Welcome back to the Healing Pain Podcast with Dr. Derek Griffin
We’ve got a great fun and informative episode. We’re talking about the ten do’s and don’ts of persistent and chronic pain. My expert guest is Dr. Derek Griffin. Derek graduated from the University of Limerick with a Bachelor’s Degree in Physiotherapy and earned his PhD in the field of physiotherapy pain and physical activity in 2013. Since graduation, Derek has worked clinically in the private health sector in the areas of musculoskeletal pain, sports physiotherapy and care of the elderly. In 2017, he was appointed a clinical specialist physiotherapist. A role where he works together with his physical therapy colleagues and hospital medical teams to provide comprehensive services to patients with a range of musculoskeletal health problems.
He has lectured on the undergraduate and postgraduate Physical Therapy Programs at the University of Limerick. He has been an invited speaker at a number of scientific conferences and regularly contributes to physiotherapy educational initiatives, both nationally as well as internationally. In our episode, Derek speaks about his work as a Pain Specialist Physiotherapist, as well as the five do’s and five don’ts of persistent pain. This is a great episode to share with your friends, colleagues and anyone who is overcoming chronic pain. Without further ado, let’s begin and meet Dr. Derek Griffin.
Watch the episode here:
10 Do’s And Don’ts To Manage Pain With Dr. Derek Griffin
Derek, welcome to the show. It’s great to have you here.
Thanks very much for having me, Joe. I’m delighted to be here.
I love the topic of the episode you proposed. The ten do’s and don’ts of persistent pain. We’re going to go through those in a bullet point fashion for people because they’re important. They’re great educational pieces for people living with pain as well as practitioners. First, tell us who you are, where you live, what you do, and how your career has evolved from being an early physiotherapist into your PhD work, and then where you are now.
I’m Derek Griffin. I’m an American specialist physiotherapist in the Bon Secours Hospital, which is a private hospital in Tralee in the Southwest of Ireland. My career starts back in 2004. I started my undergraduate degree at the University of Limerick and completed that in 2008. I went directly from my BSC into the PhD. At a very early stage during my undergraduate training, I took alight to the whole topic of pain. My very early interest and still a big interest of mine was around the physiology and mechanisms underpinning pain. When the opportunity arose towards the end of my BSC to go on and do my PhD, that was a great opportunity for me.
Importantly, through my PhD work, you get to interact with people with pain in the clinical setting. I value that early exposure because it gave me an opportunity to see the complexity that was out there. To sit back and look at other clinicians, consultants, nursing staff and other healthcare professionals interact with patients gave me a real insight into the value of listening to the patient’s journey and story. From then on, I did a little bit of academic work post-PhD. I was involved in the teaching at the University of Limerick on the undergraduate and the post-graduate physiotherapy programs. Through all that time, I was maintaining some bit of clinical work.
I’ve transitioned to full-time clinical practice. I work with a team of rheumatologists and orthopedic surgeons in the settings that I’m in now. I see quite a complex caseload of people with various persistent pain problems both trauma and non-trauma related. Because of my involvement with the rheumatology team, I’m having been more exposed to people with inflammatory disorders. My career has been a bit varied. I’ve had exposure to different patient groups, which is great learning for me. It’s all knowledge and experience.
The clinical setting you’re in, is that more of an inpatient in the hospital or is it more outpatient where people are coming to you on a daily basis?
My primary role is in outpatient. From time to time, we do get people that are admitted and one of their main complaints would be pain. I will consult with them as an inpatient and then potentially follow them up as an outpatient. It’s nice to be able to follow these people up that have been admitted to the hospital as an outpatient because it’s an opportunity to develop trust and continuity of care in a particularly demanding patient group.
As early clinicians and even for some who are seasoned clinicians, they don’t necessarily think of health promotion on a bigger public health scale. Why is it important for physical therapists, physiotherapists, and other licensed health professionals to start to engage with the general public with regard to safe and effective means of pain care, as well as some of the misconceptions?
There’s a good body of evidence now that suggests that there are a number of behavioral risk factors that influence many health outcomes, not just including pain. We all know the benefits of exercise, having a good sleep routine and other various lifestyle factors. It’s important that we try to access patients before they become patients. When we get a chance to see them in the clinic, they’re presenting with a specific complaint, pain in this situation. However, there’s a scope that if we can educate these people prior to developing symptoms, there’s good reason to believe that this might alter their trajectory. Having good evidence-based information prior to developing back pain might change how they respond and manage their acute back pain, comparative they didn’t have that information.
