Physios Are Soft!

Good, I've got your attention!!! Well now you're here, let me tell you why I think physios and all other therapists are soft, and it's not for the reasons you are probably thinking.

I think many therapists are 'soft' as they are often more afraid, scared, and fearful of pain in their patients than the patients are themselves. As a consequence, I think this fear that many therapists have around pain is, directly and indirectly, transferred onto those they see.

One of the biggest contradictions I see with many therapists is how they often say they assess people in pain checking for signs and symptoms of serious and sinister stuff, but often recognise how most musculoskeletal pains are not serious or dangerous and poorly correlated with tissue status or pathology, and how pain doesn't equal damage, hurt doesn't mean harm, and sore can be safe, but then act and behave completely differently.

Despite many therapists saying pain is safe and normal many still tell their patients to avoid it and stop doing tasks or activities that cause it. Also, despite many therapists saying pain is often nothing to be alarmed or concerned about many still look to reduce and remove patient's pain with their 'symptom modification' tricks, manual therapy techniques, neon coloured tapes, silly little needles, or laser machines that go pew-pew!

Therapists and Pain

Why so many therapists say one thing about pain and then act completely different is both confusing and perplexing! Especially when I see so many of them telling people in pain to stop tasks or exercises that hurt, but quite happily press, push, poke, or scrape them with their manual therapy treatments causing them immense pain and discomfort!

Again, why so many therapists think that pain during manual therapy treatments is ok, but pain during exercise or other meaningful active tasks is not ok is just confusing to me?

I think this mostly comes down to how therapists are trained and their inherent desire and empathy to want to help those they see in pain. Most therapists do this job because they want to help others in pain, and often it is thought and taught that the best way to do this is by rubbing, poking, and pressing painful things in patients and asking them to avoid tasks and exercises that cause pain.

However, I don’t think this is right or correct advice for many in pain and I think if the therapy professions want to play any role in reducing the chronic pain epidemic that our species has got itself into, we need to understand and recognise that avoidance of tasks and movements that hurt and the quick fixes and treatments we often use to reduce or remove pain is not always the best solution.

However, I do recognise this is challenging, alien, and almost unthinkable for many therapists due to their training and instincts that often means they would not consider asking someone in pain to do something that hurts or makes their pain feel worse, even for a short period. Some therapists even think it's immoral and even unethical to let pain continue or go untreated, breaking one of the fundamental rules of healthcare... "do no harm'.

Do No Harm ≠ Do Not Hurt

Trying to convince therapists and other healthcare professionals that pain doesn't always need to be reduced or removed is hard. But it's even harder to convince those who are experiencing it. Pain is unpleasant, at times downright awful, it demands attention, it makes you think the worst, it changes your behaviour, and no one wants it. But we have to start thinking about pain differently.

Pain is a fundamental part of being human and as much as we think it would be nice to live without it, it would actually be horrible. At first, you may think living without pain it would be an advantage, allowing you to go through life easily, tolerating things others couldn't like a superhero.

However, a life without pain is a terrible affliction and an awful curse. A rare genetic condition called congenital insensitivity to pain does cause a few people to never experience pain, but unfortunately, these individuals often have short life spans and live in constant fear of a serious injury or illness that goes undetected until it's too late.

For example, just imagine what would happen if you didn't get any pain when you bite your tongue whilst eating? You would carry on chewing with a bit of extra tongue blissfully unaware. What about when you lean on a hot cooker, or cut yourself, or get an infection or some other disease and not know about it until you see your flesh melting, bones sticking out, puss oozing from a wound, or pass out from a fever you couldn't feel?

Simply put, pain is a much-needed part of our existence that protects us and keeps us safe. To go through life without pain is neither safe nor practical, yet this is exactly what's happening more and more to our society.

Our easy convenient lives mean we rarely have to do things today that are hard, difficult, challenging, or painful. As a consequence, we are not experiencing effort, hardship, or pain as often or as regularly as we used to. And even when we do experience pain we don't endure or tolerate it for as long as we used to. Again you may think this is good, I don’t!

We all live lives so comfortable and so pain-free that I think it is causing many of us to become less and less tolerant of pain and just as with those with 'congenital insensitivity to pain' I think it is putting us in danger.

We have over generations gradually lowered our tolerance to pain, and as a consequence we feel it sooner and easier than ever before with lower and lower stimuli. The human race is becoming more hypersensitive, more intolerant, and more vulnerable to pain, and this is in part, the fault of our modern lifestyles, technology, but also healthcare.

The Solution?

Now don't get me wrong, I love my central heating, warm showers, wifi connection, home deliveries, and soft comfy mattress, and I am not advocating we all suddenly devolve back to cavemen, sleep in caves and live lifes of hardship and strife. But when you're intolerant to something one of the most effective ways to become more tolerant to it is through exposure to it, and that's what I think is need with pain!

