A response to Lorimer’s editorial in the BJSM

Whole of community pain health education. for back pain. Why does first-line care get almost no attention and what exactly are we waiting for?

 

I read with intrigue and interest Lorimer’s editorial in the British Journal of Sports Medicine (G. L. Moseley, 2018). I have huge respect for the man who has effectively flipped the traditionalist healthcare world upside down. Take physiotherapy for example, the scourge of biomedicalism and manual therapy is ingrained within all physiotherapists. Yet among them there are those that have shifted their practice to a more behavioural/activity approach (which could be imprudently misrepresented as a “hands off” approach) since much of the theoretical underpinnings of the postural, structural, biomechanical and manual therapy models have been refuted (Bereznick et al., 2002; Lederman, 2010, 2015; Schmidt et al., 2017; Van Ravesteijn et al., 2012).

 

I digress, back to Lorimer’s editorial. I have a big question. Undeniably Lorimer has devoted his life to understanding pain and for that I applaud him. Yet, within the first paragraph I became frustrated with his choice of words. I agree that the majority of back pain does not require surgery. I also agree that the majority of back pain does not require long term analgesics. I also agree that most will resolve over time. Yet the next part of that sentence stopped me in my tracks. ‘If we do not mess them up.’ I pondered on what he actually meant by that? If we assume he is talking about the patient there’s a really big BUT with that. If he meant the clinician there is also a big BUT with that! I want to return to both those points a little later but firstly focus on Lorimer’s main point – education. I won’t deny that education is incredibly important and that there is a significant amount of research that supports the use of education for pain management (Louw, Zimney, Puentedura, & Diener, 2016).

 

Yet there are many barriers to why pain education is not headline. Pain education’s integration within university curriculums (which is the corner stone of any healthcare training) is significantly lacking (Briggs, Carr, & Whittaker, 2011; Hoeger Bement & Sluka, 2015; Loeser & Schatman, 2017). Healthcare continues to be delivered under biomedicalism, educating clinicians with a language that represents pathology. This figuratively goes against the grain of pain education, and so changing that language with a proverbial click of the fingers is no easy feat. Lorimer himself identifies that clinicians do not have the understanding or resources to engage in what can be a complex and challenging exchange of health reconceptualization for the clinician and the recipient (L. Moseley, 2003) Yes, that paper is outdated but there are more recent publications that would support his paper (Domenech, Sánchez-Zuriaga, Segura-Ortí, Espejo-Tort, & Lisón, 2011; Gardner et al., 2017). My own experiences of working with other clinicians would appear to suggest that learning the complex neurobiology is fundamental prior to simplifying through the use of (say…) metaphor (the buzzword in healthcare) to facilitate reconceptualization.

That sentence…

So, let’s go back to the ‘if we do not mess them up’ comment and consider the reciprocal perspective between the patient and the clinician. There is much research that identifies the implications between clinician and recipient in communication, which is a skill in itself. Pain education is one small part of communication. Collaborative exchange of information without patrony is a challenge (Zanini, Sarzi-Puttini, Atzeni, Di Franco, & Rubinelli, 2015), as is clinician discomfort of risk of stigmatizing a patient (Synnott et al., 2015). The shift from medical, scientific terminology to understandable language has its challenges. Significantly, patients and clinicians define terms differently leading to misunderstandings when both think they are talking on common ground. Furthermore, recipients can choose and hear words important to them without considering the context of how the words are delivered  (Barker, Reid, & Minns Lowe, 2009; Greville-Harris & Dieppe, 2015). Moreover, Patients seeking information from HCPs can experience difficulties understanding them and the medical literature (Darlow, 2016).

 

Now I am all for pain education, it is influential to my practice. However, i personally feel it is crucial that it is tied to activity. There is a wealth of evidence to support the importance of exercise/activity in the management of musculoskeletal pain (Babatunde et al., 2017; Brage, Ris, Falla, Søgaard, & Juul-Kristensen, 2015; Kroll, 2015; L. Moseley, 2002). However, there’s a but, again! Despite the extensive research in exercise dosage and health promotion, exercise/physical activity or health promotion is, like pain education, not a compulsory part of medical and physiotherapy training, with very little understanding of physical activity guidelines (Lowe, Littlewood, & McLean, 2018; Lowe, Littlewood, McLean, & Kilner, 2017; Weiler, Chew, Coombs, Hamer, & Stamatakis, 2012). So, the disciplines that have demonstrated a lack of uptake in pain education as identified in Lorimer’s editorial also demonstrate a lack of knowledge in exercise prescription. Tie that in with the universities not providing a basic grounding of exercise prescription or physiology, well, to me that is a crisis people!!