We need to be thinking much more broadly. We know that chronic pain coexists with other general health problems so there will be a higher risk of cardiovascular disease, hypertension, diabetes and other medical comorbidities. It’s very important that we stop seeing these conditions in isolation. All of these conditions have shared risk factors. As healthcare professionals with this knowledge, we have a duty of care to engage with our local communities and even broader than that as a way of prevention or at least, giving people the tools that they can adapt and respond in a positive way to various health challenges they may encounter.
We can plant those seeds early on through public education and health promotion. Those behavior change might not happen at that moment for people, we hope and wish it does. If those seeds are planted early on through public education once they come to us in a clinical setting, it will be easier for us to cultivate the behavior change that’s required.
If you take something like lower back pain, if you look in the general population and the beliefs of people that may have never been exposed to lower back pain, you’ll often see that even in people that have never experienced persistent back pain, they’ll often have negative beliefs towards this. It’s purely based on what they’ve heard, what they’ve read, or someone that they’ve known. It’s important that we try to reframe that or at least we put solid evidence-based information out in the public domain because I do believe that pain is a societal problem. It’s not necessarily at the level of the individual. If we can change societal beliefs. We’ve done that in other things like antibiotic use and smoking. We have managed to shift societal beliefs in relation to these conditions. It’s not easy but it’s a very worthwhile adventure. It’s why I did the ten do’s and don’ts of persistent pain. It’s getting information out there in a very user-friendly manner.
Let’s take a moment. Let’s dive into those do’s and don’ts. We can run through them. Let’s start with the do’s.
The first one is know that your pain is real. This is the most important one, hence, I put it as the first do. That’s because there still appears to be a stigma around persistent pain. This is based on the very early biomedical or medical model where pain is attributable to a specific pathology or an injury. If these people have had multiple scans, multiple investigations and may have been told, “We can’t find anything wrong with you.” The implication of that is the patient may believe that it’s in their heads. We still get patients in the clinic that use this type of language. They almost feel that they have to tell the therapist that, “It’s not in my head. This is real.”
That’s a shame that the patient feels that they may not be believed. We can at least empathize with them and validate their experience while it might not be always attributable to a specific injury or pathology that we can see on an MRI scan or when we examine a joint. We can still validate their experience based on an emerging body of scientific evidence that tells us that perception that is pain is complex. We know that it’s not simply a measure of tissue damage. We have a good enough explanation as to why you can still have these symptoms and not necessarily have something showing up on an MRI scan. In the clinic, I would tend to use very simple examples to illustrates what I’m talking about.
Something like the flu, we know that one of the symptoms of having flu is pain. There’s no objective damage to the tissue but because there’s an immune response, there’s a nervous system response or neuroimmune response, these mechanisms can contribute to a heightened level of sensitization resulting in pain. It’s an everyday example of where you can have pain without known injury or damage because there’s a system that’s under threats and you have a protective response orchestrated by the body as a side effect to that may increase your sensitization and you feel pain.
I like that analogy of the flu. It’s simple. Everyone has had the flu and they can relate to having some body aches and pains. You didn’t mention the brain which I think at times is a double-edged sword because some people can relate to it. For some people, when you start talking about the brain, it puts the experience of pain “back in their head,” which can be a little problematic for them.
I tend not to talk about the brain as being separate from the body. Clearly, we know that there are brain mechanisms that contribute to pain. It’s beyond my expertise to delve into the precise mechanisms at play here. When we start to differentiate the brain and the body, it can sometimes give the impression that’s done in the wrong way or done often in a way that’s not intended. It can come across in effect saying that this is in my head. When we talk about the brain and body as a single unit, I don’t necessarily see a need to separate the brain and what’s happening in the bod. We know this is a two-way system that’s not working without the other.
First, know that your pain is real. The second one is staying active.
We all know the benefits of physical activity. That’s not in question here. The difficulty is how do we get people with chronic conditions or persistent pain problems to become more active when they may have been very sedentary for long periods of time. We tap into models of behavior change which in itself is a very complex area. When we’re discussing exercise with patients or when we’re prescribing exercise, we can be a little bit too prescriptive in how we tend to do that. When we look at the chronic pain literature in its entirety, we don’t see that one type of exercise is superior to another when it comes to pain relief.
