Register Feb 2022

Words Of Wisdom From Former Speakers

On Working With Patients

 

Clinicians and researchers who spoke at prior San Diego Pain Summit conferences share what they think is important for clinicians to know.

"Be patient and kind with yourself and with the person you're trying to serve. It's easy when it's easy - but can sometimes be challenging when we are tired, rushed, overworked, overwhelmed, or feel like we've failed in some way. Remember that some of the most valuable and therapeutic skills we have are to be fully present, genuinely listen and create a safe space for the person to experience whatever it is they need to."

Shelly Prosko, PT, C-IAYT, CPI

“Keep it simple”

Sarah Haag, PT, DPT

When using the visual analog pain scale inject some empathy into your interpretation of the number the patients is telling you. The VAS is more than just a rating of pain. It is a rating of pain + suffering, pain + fear, pain + the need to be truly heard, pain + the disruption to their life, pain + etc, etc. If a patent tells you their pain is a 10/10 believe and then ask more questions. Try to understand what a 10/10 means to them. Because I can tell you from experience it is so much more than just a rating of pain.”

Karen Litzy, PT, DPT

“To ask our patients what do they believe is causing their pain?”

Sharna Prasad, PT

“One of the key areas for clinicians to integrate into their clinical practice when treating persistent pain from a biopsychosocial perspective is to utilize screening questionnaires to objectively profile the patient's sensitive nervous system, and target these constructs specifically.  

Persistent pain has a sample size of n=1.  Each patient is like a snowflake with a unique presentation.  

If we take a biomechanical approach with acute pain, we always use objective measures to assess the range of motion, muscle strength, joint laxity or stability, proprioception, and function of the affected area. In persistent pain, tissue health is just one consideration to address in a biopsychosocial framework. 

The psychosocial considerations are perhaps even more relevant in persistent pain since the tissues have healed despite the pain persisting. Hashmi et al (2013) demonstrated that questionnaires can predict who will develop persistent pain based on which brain areas are involved in acute pain; those who demonstrate involvement in the emotional areas on fMRI went on to develop persistent pain. 

However, most clinicians still do not use objective questionnaires to identify the specific profile or fingerprint of each patient's psychosocial presentation.  

Why don't we regularly use questionnaires to assess the phenotype of persistent pain to really understand each person's presentation?  Questionnaires have become synonymous with outcome measures, and many clinicians see these as an unnecessary nuisance to the therapeutic interaction. 

However, questionnaires are a window into the sensitivity of a patient's nervous system and are an indispensable way to objectively assess the characteristics of their individualized sensitivity. They are also paramount in objectively assessing whether their sensitivity is changing through serial re-testing throughout the treatment program.

I have summarized some of the key characteristics of a sensitive nervous system in an easy to remember mnemonic: SAD CLLIFSS.  SAD CLLIFSS stands for Stress, Anxiety, Depression, Catastrophization, Low Self-efficacy, Low Positive Affect, Injustice, Fear, Shame, and Sensory Motor Dysregulation.

Included (scroll down to download) is a one-page summary sheet of each of these characteristics, the screening tool to identify them, and a few evidence-informed treatment strategies to address them.

If we can objectively identify the characteristics of central sensitization more accurately, and address these characteristics with evidence-informed specificity, outcomes may improve and patients can expect to do better than learn to live with their pain with increased function. 

Patients can expect that these targets of sensitivity can change, and so can the overall sensitivity of their nervous system. In this way, function improves, but so does the sensitivity of their nervous system.  As their sensitivity decreases so does the likelihood of having a pain response when tissues are not under load or threat.  Pain and function improve hand-in-hand.”

Carolyn Vandyken, BHSc (PT)

Download Questionnaire

Focus on patient-led specific goals by asking, "Can you name 3 activities that you would like to get back into doing again that they currently have difficulty with."

Then pick one and focus EVERYthing you prescribe to be towards getting closer to doing that activity, which most often means various ways of modifying the activity! Creativity and positivity is required here.”

