Avoid or Confront?

One of the biggest dilemmas I still have as a physio, even after 20 years of practice, is trying to decide if I should ask someone to avoid things that cause pain or ask them to do the opposite and confront it. Trying to figure out who, when, and why we should ask to avoid or confront pain can be really tricky and difficult as hell to get right.

The first thing to say is there are no right or wrong answers here. Unless you find yourself ALWAYS advising those in pain to stop doing everything that hurts, or you find yourself ALWAYS advising those in pain to ALWAYS do things that cause pain, then you are most definitely doing it wrong.

The facts are not everyone in pain needs to stop doing painful tasks, activities or exercises, but some do! And not everyone in pain needs to start doing painful tasks, activities or exercises, but some do! Some people in pain need advice and guidance to stop doing painful things for a while, others need reassurance and encouragement to start. But who, when, why, how much, and for how long for are where it all gets a little tricky and uncertain.

Boxes

As much as we try, people just don’t fit into nice neat little boxes or follow rules or guidelines very well. Yet we healthcare clinicians still try to cram people into sub-groups and categories using arbitrary generic factors such as their age, diagnosis, chronicity, and pain levels. But the uncomfortable truth is that no two people in pain are alike, even if they are the same age, have the same diagnosis, or even the same pain levels, yet we assume these factors inform us that we should treat them the same.

When I see clinical guidelines and recommendations stating those with certain ages or certain pathologies should have similar treatments, like all those under 50 years of age with rotator cuff tears should have surgery, or all Achilles tendinopathies should do rehab that causes pain, or all those with lumbar radiculopathy should never do anything that hurts, I get rather frustrated. That’s not to say I never follow these guidelines, it’s just that I don’t think it’s as simple as this when deciding who, when, and why pain is or is not advisable in rehab.

I don’t think deciding ‘who’ should avoid or confront their pain really has that much to do with ‘why’ they have pain. That’s not to say I think diagnosis or pathology isn’t important in our decision making before you all jump on that false dichotomy bandwagon and ride it to the comments section. It always has been, and always will be rule number one to first and foremost assess and screen those in pain for any serious or sinister pathologies.

Rule No 1:

It goes without saying that ALL clinicians should ensure that someone in pain doesn’t have an underlying serious or sinister issue that could cause them further harm or detriment if left untreated. Things like fractures, major soft tissue injuries, tumours, blood clots etc are all essential to check for in those in pain as these need urgent medical treatment and therapy is not the place for them to be.

However, when there are no clear signs or symptoms of any serious or sinister pathology and the diagnosis is more musculoskeletal, but less certain in its specific source, as it often tends to be in most we see in pain, then deciding if I do I or don’t I recommend painful or pain-free tasks or exercises becomes tricker.

These days deciding if I suggest a person in pain does or doesn’t continue on with something that hurts is not only based on their diagnosis, but more on what they have already been doing, how that has made them feel, and how it has gone so far.

No one in pain goes to see a physio immediately, even with acute issues in private settings, usually, there is a period of at least a few days, if not a few weeks or months or longer where they’ve been struggling on with their pain as best as they can before deciding to seek some advice and assistance. Over the years I have realised that it’s not the diagnosis that helps decide if they should or shouldn’t do painful things, it’s more about what they have been doing already with their pain that does.

Rocket Science

Now, this is not complex, complicated, rocket science, or any other science for that matter, this is just 20 years of experience in dealing with various people, in various levels of pain, for various different reasons and is a principle so simple its almost embarrassing, but it seems to work… most of the time.

As the father of modern medicine Sir William Osler was famous for saying “listen to your patients they are telling you their diagnosis” I also think listening to your patients also tells you their treatment plan. Asking a few more questions and listening to what someone has already done whilst in pain, why they’ve done that, how that made them feel and most importantly how it has responded pretty much tells you what their management plan should be.

In a nutshell, if someone in pain (with no signs or symptoms of anything serious) tells me they have been mostly continuing on with painful tasks, activities, or sports, pushing into pain regularly and often, and this hasn’t helped or settled things down over a period of time, and this is making them feel upset, anxious, and/or frustrated, I often would suggest they try and do the exact opposite as their treatment. I told ya… not rocket science!

In this situation, I would spend time with this person trying to find ways, means, and strategies to reduce their pain on the movements and tasks that hurt them the most. I would also advise and reassure them that doing something different for a while can be beneficial, and I may even suggest they stop doing something altogether for a period of time.

Rest isn’t Evil

In these days of “can’t go wrong getting strong”, “just load it” and “no pain no gain” it seems that advising someone to stop, rest up, and avoid pain is frowned upon and considered to be bad advice. It isn’t.

I see many people in pain who just continue to push, press, poke and hammer on with painful tasks, activities and exercises, aggravating, irritating and sensitising the shit out of themselves and their tissues in a belief this is beneficial. Sometimes it can be, but often it isn’t.

These individuals regardless of their pathology or diagnosis often need advice, reassurance and sometimes permission to stop doing things that hurt. They also need a lot of distraction and amusement with something else whilst they are avoiding or stopping painful tasks or exercises and so I often give them rehab that works them hard but doesn’t provoke their pain.

I may even suggest they try some manual therapy, taping, quacupuncture or other temporary passive pain modulation treatment thingy if they want to try it (as long as it doesn’t waste too much time, money, or distract them away from other things). I know, I know, I can hear your jaws hitting the floor from here, but my argument against these things has never been they cant help some people, just they shouldn’t be used on everyone, and certainly not in the belief they are skilled, special, or super effective.

Rocket Science Again!

However, if someone in pain tells me they have already stopped doing things that hurt and have avoided their pain in tasks and activities as much as possible for weeks, months, or even longer, and they are worried about making it worse or express concerns about doing harm or damage, and this hasn’t helped settle down or reduce their pain, then I would probably suggest that they need reassurance, encouragement, and motivation to start doing things that hurt a bit… again… its not rocket science.

As Albert Einstein’s said “the definition of insanity is doing the same thing over and over again, but expecting different results” and this is no different with things that hurt. As much as we clinicians don’t like to admit or discuss it, many things that cause pain in musculoskeletal medicine have a very favourable natural history. That is they tend to get better on their own over time thanks to the remarkable adaptable and self-regulating ability of human physiology.

However, when this doesn’t look like it’s happening its often because something is getting in the way of natural history, and yes this can be other pathology and as I’ve already mentioned should be checked for as best as able, but more commonly in my experience, this is due to an individual either avoiding or confronting their pain too much, too often, or too little, for too long.

Our job as clinicians and therapists is therefore very simple, but not very easy. First, we must, to the best of our training, skill, and ability exclude any serious and sinister pathology that could be causing someone persistent pain. Next, we need to identify what, how, and why a person in pain has been dealing with their pain so far, either avoiding or confronting it. Then decide if this is, or is not a successful strategy and if it needs to be continued or more often than not changed to do the opposite. As I said… it really isn’t rocket science!

As always thanks for reading

Adam