We can see that in the negative sense that none of them are jumping out as being particularly better or we can see it in a more positive way. We can look at what the patients or the individual likes, how it might fit into their lifestyle, and how do we engage them with exercise or activity that they’re more likely to do. That’s the first thing. The second thing would be the public health guidelines are often misinterpreted in my opinion. It’s nice to have them and there’s a nice message there. Sometimes this idea that you have to be exercising for a certain amount of time. It has to be 30 minutes of moderate-intensity exercise at least five times a week. If you’re somebody that’s not doing any structured activity, that’s a world away from where you’re at the moment.
We know that if you set unrealistic goals and expectations, they’re unlikely to be met. When they’re unlikely to be met then you’ll have very dissatisfied patients that will feel that they can’t do this. That’s not a good start in building a therapeutic alliance. I’m always looking at what their baseline is. My message is that a little bit more, regardless of how little and what intensity is a good place to start. The journey is more important than the destination. We might have an aim of being able to exercise for 30 minutes at a moderate intensity. That might take a few months or over a year to get there depending on the individual, their risk factors, and other medical conditions that might limit that.
The final thing that I thought as part of staying active is we can start to tap into the social side of things. We look at where people are active and with who are they active. Do they prefer for it to be in a group setting where we can look at building social support and that becomes a motivating factor for the patients? Do they do it as part of a community initiative? Something like a park run or walk in the park or various community strategies. We need to see physical activity from a much broader perspective rather than this specific type of activity that has to be done for this amount of time in a certain way, which is a little bit more restrictive for the patients. It’s often unrealistic and therefore you lose them because they don’t achieve that goal.
A hundred and fifty minutes, which is the standard of the WHO and most national organizations for exercise, as you mentioned, 30 minutes per day is almost unfathomable for some people with chronic pain.
The evidence is very clear that the benefits of exercise happen well before that volume of activity. It’s still a very strong evidence-based message that doing a little bit more than what you’re doing is helpful. If we look at the knee osteoarthritis literature, we know that above 6,000 or 7,000 steps per day separates people with higher levels or lower levels of functional disability. The 10,000 steps is a nice number but it’s not as if they’re under that, there are no benefits. That’s the message that we need to enforce with patients.
Moving at any level from where you are a little bit more goes a very long way. Staying active tends to parlay into point number three. It is focusing on meaningful activity.
As part of my do’s and don’ts, I wanted to emphasize the importance of social factors. When I’m talking about social factors, I’m talking about things like a person’s identity, whether that identity is as a parent in terms of their work, where they see their value in their social support or social networks. When it comes to what we’re trying to get patients to engage with, it’s very important that we look at what’s that meaning to them. That might be anything from going for a coffee with a friend, being able to look after and play with their grandkids, or be able to maintain their work role.
This is the conversation that you need to have with your patients around what adds value to your life. Therefore, you can build your activity prescription or the broader rehabilitation aims around how do I help that patient enhance the activities that are of value to them. It’s not about what I feel is of value to them. They can tell me exactly what’s of value to them. It’s not about us setting goals for the patient. It’s about looking at where their goals lie, what’s the meaning to them and what’s the value to them.
They might be walking for 30 minutes, five days a week, but that’s not a value to them. They want to be able to do a different activity that they can’t do. We can’t see exercise and activity in isolation to their goals and their long-term aims as to where they want to be. The social factors have been underestimated in the pain literature and across all areas of medicine. We tend to focus on behavioral risk factors like exercise, sleep, diet and nutrition. At the basis of all of those are social factors. We know that social factors often dictate the exercise behaviors of an individual or their eating habits.
It has an influence on their life stress which will not have an effect on other behaviors like their sleep and stress management. It’s important that we look at the patient in their environment, context and try to build a rehabilitation program around that rather than setting them functional tasks but have little meaning or value to them. We can do better in taken account of the social factors in addition to the behavioral factors because they’re the same thing. They’re influencing each other.
Help people identify and connect with valuable, meaningful and pleasurable activity in their life. You started to touch base on point number four, which is maintaining social relationships for people with chronic pain.
