It’s all in your head, that’s ok or maybe not?

It’s important to acknowledge that we can have two sides of the spectrum when discussing notions of pain with patients.

A recent masterclass article in manual therapy by Nijs et al, (2013) highlight that the biomedical framework is the core of most clinicians training and yet ‘it falls short in explaining and treating chronic musculoskeletal pain’. Furthermore, there is ample evidence that the therapists’ attitudes and beliefs regarding musculoskeletal pain are associated with the beliefs of their patients and the clinical management. Thus having a broader understanding of a multi-dimensional problem aims to facilitate critical thinking when faced with  such a complex problem.

There’s a bit of a trend in the teaching pain world, something that clinicians have been careful to avoid alluding too. The phrase “it’s all in your head.”

I have a bit of an issue with this and wonder whether we need to be less sensitive about this but at the same time be mindful of the people we explain it to. Perhaps our ability to clinically reason with whom talking about pain experiences being an output of the brain is what is lacking. I have had mixed reactions, some people have become angry when talking about pain in a way that doesn’t reflect the state of the tissues. That’s a situation when it’s just not worth going there. Others… well… are perfectly comfortable with the idea.

A recent experience I had with a person experiencing persistent pain captures this perfectly in my honest opinion. This person had received previous exercise and education programs with too much of a focus on a biomedical approach to explaining pain. It wasn’t till I explained brain concepts and cognitive process related to fear and threat that she realised it was the thoughts in her head that were perpetuating her fear and increasing her pain.

After a few sessions she was back to playing touch rugby and playing with her children on the beach. She was so happy that she knew that it “was all in her head” and she could get on with “normal” aspects of her life that she was unable to do prior because of her pain.

In contrast, I recently saw a gentleman whom had live with persistent back pain for 7 years and was angry at the fact that clinicians had repeatedly (perhaps unintentionally) implied that his pain was in his head. His response, “The pain is in my back! Not in my head!” So in this case is talking about pain and brain appropriate? Perhaps talking about pain is not the issue, perhaps addressing his understanding of tissue damage vs healing vs living well with pain is more appropriate.

This got me thinking that perhaps there isn’t a need to be overly careful about the whole “it’s in your head” thing. Why? Well perhaps this comes down to the patients interpretation, however you explain it, whether you do your absolute best to avoid the “all in your head” suggestion the patient may still see it as that, which then means it is open to how they view it. It is important that we think critically about the subject matter, beliefs, culture, experiences and history of the person living with pain. A multi-dimensional problem needs a multi-dimensional approach to thinking, treatment and care.

In reflection I’m perhaps less careful about the “all in your head” issue but more careful about screening the person appropriately as to how they might react to education that might allude to the suggestion.

It’s important to question appropriately through use of guided discovery and to be honest and upfront when explaining concepts of pain and the brain. To highlight that there are biological adaptations going on all the time.

Clinical reasoning and critical thinking should be used in all aspects of our delivery. We have done it during our subjective assessments to lead us to a hypothesis and what is considered in our must, should and could lists when it comes to testing and movement assessments.  It’s just as important for our communication. Be mindful of how you educate because the one size fits all approach doesn’t apply in any individual context.

Cheers all have a happy weekend!

TNP

Nijs, J., Roussel, N., van Wilgen, P. C., Koke, A., & Smeets, R. (2013). Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18(2), 96–102. http://doi.org/10.1016/j.math.2012.11.001