Last post we discussed helping people change their limiting beliefs they have about themselves in order to move past their problem. Nowhere is this more important than with pain. Things that affect our body, affect the mind. The most common belief is “I have X which causes my pain” with X being arthritis, slipped discs, bone spurs, etc. This can be simplified to the belief: “X causes pain”.
Let’s take the statement, “my pain is due to arthritis.” The fundamental belief of this statement is that arthritis (A) causes pain (B). To ‘crack’ this belief open, you can cast doubt on the cause-effect relationship by explaining counter-examples of when A happens but B doesn’t (A, not B) and when B happens and A doesn’t (B, not A).
A, not B: arthritis but no pain.
- This discussion can be started with general counter-examples. Research indicates that many people who have x-rays showing arthritis, don’t have pain. For example, 37% of those over 65 have x-rays showing knee arthritis but only 10% of men and 13% of women have arthritic knee pain. Then you can plant this seed of doubt: what’s different between those people with pain and those without?
- Now you can also get specific to your client. When you took their history, they probably already told you how their pain fluctuates throughout the day. But if all of their pain is due to arthritis, why would that happen? Since arthritis is provoked by weight bearing, it shouldn’t hurt while sitting down but many people do report aching at rest. Why does it hurt worst just after standing up but then gets better after they moved a little? If all of their pain is due to arthritis, shouldn’t it feel best after resting and only get worse with walking? If they don’t tell you these things, you can ask probing questions about when they have pain so you can later point these counter-examples out.
- Research is all well and good, but most people don’t think it applies to them because they’re a special case. You can, innocently, ask about other areas in their body. If one knee hurts, does the other knee hurt? Or hurt just as bad? If their back hurts in one area, do the other levels of the spine also hurt? After they answer these questions, you can point out that if one knee has arthritis, you can almost guarantee the other one has a similar amount of arthritis. So why don’t they hurt the same? And the same logic goes for different levels of the spine.
- All of these counter-examples serve to point out that all of their pain might not be due to arthritis alone. This leads nicely into ‘B, but not A’.
B, not A: pain but not all due to arthritis.
- So now your client is likely more open to believing that their pain might not all be due to arthritis. The question, then, is what is causing their pain?
- If you’re working with someone in pain, then I assume you’ll also do some sort of examination in order to make your own decision on what is wrong with the client. Say you do your examination and you find they have weak core muscles, tender/trigger points, muscle tightness, nerve tension, soft tissue restrictions, joint mobility restrictions, etc. These are your explanation of what else is contributing to their pain (besides arthritis). You’ll then follow-up by explaining how you will help them resolve these problems which will decrease or eliminate their pain.
- This is incredibly important to success because now your client understands that there are other contributors to their pain and that you can address them.
How to use this
With this covered, I’ll now go into how I believe this can best be accomplished. First, when you’re planting seeds of doubt, it’s usually best to ask pointed questions rather than just bombarding them with counter-examples. Telling them, “Well you told me your other knee doesn’t hurt as bad and since that also has arthritis, arthritis must not be the only cause of your pain” – is a great way to get them to shut down and clam up. Instead, you can ask, “does your other knee also hurt this bad? If that knee also has arthritis, what might be different? Ok, so you think arthritis is the difference?” The last question really plants the seed when you place a doubting tone on the word arthritis, to convey to them that you might have your doubts about it. They’ll probably respond by being slightly confused at which point you can just move on to either counter-examples, or straight to your examination. Your examination will then reveal other factors that were contributing or even causing the pain which will answer your question for them.
I won’t tell you how to do your examination or what impairments to look for. However, I will say that I think every clinician should include a discussion of the nervous system. This doesn’t need to be complex, but explaining how the body’s “software” contributes to pain is extremely valuable. First, there is the threshold concept. This is usually explained using the metaphor of a cup. Your body’s pain threshold is like a cup. Different things can fill it up which is no problem. But once it is overflowing, then you have a problem. Similarly, the different impairments in a region can all add to the ‘cup’. This can include arthritis, muscle weakness, soft tissue restrictions, etc. If the cup is overflowing, then removing some of these problems (treating weakness or using manual therapy and so on) can decrease the problem. This is the equivalent of pain reduction. If you can remove enough of the problems so that the cup is no longer overflowing, well then you have no pain. Even though there might be things in the cup like arthritis, if it’s not overflowing, you don’t have a problem. This nicely opens up the possibility of partial or complete pain relief while still acknowledging that you cannot remove things like arthritis for them.
The other important piece of information is where pain is. If your right knee hurts, you assume pain is in the right knee. However, your right knee is just sending the signals up to your brain. Where you actually have pain is in the ‘right knee’ area of the brain (to be more complex, in the somatosensory cortex). This information can be extremely important because it helps explain why your interventions and treatment might work. After all, most believe that exercises, adjustments, massage, etc. can’t really ‘solve’ problems like arthritis, a torn meniscus, bone spurs, cancer-related pain, and other ‘structural’ problems. Sure, they can help, but the relief won’t last or they’ll never truly get rid of it. By explaining that your interventions not only affect their body but also their nervous system, you can ‘change the target’ so to speak from something impossible to change, to something that can be changed (how the nervous system processes pain signals).
When someone tells you their problem is something you can’t change (like arthritis), you goal is to open up the possibility that their problem is something you can change. This often starts with planting doubt that what they believe is the problem may not be the problem, or at least not the whole picture. Then, you should identify, with your examination, what the problem is and how you’ll address it.