We know that social factor is about risk factor for pain, but also when you have a persistent pain problem, that can severely impact your social functioning. It can influence your work. There are many people with disabling pain that are not able to work anymore. They are not socializing with their group of friends. It has impacted their identity as a parent, carer, whatever role they see themselves as. As part of our intervention, in addition to what physiotherapists have traditionally focused on which might be simply prescribing exercise or the more behavioral side of things, we can look at how do we do that in a way that engages people more socially.
Can we get the movement and exercising in a group? Can we get them involved in more community-based activities that give them that sense of value and worth, and build a social network around them? The term that we will hear in the literature for this is the whole concept of social prescribing. It’s about encouraging people. We don’t have to be the experts in the area. We don’t need to necessarily be a psychologist or in that domain to encourage people to reach out to friends to talk with people in their community that they respect or trust. These are part of broad health promotion strategies given that we know that social factors and social interaction are so important to function.
There’s a huge overlap between my previous point about engaging in meaningful life activities and maintaining your social relationships. It’s fostering, how do we get people back to work? How do we keep people at work? How do we look at getting people more involved in their community setting, meeting people, and talking to people? It’s not always easy. If we look around in our own communities and we have a link to various networks and organizations, then it’s our role to put patients in touch with these groups that can then become the experts in fostering this.
We’ll round out the do’s and then we’re going to come up to number five. I’ll review this real fast. Number one is know that your pain is real. Number two is stay active. Number three is focused on meaningful life activities. Number four is maintain social relationships and number five, which is an interesting one brought from the perspective of social interaction as well as exposure-based pain is to face your fear.
One of my primary interests in the field of persistent pain is the application of an exposure-based intervention at a very simple level. This is identifying movements or tasks that individuals are avoiding. They’re doing it in a different manner based on a belief system that this might be damaging. They’re doing harm or they might be avoiding it because it has become associated with a pain response. That’s a human response. I’m very clear with patients that often these avoidance behaviors are normal. Sometimes, we pathologize this. We talk about fear and avoidance has been maladaptive. It can be maladaptive in the long-term but it still can be a normal human response. If something hurts, you would immediately pull away from this or we would try to avoid pain. There is some natural instinct to do this. When someone has widespread pain, everything starts to hurt.
There’s no consistent pattern to it. Lots of daily activities start to hurt and they become more avoidant until they’re doing very little. The concept around exposure is that we integrated manner, gradually get them doing the things that they’re avoiding because of fear or because of a pain response. We do that in a way that we gradually get them doing more difficult tasks. At the same time, equipping them with the skills to deal with an increase in pain and how to manage flare-ups. The exposure isn’t done in isolation, it’s done with a package of care where we develop their ability to self-manage.
When they understand the meaning of pain, they don’t see the pain that they’re experiencing anymore as a thresher or as damage. They can see it as a heightened protective system or a general increase in sensitivity. That then allows them to engage with that activity. Over time, what we’re looking for is that they become less avoidant and start doing more. First and foremost, it’s about reducing their functional disability. You will often find if don’t for long enough and in a progressive manner, we will see a reduction in pain in a good percentage of individuals as well.
We can use our clinical skills in the practice to help with effective exposure to people. They can take those skills and apply it to their life outside the clinic, which is where the real exposure starts to happen for people. I love those five points on the do’s. Let’s move into the don’ts. The first one is don’t blame yourself or fight the pain.
It goes back to the first point that we discussed under the do’s and it’s this stigma around pain. There’s a perception in the public that you have to be seen as strong, to be able to deal with pain, and be able to fight it. These are metaphors that the patients use that they won’t give in to the pain or they won’t let it beat them. They talk about it in a very metaphorical language. Something what I would routinely talk with patients about is when we fight with something, that creates a stress response. We see pain as the enemy that we need to get rid of, fight and give a state of relief. That backfires because it leads to an endurance style of coping so they push to the point where they might flare up or it’s the opposite of what might be recommended in something like an acceptance and commitment model.
What we were trying to suggest is that they understand the pain and the meaning of the pain for them. Rather than try to fight it, we develop resources that they can manage and deal with it better. Some of the metaphors that I would use would be something as simple as a tug of war. If you pull harder on one side, you will generally get an equal opposite reaction on the other side. If you try to ignore pain or push through it, that results in an increase in symptoms. Long-term, that’s not helpful for the patient. There’s an element of acceptance. Understanding what the pain is and then developing a plan on how can I better control this through more active coping strategies that are more feasible in the longer-term.