Bahram Jam, D.SC.PT, M.PHTY, B.SC.PT, FCAMT

Pleasure Breaks to Combat Pain

A day devoted to managing pain can be full of determination and working on exercises, self-treatments, resting to get ready for the next task, and a lot of enduring.  Where is the time for doing purposefully pleasurable things? When you ask your patient/client what they do for fun, what is the answer? 

Try it, and encourage them to take time each day to do something that feels good. If they can't think of anything, help them come up with a list that brings in all the senses:

Smelling something pleasant

A taste they love

Touch that feels good anywhere on their body (using a lotion they like can be a multi sensory experience) 

Sounds they enjoy (laughter, music, birds, the wind, the ocean waves, rain) 

Watch something they like (in nature, on TV, in their home)

The thing is not the important part, the enjoyment and engagement of positive sensation is the key. This is to facilitate the inherent cortical responses of anti-inflammatory mediators and promote a sense of hope that all is not wound up in hard work and pain, there can be pleasure too. 

Dosing:  3 - 5 minutes of a pleasurable experience, engaged in the sensation 7 to 8 times a day.”

Sandy Hilton, PT, DPT, MS

“When helping people make sense of pain, it is crucial to consider how best to draw out meaningful experiences from them rather than pouring in your own experiences, which often casts them as a passive recipient of your information and advice.”

Mike Stewart, MCSP SRP BSc (Hons) MSc PG Cert (Clin Ed)

1) beliefs are malleable if, and only if, the person (patient) feels they have been heard and it is common knowledge that they have been 

2) psychologically informed practice starts with becoming aware of your own individual psychological flexibility “

Marcos Lopez, PT, DPT, FAAOMPT

BE PRESENT, or in-the-moment, with your patients Slow down and 'land' with every patient by 'parking' personal and professional distractions.”

Maxi Miciak, PhD, BScPT, BPE

"Use manual therapies as educational agents - “this is excellent, your pain changes with movement - let’s see how many other things can change it too”

Use prescribed movements/exercise as educational agents - provide your patient with repeated experiences inconsistent with previous determinations that movement is dangerous.

When your patient is precontemplative or contemplative, your options are to provide knowledge and build alliance. Share knowledge and experiences with the objective of creating curiosity, rather than changing your patient’s beliefs. 

2 tips to provide patients…

Through thought and touch, spend some time every day loving the part of your body you previously referred to as "your bad ______”

Move from dabbling in self-care to finding positive results through practice and increased proficiency.”

Neil Pearson, PT, MSc, BA-BPHE, C-IAYT, ERYT500, YACEP

“Don't underestimate the value of non-specific things that people can do to improve their health.  Health is multidimensional and so is pain.  Sometimes working on general things can carryover and help a pain problem.  Related, not everything needs to be perfect but working on small health related goals can be helpful” 

Greg Lehman, BKin, MSc, DC, MScPT

"It's important to spend time reflecting on what it means to be human and in a vulnerable state."

Tim Beames, BSc MSc

"To effectively treat pain, we must target the BRAIN in addition to the body."

Rachel Zoffness, Ph.D.

"Focus interventions, both physical and cognitive, on creating a sense of change rather than trying to fix something. 

We are not a mind and a body, we are integrated humans who have thoughts and beliefs which impact how we move ourselves through the world. Changes in our thoughts and beliefs can unlock powerful agents within our physiology. Changes in our physical self can lead to changes in our thoughts/beliefs of self and likewise changes in our cognitive self can lead to changes in our physical self.  

Our goal is to help create change in both cognitive and physical selves to make moving through this world a little easier. "

Richard McIlmoyle, BSC, DC, PGCPain

“Are you asking your clients about their sleep? Sleep duration and quality can impact the pain experience and pain severity. Discuss strategies to promote sleep health, and refer to a provider who can address their specific sleep concerns if needed.”

Catherine (Katie) Siengsukon, Ph.D., PT

"Create a placebo-enhancing clinical experience for better treatment outcomes – spend time building therapeutic alliance (via trust, rapport, empathy), use placebo-maximising and nocebo-minimising communication, and ensure your clinical environment is professional, comfortable, and private."

Felicity Braithwaite, Ph.D.

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