Beyond Techniques: Transforming Pain Care

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This is the Modern Pain Podcast with Mark Kargela.

So what if I told you the weekend course full of new techniques was actually holding you back for becoming an expert clinician in this video, I'm going to try to convince you that you don't need to continue to search out new ways to help change pain for the short term, and that you really need to focus on how to get people off your treatment tables and moving in valued ways in the life they want to live. Now, don't get me wrong. These courses on weekends can be helpful. It's not bad to learn New techniques, but when's it enough? I want to lay a little groundwork on why your current way when used with good clinical reasoning and critical thinking is likely more than Enough to provide positive short term changes in pain and you don't need to look for new ways of doing it It seems clear that there are a myriad of ways we can provide short term pain relief and that there are no Treatments showing major long term changes in pain There are two studies one that we should be taking notice of as it really points to this fact This study was a systematic review published on non specific low back pain 118 trials were found using a wide variety of pharmacological and non pharmacological methods. The studies had a strikingly similar pattern of more rapid improvement initially, followed by smaller improvements in the short term. But what does that mean though? For some of the more nihilistic or cynical said I've been one of those people This means, well, nothing works at all, or man, it's all just a waste of time. If people are going to improve regardless of what treatment we provide, then why even provide care? That's what I hear some folks say. Now that's not what I would do. While there are likely plenty of people who choose not to see care and are probably navigating their back pain independently, We're not talking about those people in this type of study. The people you see in your clinic are people who are seeking help that do want the ability to see someone and find a way for some help from an external source to navigate back into their life. So to say, I just won't provide care, I'm not going to provide any interventions, seems a little clinician centered. And there's a massive variance in techniques and interventions to treat back pain and it's downright shocking to see that they aren't. all seem to provide a similar recovery trajectory despite their often differing proposed amazing mechanisms of effect. We see clinicians taping, scraping, manipulating, MDT ing, cupping, needling, and all sorts of other different theories without major differences in recovery trajectory. So what does that mean? To me it means that there must be a common denominator within these treatments that allows for such a similar recovery. Let's go over what we think might be part of that. The first one that comes to my mind is regression to the mean. And what that means is when somebody comes in with pain sky high, significantly over their normal baseline of pain, which is often usually none, the back pain usually has only one way to go and that's going to be into some improvements. So it's going to go to the average. It's going to go to levels where often there's minimal to no pain in that person's life. Natural history is also something we need to look at, as the research really points to the majority of people improving rapidly within the first six weeks. Although there is a small percentage of people who are going to move on to chronic low back pain. Those are the folks we need to start really thinking and worrying about because those are the folks that often become the bigger consumers of health care. The folks that end up on your schedules really having some difficulties and not responding to traditional intervention tissue based ways of looking at pain. If you listen to this podcast at all, you know that we discuss clinical equipoise and how research has been shown that if a clinician carries a positive expectation, or positive beliefs on our intervention. And let's face it, all of us have positive expectations on what we're delivering to patients. We wouldn't hopefully produce an intervention or provide intervention that we didn't think was going to help. So that belief that we have causes us to present the intervention in a more confident manner. We're going to explain it more confidently. We're going to deliver it more confidently in our non verbals. And often that can relate to improved outcomes with that intervention. So it shouldn't come as any surprise as clinicians that are more confident. are going to provide more positive contextual effects around their preferred interventions than ones they don't have that belief around. And you couple this with patients who are not coping well and feel they really need something to help them are going to respond to clinicians who create positive expectations and provides a confident explanation that their treatments are really going to help solve that problem. Could it be that if patients feel like something has been done to help them heal regardless of the scientific method of the treatment at hand that they're going to progress well? I think it's worth considering. So let's go back to my original point that we don't need more techniques to learn short term ways to change pain. You've likely have more than a few you've already learned, probably learned a bunch in school and none of that's wrong. They're all probably sufficient right where they are. What we don't have good training on and coursework on is the now what components of our care. And what do I mean by now what? By now what we're talking, well, sure you, I changed the patient's pain in the short term while they're laying on this bed. Now what? If they feel good in the four walls of your clinic, wow, that's wonderful. But now what? How are you going to help that patient feel good in the four walls or in the context of their life where psychosocial factors and all sorts of things that can have negative impacts on pain and cause them to roll right back in your clinic for the next treatment session? with pain no different than it was prior to the first session you had where the short term pain relief happened and then you end up on the short term pain relief merry go round with this person. We need to get better at that now what to help people navigate outside those four walls. And it's not something you're learning on weekend courses rarely. Now there are some weekend courses like our friend Mike Stewart's courses. Bronnie Thompson talks about some things that helping people move towards valued. Activities in life using a more ACT model, our friend Laura Rathbone. So there are some out there, but there are still a preponderance of technique driven courses where we're learning new ways to short term modulate pain. And I think it's time to put those down a little bit, maybe figure out the ones that you might have a few techniques to roll with, but then let's move on. And now what with our patients? We need to be better at helping people see their pain from more than the narratives around the short term effects in clinic we give them that are often sketchy at best in scientific merit. We need to be able to help them navigate their psychosocial existence and resulting embodiment of that psychosocial existence. When I say embodiment, we embody the world we live on. If you're living in a haunted house of a lot of scary, distressing, abusive, stress inducing things, your body's going to behave more in the haunted house that has GI effects, that has muscle tone effects, that has pain effects. We know this. Um, when your life's in a better, more robustly supported You're getting good sleep. You have good diet. You have good social relationships. You're, you're moving well, and you're active. Then obviously you're gonna have better options to move well and do better when it comes to pain. But we don't get techniques in school to help us get people who are struggling in the haunted house existence to process that existence, to manage it, and to still move towards positive valued goals in their life. Weekend courses may touch on them between the main events of techniques. But they often don't go deep and help us learn within the context, especially the context of the patients we're struggling with right now in our practice. So you need to find a learning and mentoring program or group of people that can help you have these tough conversations around what happens outside the four walls of your clinic. You need to find people who can supervise your work with patients or at least give you pointers. You're all in this together. We're all in this together. And it's something that if you can find clinicians who are like minded, who share some of that, Similar struggles and similar wants to do better than just simply modulating pain in the short term. Then you can really group together and make a big impact in pain. You need to find mentors who can help you determine when mechanical treatments may actually be helpful and necessary in this instance. And when maybe that's not the best approach for some folks who are demonstrating pain that's much more complex than simple mechanical factors. Sadly, this isn't present on the vast majority of weekend courses. The whole reason I created our Modern Pain Pro community was to help clinicians get better at this now what part of our care. We're having conversations right now with clinicians who are struggling with patients who are having a tough time seeing past their imaging or being able to move well outside the four walls of the clinic where pain relief is happening for the short term. You can also jump on our waiting list if you want to get involved in our community the next time we open doors to clinicians. Or you can simply just start looking around your environment. Are there clinicians that you know in your community, in your clinic, or somewhere around you that can help you start applying this stuff in your practice, that can help you start navigating some of the struggles you're having with some of your patients outside the four walls of your clinic? I firmly believe if we can shift our focus. From the shiny new intervention to provide short term pain change into the real work of getting people off our treatment tables and moving successfully toward valued goals in the context of their life, then we have the ability to make a massive impact on pain in the world. What would you do? What are you going to do? And what would your patients want you to do?

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.