Helping people drop that struggle with the persistent need for pain control knowing that they can still engage with some activities even if there is some pain. A good mindfulness and acceptance-based approach tends to help people with that fight or struggle with pain. Number two in the don’ts is don’t assume that persistent pain always means damage. This is always a good one to keep reiterating over and over again to both clinicians as well as the general public.
Most people talk about this with stress. What we’re not saying is that pain is never associated with an injury or damage. We know that many times it is. If you sprain your ankle and it hurts, there’s a clear reason as to why your ankle hurts. Even in a scenario like that where there’s a very obvious acute tissue injury, we see variations in the clinical presentation. What looks like a very similar level of trauma injury, the patient reports very different levels of pain. The message is the amount of pain that you have isn’t necessarily a measure of what’s happening in the tissue. There are many various mechanisms now that we understand from the basic science work. There’s a difference between what’s happening in the tissue and how much pain somebody is experiencing.
That’s the message. We’re not undermining the value of healthier tissue. It’s still very important or peripheral susception from a more academic perspective. What we are saying is that there’s much more to the pain that you feel rather than simply what’s happening in the tissue. When you’re moving, it must be a movement relative pain, it doesn’t always mean you’re injuring yourself or doing damage. The analogy that I would use here would be sunburn. It is a good example because it’s an acute injury and trauma to the skin. If you have a shower after having an acute episode of sunburn, something as simple as the heat of the water will hurt your skin. Even though you know that that’s not doing any further damage to the skin, but because that area of your body has become sensitized, it’s a way of making you aware of that body part.
You’re not going to go back out and lie in the sun for another hour and get burned even more. There’s a protective component to that. Similarly, if someone has had established knee osteoarthritis and they have pain with walking, that doesn’t a bit like the sunburn while it’s not denying that there is a peripheral tissue process. The pain itself is not a measure of damage or you’re doing more damage. It doesn’t always mean stop. Using analogies, listening to the patient’s story, and using their story as a way to illustrate your point is very important rather than giving them random bits of information that are of little meaning or value to them.
Moving on to number three in the don’ts is don’t panic if you have a pain flare-up. It’s so important to talk about how to manage a flare-up with people.
This is an important issue and it’s an issue that hasn’t been looked at in the research enough. We’ve seen lots of trials around lower back pain. We have different approaches whether it’s a cognitive functional therapy approach, general exercise approach, or psychotherapy type approach. What we generally tend to see with most of these interventions is that we get a useful change in the short-term that’s not maintained that the medium or longer-term follow-ups. That’s typical of the pain literature that the effect sizes become less the further away from the intervention we see.
My perspective on this is that there are multiple reasons as to why the effect size decreases. As a clinician and looking at it with my clinician role rather than from a researcher perspective, patients inevitably at some stage, given the complexity of what’s going on, will have a flare-up. The flare-up is like a crossroads or you come to a park on the road, do you go down the road you’re used to traveling which you might start thinking, “This isn’t working. Here I am again, the pain is back. All of that new stuff I was taught isn’t for me?”
Do we see the flare-up as a chance to learn and to use that experience to help us going forward? I try to encourage patients to look at the flare-up as an opportunity to see what might have changed and that reinforces learning. It might be that they’ve had a period of bad sleep, a stressful situation arises at work, or they’ve doubled their level of activity over the last week. We use that information going forward as a way of preventing a flare-up. It’s my opinion that when some people flare-up, for whatever reason, we haven’t educated them in the way that we would have liked. The way they’ve received the information hasn’t been the way we intended. They flare-up and that ends their journey for that approach and then they move on to the next approach.
There’s a need in the literature to look at what happens when people flare-up and what are their experiences about that. We need a little bit more qualitative research to tease that out or embedding in these randomized control trials rather than just looking at the 3 months, 6 months or 12 months data. Looking at least for a subgroup of these people and they’re trajectory on a two-weekly, fortnightly or monthly basis to see if they’re doing well. They then have a flare-up and then they’re dropping off, what’s happening here?
Teaching people that flare-ups are not a sign of harm or injury in the vast majority of cases, and then looking at developing their skills and giving them permission to alter their activity to back down on their activity for a period of time and allowing them to respect their pain then going again. It’s a conversation that I have with patients from the very beginning. I’m not guaranteeing that they will flare-up but there’s a likelihood that they will. If they do, here is the plan, this is our plan. They can contact me and we’ll talk it through so they don’t see this as out of the blue, and then we lose that trust. Therefore, their outcomes can be negatively impacted.