Jackasses and pain ed

It is generally accepted that knowledge translation is important but essentially it is nothing more than that, the exchange of data between two individuals. I have previously stated pain education is one small part of an interchange between the individual living with pain and the clinician. It was Bill Fordyce that coined the phrase ‘Information is to behavior change as spaghetti is to a brick’. So, whilst explaining pain at front line care might help some people to get going again, for others we need to offer more. A further idiom that I would use to describe this issue – ‘A jackass can kick a barn down, but it takes a carpenter to build one.’ – Meaning that anyone can attempt to teach pain education but it takes more than just telling people that it is safe to move when they are avoidant of movement. As clinicians, we need to modify our role if we are to support people through the challenge of learning to live well with pain. Prochaska & Di Clemente, (1982) developed the trans-theoretical model of change. It suggests that our role should adapt as the person engages and goes through change – see image. So, whilst attempting to change the beliefs of patients through pain education it makes little difference if the person continues doing what they are doing. This is why (and this view is shared by many of my colleagues) I am probably a behaviourist.

I want to finish with a final thought. Should the title read ‘community pain education’ or should it read community health education, with the deletion of the words back pain?

 

Pain is a symptom of a larger emergent problem – poor health. When I say health, I don’t just mean the integration of bodily systems I mean health as a determinant of social integration and context. I have discussed the case for change in a previous blog.

 

Thanks for having a read.

 

TNP

 

References

 

Babatunde, O. O., Jordan, J. L., Van Der Windt, D. A., Hill, J. C., Foster, N. E., & Protheroe, J. (2017). Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS ONE. https://doi.org/10.1371/journal.pone.0178621

Barker, K. L., Reid, M., & Minns Lowe, C. J. (2009). Divided by a lack of common language? A qualitative study exploring the use of language by health professionals treating back pain. BMC Musculoskeletal Disorders, 10, 123. https://doi.org/10.1186/1471-2474-10-123

Bereznick, D. E., Kim Ross, J., McGill, S. M., Kukkonen, J., Joukainen,  a., Lehtinen, J., … Katz-leurer, M. (2002). The frictional properties at the thoracic skin-fascia interface: Implications in spine manipulation. Clinical Biomechanics, 17(4), 297–303. https://doi.org/10.1016/S0021-9290(02)00014-3

Brage, K., Ris, I., Falla, D., Søgaard, K., & Juul-Kristensen, B. (2015). Pain education combined with neck- and aerobic training is more effective at relieving chronic neck pain than pain education alone – A preliminary randomized controlled trial. Manual Therapy, 20(5), 686–693. https://doi.org/10.1016/j.math.2015.06.003

Briggs, E. V, Carr, E. C. J., & Whittaker, M. S. (2011). Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom. European Journal of Pain (London, England), 15(8), 789–95. https://doi.org/10.1016/j.ejpain.2011.01.006

Darlow, B. (2016). Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine. https://doi.org/10.1016/j.ijosm.2016.01.005

Domenech, J., Sánchez-Zuriaga, D., Segura-Ortí, E., Espejo-Tort, B., & Lisón, J. F. (2011). Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: A randomised clinical trial. Pain, 152(11), 2557–2563. https://doi.org/10.1016/j.pain.2011.07.023

Gardner, T., Refshauge, K., Smith, L., McAuley, J., H?bscher, M., & Goodall, S. (2017). Physiotherapists? beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy. https://doi.org/10.1016/j.jphys.2017.05.017

Greville-Harris, M., & Dieppe, P. (2015). Bad is more powerful than good: The nocebo response in medical consultations. American Journal of Medicine, 128(2), 126–129. https://doi.org/10.1016/j.amjmed.2014.08.031

Hoeger Bement, M. K., & Sluka, K. A. (2015). The current state of physical therapy pain curricula in the United States: A faculty survey. Journal of Pain, 16(2), 144–152. https://doi.org/10.1016/j.jpain.2014.11.001

Kroll, H. R. (2015). Exercise Therapy for Chronic Pain. Physical Medicine and Rehabilitation Clinics of North America, 26(2), 263–281. https://doi.org/10.1016/j.pmr.2014.12.007

Lederman, E. (2010). The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, 1–14.

Lederman, E. (2015). A process approach in manual and physical therapies: beyond the structural model.CPDO Online Journal, May, 1–18.

Loeser, J. D., & Schatman, M. E. (2017). Chronic pain management in medical education: a disastrous omission. Postgraduate Medicine, 129(3), 332–335. https://doi.org/10.1080/00325481.2017.1297668

Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 3985(August), 1–24. https://doi.org/10.1080/09593985.2016.1194646

Lowe, A., Littlewood, C., & McLean, S. (2018). Understanding physical activity promotion in physiotherapy practice: A qualitative study. Musculoskeletal Science and Practice, 35(November 2017), 1–7. https://doi.org/10.1016/j.msksp.2018.01.009

Lowe, A., Littlewood, C., McLean, S., & Kilner, K. (2017). Physiotherapy and physical activity: a cross-sectional survey exploring physical activity promotion, knowledge of physical activity guidelines and the physical activity habits of UK physiotherapists. BMJ Open Sport & Exercise Medicine, 3(1), e000290. https://doi.org/10.1136/bmjsem-2017-000290

Moseley, G. L. (2018). Whole of community pain education for back pain. Why does first-line care get almost no attention and what exactly are we waiting for? British Journal of Sports Medicine, bjsports-2018-099567. https://doi.org/10.1136/bjsports-2018-099567

