Blog 12b: Be careful what you believe; it can become your reality (part two).

Following on from the first part of this two-part blog, here are some other examples of unhelpful comments. These comments are, at best, thinly evidenced in science and are therefore more accurately described as beliefs that can then become unwanted realities. Suggested alternatives are offered:

Common feedback to patients in pain

Alternative suggested comments

 “Your spine is degenerate / damaged / unstable etc.”

“You have a slipped / bulging / worn out / ruptured / prolapsed (etc, etc, etc) disc”

“You have bad arthritis in your spine”

 

 

“Your back / neck will likely get worse with time and ‘may need surgery’ one day if it doesn’t get better with physiotherapy or injections …”

 

 

 

 

 

“Any longer work period will put major strain on your lumbar disc and could result in permanent back and neurological injury”

“I do believe you will require spinal surgery … I am concerned that with each passing moment, you may be doing further damage to your S1 nerve root

PS: the last two comments are accurately quoted from a spine surgeon’s real correspondence in a worker’s compensation context.

“Your back does not look as good as it did when you were younger, but it is strong and adaptable. Most people have such changes and worse and feel no pain at all.”

“In fact, the recent research says that people who worry about their scans do much worse than those who don’t have scans at all. Let me explain how this works via the brain’s pain equation …”

“The long term results of pain is the same whether you have spinal surgery or not, but clearly with no potential harms if you don’t and just do your rehab exercises really well and confidently”

“The results of spinal surgery are quite different for the same problem depending on the context of the pain.”That can’t be logically explained by the ‘injury’ itself. I know a good blog that may help explain that to you based on really interesting science …”

“Going back to work is part of your physical and neurological re-adaptation process and is a vital component of recovery.”

“Discs tend to shrink with time, not get worse; nerve damage that doesn’t recover spontaneously is a rare event”

“Your worn joint needs a ”clean up'”.

 

 

 

“You have bad arthritis and will need a joint replacement one day”

“You have ‘bone on bone’ arthritis”

“You have degenerative disease”

“Your degenerative (fill in any body part here) is causing your pain”

“There is really good evidence that ‘cleaning up a worn joint’ is not directly effective but works through a placebo effect when it is effective. There are potential harms that can be worse than what you started with.

“Your joint is undergoing a natural wear process. The relationship between such changes and pain is really vague. Most wear in joints actually DOESN’T hurt. Every now and then pain and inflammation can occur due to a change in the adaptation process. It is all about how you go about your rehab exercises. There is no reason to think that it won’t re-adapt well. And let’s have a chat about how pain actually happens …”

“Degeneration is not a disease at all; it is just a change like skin wrinkles. That is because the vast majority of degenerative change does NOT cause any symptoms or disability at all. It is all highly adaptable and even people with a lot of degeneration can have very few problems.”

“Pain occurs commonly when the tissues are seen to be normal. Scans can be terrible but with no pain at all. And there is everything in between as well.”

“You better be careful and stop doing this and that …”

“You will be harming yourself by doing that”

“You will get worse if you keep doing …”

 

“Sometimes a short period of rest is required to settle inflammation. But even in this time some muscle contraction exercises can be done. And then when it settles the people who stay active and keep doing most things do much better than those who don’t. And let’s have a brief discussion about how pain actually works to explain how that happens …”

“You are doing no actual harm doing that exercise, even if it hurts. Let me explain …”

 “You have tendon damage which is causing your pain and may need surgery” “Tendons commonly wear with time and most times people are not even aware that it is happening. No matter how bad it looks, exercise, even highly provocative exercise, seems to help. Let me explain how this probably works …”
 “You have the (whatever) of an 80 year old”  “Changes are seen in body tissues at a very early stage in many studies. The model that equates tissue changes with pain is not a very reliable one and believing this can actually make you worse. Want to know how?”
“Because your pain won’t go away, you need strong painkillers; here are some morphine type medications”

“This medication isn’t working? Let’s try a different one.”

“Only getting some relief from this medication? Let’s increase the dose and/or add some other medications.”

“Strong painkillers have a role with great care in pain from fresh injuries or after surgery. The role of such painkillers on a long term basis quite often creates further huge problems. Often you just get a ‘high’ rather than really good pain relief – that is a problem. Feeling that pain has improved can also be explained by the very interesting placebo effect. When injury pain is persistent it is best explained by problems with the way it is processed by the brain, not by the injury itself. It is then remarkably resistant to all treatment.”

“Strong painkillers can cloud your ability to understand what is going on properly and make good decisions. Thinking clearly is vital so that you can understand your pain, make good decisions and start to wind your pain down.”

 “We have many options for your pain. We can do injections of this, this, this and that. We can ‘stun’ sensory nerves which is called radiofrequency. We can insert very expensive nerve stimulation devices into your body etc, etc …”

(PS: The following was tweeted happily by a physician, who offers various external interventions for persistent pain management, after what he believed to be a good day’s work:

NC1

I noticed a tweet from the same person a few weeks later:

NC2

“One reason there are a lot of options to throw at persistent pain is that there is not one of them that is really reliable. Many desperate people essentially turn into dartboards and just have one ‘dart’ after another thrown at them trying to hit a bullseye. Also higher level research actually questions whether these techniques are directly effective at all. Placebo controlled trials are deficient and when done, they are not flattering.”

“Quite often when such measures fail, you become more desperate and convinced that some structure needs to be fixed. This failure of treatment quite often results in seeking surgical ‘fixes’ of greater potential harms and highly questionable effectiveness. That pathway can end very badly.”

“Furthermore let me discuss with you how it works that simply thinking that you have something that needs to be ‘fixed’ can make your pain get stuck. And the more it sticks around the worse it gets. This is explained by the ‘brain’s pain equation’. Have you every heard of a ‘catch 22’ situation? Let me explain. Treating pain by convincing people that they are faulty, damaged and need ‘fixing’ can actually worsen that pain …”

“If there is a role for these sorts of less harmful interventions, it is as possible ‘circuit-breakers’. This is then best considered only after you learn to understand your pain really, really well.”

“Interventions mainly target the electrical signalling side of your pain. Now please be quite clear – you can have severe pain as an output from the brain even when there is no signalling input at all.”

“There is very little reason to consider that anything in the musculoskeletal part of your body is capable of producing ongoing signalling input tp pain that equates with the type of unrelenting pain you have.”

“You need to learn to live with your pain”.

 

 

 

 

 

“There is really nothing / not all that much wrong with you …” (Patient thinking – “I am in pain! Are you telling me I am imagining it!! I will go out and get someone else to check me and do more tests to find out what is wrong with me!”)

“I see no reason why you should have to live with your pain forever. There is no evident ‘injury’ that equates with that advice and people with serious injuries don’t all suffer that fate inevitably. Your nervous system has adapted badly to result in your current situation. Just as it has adapted badly, it can be re-adapted back to what it should be. Let’s discuss how this can be achieved …”

“There is nothing to worry about at all in terms of a visible contribution to your pain response. Let me explain pain to you according to the really interesting science so that you can understand what is happening to you and start to wind the pain down by doing the right things.”