Setting some expectations in the beginning can be helpful for people, and then helping them reframe that flare-up is a challenge and not necessarily a crisis for them. It can be a good place to start.
Rather than it seeing it as a setback, it’s merely a detour.
Let’s move on to point four with the don’ts. I didn’t expect this one to come up and this is so important with social media and how much information we have in the world. It’s don’t believe everything you hear or read. Let’s talk about that one.
This is where clinicians have to engage with their communities and reach out to the public. We need to be promoting best practice and good evidence-based information that can help people with pain. When you go on Facebook or on social media platforms, you look in your local newspaper, you’re going to see claims made about a variety of different potions, lotions and interventions for people with pain that claim to be curative or at least have a profound effect on influencing people with pain.
We have a duty of care to protect patients because when you’re in pain and particularly when the pain has gone on for long periods of time and your life is affected by it, you’re going to grab onto any bit of positivity or hope that you can. I don’t blame patients for seeking treatment or having an intervention that to me looks totally off the wall. Unfortunately, the way that it’s published on social media can be done in a professional way and it can look like this thing works. The reality is it doesn’t for the majority of people. It keeps them on the merry-go-round and then they become more dissatisfied.
The more dissatisfied they become, by the time they come to see someone like us, it makes our job a lot harder because we know that the poor response to previous treatments that people have had, we know that’s predictive of poor response to treatments at a later stage. We need to try to stop people from being exposed to some of this type of stuff that is not going to help them. As physios across the healthcare professions, we need to be engaging with the public around the simple bits of information that we’ve discussed around exercise, promoting social activities, general health-enhancing strategies that we know are evidence-based.
We’re not making any big claims about what they can do or can’t do, but we know these things are health-enhancing. They do set patients up in a more positive way against some of these claims that are out there. This is something I’m very passionate about simply because this is a vulnerable group like any group that has a long-term condition. They have to be protected somehow from being exposed to some of this because the other side of it is it can be very costly. People spend an awful lot of money on interventions that were never going to help them. That’s not fair if we can intervene and we can at least go some way towards trying to reduce the risk of that.
There’s a physical cost, emotional cost and financial cost to engaging in these quick-fix solutions. We can do a lot as licensed health professionals to help people move away from that and move towards evidence-based health-promoting activities. We’re going to round out and come up to number five, but I’ll review the don’ts. Don’t blame yourself or fight the pain. Don’t assume persistent pain always means damage. Don’t rush or panic if you have a flare-up. Don’t believe everything you hear or read. Finally, don’t rely on scans, X-rays or MRIs to tell the entire story.
This goes back to point two of the don’ts about the pain doesn’t always mean damage. Particularly advanced imaging like MRIs and CT scans, they’re getting better all the time. We can see changes in the tissues now that we might have not being able to see before. It’s one very useful tool. In general, medicine and physiotherapy have been enhanced greatly by access to imaging. We’ve also had situations where people have treatment dictation purely based on an imaging finding. That’s one of the fallouts of relying solely on a scan.
The bigger fallout is that MRI scans, CTs and X-rays will tend to show lots of changes in people both with and without pain. If you’re of the anxious predisposition, if you already have quite negative beliefs around what’s causing your pain, and particularly sees it from the very structural and a biomedical perspective, and now you have this sophisticated MRI scan that shows the change to the facet joint or shows that meniscal tear. It’s quite easy to put those together and say, “I have pain because my scan shows that I have a meniscus tear or I have wear and tear in my facet joint.” It’s not to discount the value of MRI in certain situations. Are we saying that the tissues are not playing a role? The evidence is very clear now that pain is much more than what we’re seeing on an MRI scan.
The amount of pain that someone will have will not necessarily be one in one with the MRI findings. We can use examples like that in the clinic to explain to patients. We can use examples like a knee X-ray. We know that there’s not a strong correlation between what your knee looks like on an X-ray and how much pain that you will experience in your knee. It’s not saying that what’s happening in your knee is not relevant. It’s saying that it’s not a simple more damage, more pain relationship. The important point is there’s both overuse of scans. There was a review in 2019 that was published by Professor Chris Myers group in Sydney. They showed in certain situations that there’s underuse of scans.