Now again don't get me wrong, I don't think we all need to start going out there and deliberately start inflicting pain upon ourselves or others, rather that when we do experience some pain that isn't serious, sinister, or harmful that instead of immediately reducing or removing it, we endure and tolerate it a bit more!

I was taught as a physio to always try and reduce pain in all of my patients, and I used to try my hardest to do this. But I wasn't always successful. This used to frustrate and dishearten me, making me feel like a failure, and I thought about quitting this job many times. However, I began to realise and learn that it doesn't have to be this way.

As I learnt more about pain, and started to understand it better and recognised that it didn't need to be reduced or removed immediately, I started asking patients in pain to carry on and persist despite their pain, reassuring them it wasn't dangerous or detrimental but normal and natural. And many improved and got better.

These days I tend to advise more and more patients after a full and thorough assessment to continue on as they are despite their pain and not to worry too much about things that hurt or cause discomfort, rather than always ask them to avoid it or me trying to reduce it. And despite this sounding harsh, uncaring, and discompassionate... it's not at all and in fact, it's actually rewarding and more importantly effective.

Drill Sergeants

Asking patients to carry on, or start doing things that hurt tends to be a bit of shock and surprise for many of them, and I find it often challenges and confronts their beliefs and expectations of what they thought physiotherapy was. But with clear, concise, and compassionate explanation and reassurance, many do understand, but I'm not going to bullshit you and say all do, as they don't.

Some patients really don't care, like, or believe me when when I say that the pain they feel during a movement, task, or exercise is safe, ok, or even beneficial. Some just want it reduced or removed. This often happens because I haven't done a good job in communicating or connecting with them to be trusted or believed and we have to recognise this happens because... humans are complex!

However, what I have learnt over the years of using exposure to pain is that to get patients to do things that hurt you can NOT be a cold, dis-compassionate, hard-nosed military drill sergeant barking orders at them. Rather you have to be a calm, collected, confident guide who gives them the confidence and reassurance that they can do this despite their pain

I see a lot of people these days who have been told to rest, reduce, remove, or avoid pain for weeks, months, even years and it hasn't helped them, in fact, it has often made them worse. I now find myself reversing this by reassuring, motivating, and encouraging them to try things that hurt and start to get things going again.

Difficult

But there is no doubt that getting patients to do things that hurt is difficult, really difficult and many are reluctant and some refuse. The key I find is to develop a good relationship and rapport early on and don't promise things you can't keep, like saying "don't worry it won't be as bad as you think" as usually, it is as bad as they think to begin with.

Another key point I find with this exposure to pain method is that repetition is essential, and not to let them do a painful task or exercise just once, but many many times. In my opinion repetition is essential for reinforcement and can produce confidence that they can expose themselves to more and more things that hurt and are in control of their own pain.

What painful tasks or exercises I get patients to do varies hugely based on what they tell me, but it's often the things they have told me they can't do or hurts them the most. Sometimes it's getting them to pick something off the floor, sometimes it's getting them to reach up high, sometimes it just stepping down a step.

What's The Evidence?

There is some growing evidence that exercises and tasks that are painful may have some significant advantages over and above non-painful exercises in those with chronic pain who have avoided these tasks and activities for an extended period. A recent systematic review published in the British Journal of Sports Medicine here has shown exercises that cause pain up to around 5 out of 10 on a pain scale can have beneficial effects for many chronic musculoskeletal conditions with no harmful or detrimental effects.

Source: BJSM, Smith et al (2017)

However, as with most things getting some to do painful exercises or tasks may not be best, and some caution is warranted in some populations. Repeated exposure to painful stimuli can be great in developing confidence, tolerance and habituation to pain, but it can also create increased sensitisation to it in some (ref, ref, ref). It appears that some populations and conditions do not get the same pain inhibiting central responses with painful exercises and so we do need to recognise this.

Also, I don't think we always have to ask chronic pain patients to do exercises or tasks that hurt. For example, if there is a way to continue to do a task or exercise without much pain then thats ok at times do. Sometimes creating a simple change in position, speed, or load can reduce pain in a task, however, I do think you should always revisit the original painful movement or task at some point and see if you can also develop resilience to it through exposure.

Summary

So there you go, my views and opinions on why I think a lot of therapists are soft and contradictory towards pain in a lot of their patients. Also how asking some patients to carry on with tasks and exercises that hurt and even to start to do things that increase their pain for a while is not harmful, unethical, or bad. In fact, it could just possibly be the best thing you could do for them.

As always, thanks for reading

Adam