Also I dont think we always have to ask patients to do exercises or task that hurt. For example if there is a way to do a task or exercise without pain then do it that way. Sometimes creating a simple change in position, speed, load can reduce pain and if the task that couldn’t be done is now done. But then look to revisit the painful movement or task and see if you can also develop resilience to it through exposure.
So in summary the hypocrisy and bull shit spouted by some in this profession still fucks me off immensly, and those with personal agendas and vendettas who use the thin disguise of offence and moral righteousness are simply pathetic and as far from health care professionals as can be! However, despite this crap, the main reason for this post is to highlight that a lot physios do need to stop being afraid of pain and stop being too soft. Asking patients not have those pain killers, not to get that bit of tape, that massage, and to carry on with tasks that hurt and even do things that increase pain a bit for a while is not harmful or bad. In fact it could probably be the best thing you do for them.
As always, thanks for reading