We have to be aware of what the guidelines say in terms of when we should look for ordering or further workup in the presence of red flags, when the imaging is likely to change the treatment or when you’re looking for some specific pathology that fits with their clinical scenario or presentation. Therefore, the treatment can be enhanced by confirmation of what’s going on on their scan. Whereas if you don’t fit into that category, there are no signs of anything sinister, the MRI, X-ray or CT is not likely to change the direction of treatment.
The scan is of little value in terms of how we approach the individual pain, and of no more value than listening to their story, understanding their beliefs, expectations, goals, aggravate and easing factors That’s the information that I need to guide my treatment rather than what the scan is showing. The message is we’re not saying scans are irrelevant or we shouldn’t use them. We’re saying use them when they’re likely to change practice or when you’re suspicious that there’s either a non-musculoskeletal issue going on, or an issue that would warrant referral to another medical specialty.
Appropriate use of scans with some pain education that goes along with it and some informed consent about what they mean. It’s good information there on that last point. This is a ton of information and people can of course go back to this. Sometimes the more you read things like this, the better it gets. The deeper the learning penetrates into your noodle. Do you give your patients handouts with this type of information? Do you review it in one session? Do you spread it out over a couple of sessions? How do you approach that?
We all develop our ways of doing that. There’s a lot of very useful online information now. There are podcasts. There are websites like Tame the Beast. You’re aware of that from Professor Lorimer Moseley and his group. There’s the Pain-Ed website from Professor Peter O’Sullivan and his group. These are all valuable resources. Patients particularly like hearing other people’s stories that have had a similar experience rather than me as a clinician that may not have had that experience of having persistent pain myself. They often find it harder to engage at that level, whereas if somebody else had a similar experience, they’ll say, “I valued listening to their story because I can see similarities to mine.”
When it comes to education, one of the downfalls is it’s not meaningful to that individual. We can use the patient’s own story to shape the information that we give them. What I’m not a fan of is giving them generic handouts and information about what pain means and what it doesn’t mean. Something like the do’s and don’ts is a bit generic, but I can tailor that in the clinic to their individual presentation. I can use it as a template to fill the gaps with the bits of information that they give me, and use their own story to enhance their learning.
It might be something as simple as they’ve had a bad flare-up. There was no catastrophe. They got out of it and they’re getting back on track again. Using that information to talk about how they might manage a flare-up going forward, or they have been abroad at some time and they felt much better when they were abroad. It’s teasing that out where, “You were more active, more socially engaged and you were sleeping better.” They can see from their own experience that when all of this was happening, I felt a lot better, rather than you telling them that if you sleep better, you’re going to have less pain. Trying to make the education as meaningful and as individualized as you can has value.
Using their story to enhance the learning of these do’s and don’ts, which are rooted in good pain science and pain education. Using what the patient’s story is, their values in life, and what meaning it has for them to help them cope with and overcome pain in the long run. Derek, it has been great talking to you about these ten do’s and don’ts. I know this is going to help a lot of people overcome their persistent pain. How can people learn more about you and follow all the work you’re up to?
The main platform that I’m active on would be on Twitter. My Twitter handle is @DerekGriffin86. I’m on Facebook, @DrDerekGriffin to a lesser extent. I use that as a way of putting general information out there about to help clinicians, but importantly, help patients as well. They may not read it all or they may not even fully understand it all in the context of a Facebook post. As you said at the beginning, it can often plant the seed and get people to think differently or at least consider a different approach. I’m always happy to take a direct question via email. It’s DerekGriffinPhysio@Gmail.com. If people have a specific question that they would like me to discuss or to run by me, whichever the preference.
I want to thank Derek for being here on the show talking about the ten do’s and don’ts of persistent pain. Make sure you share this out with your friends and family on Facebook, Twitter, LinkedIn, wherever you’re talking about the effective and safe care of pain. Make sure you tag Derek and say, “Derek, thanks for the great show.” We’ll see you next time.
- Dr. Derek Griffin – Facebook
- Tame the Beast
- @DerekGriffin86 – Twitter
About Dr. Derek Griffin
Dr Griffin is a physiotherapy graduate of the University of Limerick with expertise in the management of patients with complex chronic pain disorders.He holds a first-class honours degree in Physiotherapy and a PhD in the area of chronic musculoskeletal pain.
Other interests include physical activity/exercise promotion; management of tendinopathy and running-related injuries.
He an avid promoter of evidence-based practice with no time for pseudoscience!
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