50 ways of thinking differently in pain science: Part 1

I was flicking through an Auckland chamber of commerce magazine recently (it’s nice to draw creativity from other business sectors) and came across an article ’50 ways of thinking differently’ so I decided to create my own for pain science.

This list is an attempt to demonstrate the level of creativity we can have when working with people with long term pain.  The list is a means of helping us to critically appraise our own beliefs, biases and clinical delivery in order to get us thinking more creatively. This list may not be for the faint hearted, but (and this may sound harsh) pain is not a simple ankle sprain, it is a complex beast that requires time, investment, understanding, cross-fertilisation and life long learning.

This list could be seen as somewhat exhaustive so in order to minimise that I have split it into two parts. So here’s the first 25:

1. Question the status quo: There’s always more to learn and to understand. Many of us are still stuck in a uni-dimensional thought process (sometimes through no fault of our own), which only gives us a uni-dimensional approach. Take your learning further by understanding more about what propagates nociception? what is central sensitisation? Can neuropathic pain be in the smaller superficial nerves? How does stress bare similarities to inflammation? What are the relationships between sleep and pain?
2. Go against the grain: Going with the grain is easy, it’s smooth and light and you can glide through, doing the same over and over again, but to go against the grain is a challenge, you can get stuck and it can get a bit rough for you and your patients. Don’t be afraid to ask for help. Remember people are individuals, one size does not fit all, N=1 (my big up to @cause_health)
3. Keep asking ‘why’ and then ‘why not’: It’s important to highlight that pain science isn’t easy. We are no longer thinking in body parts or quadrants or silos. It’s not that “simple”. By asking yourself ‘why’ and ‘why not’ draws upon critical appraisal skills and reflective learning. We should all be having periods of critical appraisal (not just because our governing body expects it!) in order to make ourselves versatile clinicians.
4. Be empathic: It’s hard to be empathic when all you want to do is ‘fix’ things. Let’s agree that’s traditionally how we’ve been educated and what we have been taught our treatments can do! A great YouTube video here shows the true value of empathy
5. Take action – every time: Pain science is a bit of a revolution and embracing new models of clinical delivery can influence too much of a swing of the pendulum. Don’t forget the biological. Sinister pathology can still raise its ugly head and you need to be aware of recognising the signs and symptoms in order to take the appropriate action.
6. Embrace uncertainty: The old X and Y debate gets a mention here, if one is the opposite of the other then one must be wrong. This is not good use of critical appraisal skills. Embracing uncertainty is uncomfortable hence why people tend to prefer to prove one to disprove the other. Having a more nuanced approach to your understanding of pain will help in your clinical delivery.
7. Hire new thinking: Delve into the science, read the research, speak to your colleagues, ask permission from your patients, invite your colleagues in to collaborate and exchange ideas, access social media to challenge your thinking, hold a collaborative in service.
8. Think about your language: I published a blog on this last year. Language can have an incredibly strong influence on prolonging people’s fear and avoidance behaviour and metaphor has always been used in healthcare. I’m definitely not asking you to bring in a thesaurus when talking to your patients. It’s important though to consider if the language you use is a true representation of the problem. i.e. your IVD is definitely not a jam doughnut.
9. Increase visual input and stimulation: We all have computers, phones, tablets nowadays. Why not use them to your advantage. Show people YouTube videos, record the person doing movement with their mobile phone, use images and PowerPoint slides to explain pain, get out of the clinic and use the environment around you to explain pain and to show people the freedom that they can have living with long term pain
10. Have fun: I’m a huge fan of fun, you have to make it fun, mix it up, use your imagination to make your session more meaningful for the patient and for you. Being too serious about something that may not be is just… well… being too serious.
11. Think how the patient thinks: When your patient leaves your clinic, it’s important to think about the different environments they will face and how this may have an effect on their pain.
12. Embrace ambiguity: Changing something in a person (if they are sensitized) that makes them feel better is a good thing. Having to know the ins and outs of why (biomechanical flaws for example) is not always necessary.
13. Be prepared to be up for the challenge: Traditionally we have been taught from an anatomical perspective. We can get stuck within mechanistic thinking, challenge yourself to widen your knowledge base to neurophysiology, to immunology, to philosophy and to other areas that pain science draws upon. #lifelonglearning
14. Experiment: Don’t be afraid to be creative and use your imagination in education, exercise prescription and changing environments, question the persons beliefs (you may not change them) and challenge the existing concepts.
15. Encourage freedom: Allow freedom of movement, don’t place people within the confines of a movement method or give restrictions or limitations to their values  This restricts fearless, thoughtless movement and their lives.
16. Learn how to weight risk: Is what you are teaching or coaching a patient the right thing to do? What do you know about the person? Are they prone to flare ups? Or perhaps you need to push them a bit in order to encourage change.
17. Think longer term: Are your working for the short-term or the long term? Can you help the patient by providing coping strategies in times of crisis (flare up / relapse) and to encourage an internal locus of control.
18. Use those soft skills: People in pain often have concerns and are worried and can also be angry because no-one has provided them with an explanation as to why they still have pain. Reassurance, listening and having the odd joke are invaluable for earning their trust.
19. Welcome complexity, it’s an incubator for ideas: Yes complexity is difficult! But is our nervous system simple? A favourite quote of mine from Moseley ‘The nervous system is fearfully and wonderfully complex’. Take the time to learn about neurophysiology, how nerves change their phenotype, consider a nerve like a kaleidoscope, on the outside it’s still a nerve but inside it changes.
20. Open up communication of ideas: Historically our assessment procedure has encouraged a method of identifying what is wrong with the person. Shift your questioning from closed to open and to reflective listening to understand who is the person. If you haven’t already I would encourage you to learn some motivational interviewing skills. Adapting your communication style can help a huge amount when wanting to learn more about the person sitting in your clinic room.
21. Communicate, communicate, communicate: Seriously this is hugely important! This is not just your communication with the patient but also with other healthcare professionals that may be part of the integrated team. Furthermore, we know from research that treatments in isolation and combined show that the effect sizes were really small. So make sure all clinicians are sending the right message, and if you have a query then discuss it with clinician.
22. Listen, listen, listen: Did you know that the average timeframe for a clinician to interrupt a patient after they’ve started talking is under 10 seconds? Sitting and listening without judgement, acknowledgment and validation is a powerful way to gain patient adherence and trust. Create connectivity.
23. Consider the social and developmental construct of the individual: Ask yourself who is this person? What do they do? What are their values? What are their relationships like with people? What has happened in their lives? How do they interact with the environment within and outside of the clinic.
24. Access and expand your metaphor library: Not everyone will associate with a single metaphor that explains a component or aspect of a pain experience i.e. the sensitive car alarm. It goes back to understanding the social and developmental construct of the individual.
25. Learn to recognise safety behaviours: Does your patient still walk with a crutch long after the injury has healed? Do they need a knee or ankle brace? Perhaps they need to keep their “core strong” for fear of their spine buckling. Some safety behaviours may be needed in the short-term but should be gradually phased out over time.

That’s it for part 1! I’d like to thank a few people for giving me the inspiration to write this blog post. Dr Bronwyn Thompson, Prof Kieran O’Sullivan, Mike Stewart and Dr Mick Thacker.

Thanks for having a read

TNP