Moseley, L. (2002). Combined physiotherapy and education is efficacious for chronic low back pain. The Australian Journal of Physiotherapy, 48(4), 297–302. https://doi.org/10.1055/s-2004-813687

Moseley, L. (2003). Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. The Journal of Pain : Official Journal of the American Pain Society, 4(4), 184–9. https://doi.org/10.1016/S1526-5900(03)00488-7

Prochaska, J. O., & Di Clemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy, 19(3), 276–288. https://doi.org/10.1037/h0088437

Schmidt, H., Bashkuev, M., Weerts, J., Graichen, F., Altenscheidt, J., Maier, C., & Reitmaier, S. (2017). How do we stand? Variations during repeated standing phases of asymptomatic subjects and low back pain patients. Journal of Biomechanics. https://doi.org/10.1016/j.jbiomech.2017.06.016

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016

Van Ravesteijn, H., Van Dijk, I., Darmon, D., Van de Laar, F., Lucassen, P., Olde Hartman, T., … Speckens, A. (2012). The reassuring value of diagnostic tests: A systematic review. Patient Education and Counseling, 86(1), 3–8. https://doi.org/10.1016/j.pec.2011.02.003

Weiler, R., Chew, S., Coombs, N., Hamer, M., & Stamatakis, E. (2012). Physical activity education in the undergraduate curricula of all UK medical schools: are tomorrow’s doctors equipped to follow clinical guidelines? British Journal of Sports Medicine, 46(14), 1024–1026. https://doi.org/10.1136/bjsports-2012-091380

Zanini, C., Sarzi-Puttini, P., Atzeni, F., Di Franco, M., & Rubinelli, S. (2015). Building bridges between doctors and patients: the design and pilot evaluation of a training session in argumentation for chronic pain experts. BMC Medical Education, 15(1), 89. https://doi.org/10.1186/s12909-015-0374-6

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7 thoughts on “A response to Lorimer’s editorial in the BJSM

  1. Paul, your comment resonated with me: “… anyone can attempt to teach pain education but it takes more than just telling people that it is safe to move when they are avoidant of movement. As clinicians, we need to modify our role if we are to support people through the challenge of learning to live well with pain.”

    Judging by the number of hits (over 37,000 and rapidly rising), our blog on Fibromyalgia Perplex has been extremely well received, which suggests that health care professionals might need to pay much more attention to the way in which they engage with their patients experiencing pain: http://www.fmperplex.com/2016/02/08/381/

    Liked by 1 person

    1. Thank you Jon. I agree that it is more about reasoning our engagement rather than just explaining pain. I have had comments on other SoMe platforms agreeing with Lorimer that we can ‘muck it up’ yet you do not necessarily have to go into pain education to elicit change in patients. Using evidence that refutes historical theoretical viewpoints about tissue and the body can be enough. To me this is not pain education this is just using the evidence base to refute the old antiquated ideas we had about the body. Engagement as you say I key as is clinically reasoning when pain ed or other is indicated.

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  2. Great stuff Paul. I feel the results of poor health and poor health behaviors can emerge in different ways for different people due to a multitude of factors. Back pain is just one example. We definitely need to look more broadly and at a community and cultural level

    Liked by 1 person

  3. GDay Paul et al
    First up – thanks for very generous words of respect – very kind indeed. Your reflections make total sense and I enjoyed reading them. You wondered what I meant by ‘that sentence’…. what I meant was – if we, the community of health professionals they are likely to see about their back pain, don’t implant barriers to their recovery that would not have been there if they hadn’t seen us. The ambiguity as to the subject reflects poor writing on my part, but the sentiment reflects the proportion of patients I see whose back pain has been catastrophised by health professional advice, underpinned by common models of back pain and diagnostic nightmares. On reading your commentary, I think you agree and we both share a healthy respect for how complex the dance is, and how many factors contribute to its success or failure. I find the complexity of it all rather intimidating and, to add to that, I have spent the last 15 years in a perpetual state of downgrading my perceived mastery, and implementation, of it all.
    The focus on back pain, rather than health, reflects the papers to which I was responding, but I agree with your assertion that community education about health is direly needed.
    Thanks for your astute commentary and ongoing contributions Paul.
    best regards,
    Lorimer

    Liked by 1 person

    1. Hi Lorimer,
      Thanks so much for taking the time to comment on my blog. I appreciate how busy you are. I guess my perspective is one of consistent reflection and vigilance about my language, terminology and delivery. All things I have learnt from reading the likes of Fordyce, Vlaeyen, Waddell, You, David Butler, and working very closely with Bronnie Lennox Thompson and Mike Stewart.
      I believe we do share a healthy respect for the complexity. It ain’t no St.Bernards waltz, more like a foxtrot at 10x the speed!
      Keep up your astounding work as despite what you believe at downgrading your mastery there are many that have admiration for you because of your contribution and merging of the void between research and clinical practice and the broadening of knowledge beyond a biomedical paradigm.
      Thanks again
      all the best

      Paul

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