What we say to or patients, and how we say it, has a huge effect on their recovery. In fact, I’d propose that what we say, more so than what we do, ultimately determines how well a patient will react to physical therapy. Re-orienting patients’ beliefs about pain, its mechanisms, and its meaning has been discussed at length by numerous authors, clinicians, pain scientists, and researchers (cough, cough: David Butler, Lorimer Mosely, Adriaan Louw, or Todd Hargrove). We can directly influence a patients’ perception of pain by the words we use and the picture we paint.
Recently, I had an opportunity to put my pain science education skills to the test. A few months ago, I received a referral for a middle-aged runner who had been experiencing chronic unilateral knee pain for the past few months. Her symptoms began the day after participating in a high intensity interval training class…the day after she completed long race. Long story short, she pushed past her body’s ability to adapt to the stress placed upon it and set off her body’s alarm system (pain). By the time she made it to the clinic, 6 months had passed and she had she developed a variety of musculoskeletal compensations that affected both proximal/distal joints and a strong aversion to certain movements (squatting and climbing stairs).
For the first 6-8 weeks, we focused on improving her gait mechanics, reducing fear-avoidance behaviors, cleaning up her movement compensations, and reviewing pain science/education. After the initial phase ended, we re-integrated some of her functional movements into her rehabilitation in an attempt to inoculate her alarm system and improve her tolerance of the previous positions. Still, though, she was fearful of returning to her normal activities outside of the clinic, remained unable to squat/climb stairs, and was unable to jog. So we spent the next few visits exploring these movements in an attempt to find the underlying cause. Eventually, we got to the root of the issue. It wasn’t the pain itself that stopped her from going back to her normal life, it was what the pain represented to her. She admitted she had gained a little weight and was afraid the pain indicated a worsening of her condition. Eureka!
I jumped on this opportunity to delve more into the how/why/when she experienced fear or pain and subsequently ramped up my pain science education. I used this time to reframe her perception of pain, inoculate any thought viruses she may have developed, and answer any questions that remained. We spent the better part of an hour discussing her symptoms, providing positive reinforcement, and addressing her anxiety about returning to her athletic endeavors. After this session, she experienced a complete turn around. She started running again, was experiencing less fear and anxiety with squatting, was able to climb stairs, and was more positive about her recovery.
She still pops in every once in a while for a “clean up,” but overall has made strides towards returning to her normal activities. She is still running and has started going back to fitness class. Her recovery wasn’t solely related the exercise I prescribed or the manual therapy I provided, but did they contribute? Absolutely. Had I not addressed her fears and reoriented her perception of pain, though, there is a very good chance we would have experienced a different outcome and would still be working to correct a muscular imbalance that may/may not have been the primary driver of her functional impairment.
– Zachary Huff, DPT, PT