Explaining Context

When people ask “why does it hurt?” I’ll get around to stating that “… also, context of [your pain] is a factor in how it feels.”

Now this may make sense to you, the PTBT audience, but this is often not an idea that people have thought of. Most people only remember a politician saying his/her words were “taken out of context” so it may be important to explain context.

Here are two quick context stories I tell. Please use them, please make them your own…

1.) Context example… “So now let’s say you are walking in a spooky forest, it’s dark out, you’re by yourself, a bit creeped out and you feel this on your shoulder (lightly tickle the skin), what would your reaction be?” Often a patient will exaggerate looking back quickly or state “I would jump, think it was a spider or something”, etc.

If a Tree Falls in the Forest

If a tree falls in the forest, and no one is around to hear it, does it make a sound?

Ah yes, a classic riddle indeed and one I will answer. No. It does not make a sound. Let’s explore this, and how it relates to understanding pain and sensation.

First we will define a sound. The English Oxford dictionary defines it as “Vibrations that travel through the air or another medium and can be heard when they reach a person’s or animal’s ear.”  You need both waves and an ear to complete the “hear.” So in our above riddle, there is no hear of the sound due to there being no person’s ear in the riddle, as it is in the definition.

Pain Education

*via KnowPain

Allow me to make the case to discuss modern* pain science views with all who will listen, importantly, people who are NOT in pain.

There seems to be support for pre-operative pain education as an effective intervention. Studies have shown improved surgical experience and reduced health care utilization (1), improved short term pain reporting, quicker return to activities and utilization of nonpharmalogical pain management strategies (2). Long term pain outcomes are not significantly effected (that I could find), but it certainly helps the patient in meaningful way (3).

Time

Enter a caption

There is no such thing as Time Management. There is only Self Management, time goes on as it will, no matter your intentions for it.

So what can happen over time? Time is one of these factors that is hard to account for, but does a lot of the treating of a patient for you. (see: It’s not ALL about you).  The biology of tissue healing occurs over a timeline and it occurs at a pace that is affected, but not determined, by us or your patient.

Repetition

Repetition is a wonderful way to work at an issue. Consistent, vigilant, methodical practice.This does not speak to magnitude. Small efforts, in time or intensity, aimed at a goal are a real meaningful attack.

This is a perspective shift for many. For clinicians and patients. People, humans, want a “fix,” an immediate “undo” if you will. I find myself explaining that rehab is a process, not an event. So I will often try to tell a story about it.

What’s going on here? 1

Rhyme as Reason

Communication is complex, rich, diverse and ever important when attempting to portray your ideas, or persuade those around you. As it turns out, certain phrasing can lend an air of credibility to your words.

In the fantastically named paper Birds of a feather flock conjointly(?): Rhyme as Reason in Aphorisms, McGlone and Tofighbakhsh (2000) illustrate the power of structure in extracting meaning and truth from phrasing.

Patient Education Binder

Visual aid with pt Ed. My imaging and pain concept binder v1.0 HT @AdamMeakins @paincloud1 … pic.twitter.com/RKippepias

— Matt Dancigers, DPT (@MattDancigers) April 29, 2016

Seeing is believing. It can be also expressed as “only physical or concrete evidence is convincing” which you surely have heard as a popular argument on many fronts.

Well, your patients are human, and thus, adding physical evidence to your statements or positions can aid in understanding and spur conversation.

Dr. Spencer Muro ( @SpencerMuro ) suggested that, when educating pt’s on pain science or imaging results, we use the above concept to corroborate our “claims.” Use visible evidence, not just repeat it verbally. Enter: The Patient Education Binder.

We used to show patient’s pictures of these images on our phones, but a print-our hard copy in large font is more useful and meaningful (personal anecdote). So we did not make these images, and I will give credit to the maker’s / authors of them. I asked The Sports Physio ( @AdamMeakins ) to tweet some of them, PainCloud.com ( @PainCloud1 ) produces great stuff, the rest are found on Twitter or a search engine. Disclaimer disclaimer etc.  (Most credit is available on the image itself). They are great representations of current understanding.

If they help us understand, why not share with your patient?

Pain is like the Wind

Pain is like the wind.

It can only be viewed by its interface with the environment. 

We see the trees move, the leaves rustle, the flower petals quiver. We see the thick dust in the air, the yard furniture toppling in a pile by the fence, the branches dropping to the street.

Our skin turns alive with an unseen pressure. We are urged to move to the left by an unseen force from the right. It blew my hat off.

“I cannot take a picture of the wind. I can show you a picture of a windy day… but not the wind.”

The Punnett System

Oh Lord, I have heard the claims!

I have listened to the persuaders, the charmers, the charismatics.  Most of their ideas make sense and can follow logical patterns. (see How To Fool a Smart Person by Erik Meira)  I have a thirst for knowledge, and for universal truths… so I’m listening!

But I have one helpful tool that I use to quick-check these fantastic claims: The Punnett Square. The marriage of factors combined to make truth babies.  Hypothetical genotypes producing theoretical phenotypes. (I don’t know what all that means…)

The punnet Square is commonly used in biology (I’ll let Khan Academy teach you about that here,) but we can use it in our own evidence based practice.  Here’s how: Let’s take the claim that poor posture = pain and make a Punnet Square.

It’s Your World

Nociception is subject to all the truths and flaws of any other input system.

Patients never have this view, since their pain has been described to them in terms of body parts and structures.  However, the tissue is as important in pain as the eyeball is in what we see.

This past week’s viral internet subject is a great example of all that (Black ‘n’ Blue dress).  Vision is simply our brain’s decision based on the information available to it, including, but not limited to, the light waves of objects.  The eye itself is simply an