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Physical therapists, occupational therapists and speech language pathologists are helpers and fixers by nature and nurture. We are drawn into this service profession to help people and our training drives home the “we can fix it” mindset. In a previous blog, “Tips for Treating Patients with Chronic Pain,” Jim Stark presented a shift in focus from fixing the problem to a guide that enables the patient to be a part of the healing process.
Although helping is a noble reason, it may not be the optimal treatment strategy for a patient with chronic pain.
Jim reminds us that: establishing a healthy therapist-patient alliance is the first treatment strategy; and, we need to remember that the physical therapist starts as a human being in the relationship, not as a therapist.
First, believe the patient’s story.
Second, invite the patient to change.
Third, facilitate the patient to be a part of the healing solution.
“Now that I have reminded the importance of the ground rules,” Jim began, “we can identify treatment strategies.”
Technique No. 1 – Identify how the patient can take action and control their own symptoms.
In other words, help the patient establish tools to allow them to control their own pain as soon as possible. This might take many forms and is not a simple formula.
Here is an example to help stimulate possibilities.
Many chronic pain patients do not sleep well. Ask the patient his/her bedtime routine and, if possible, brainstorm about how to get to bed earlier, practice getting out of bed and starting the bedtime routine again to facilitate falling asleep. Jim recommends that the patient should associate being in bed with sleeping and not with struggle. Teach the patient that if they can’t fall asleep, to get out of bed.
Teach that straw breathing could be a helpful technique or singing can produce some relaxation. The patient starts with a short inhalation followed by exhalation through the straw to elongate the exhalation versus the inhalation. Jim explained that a longer exhalation facilitates the parasympathetic response that increases relaxation. Again the important take-home is that the patient is equipped with activities that they can perform to start to control pain.
Before moving onto the next technique Jim wanted to remind all therapists that the patient needs to be invited to change and invite their feedback to how to sleep better. For example, you can say, “I hear you are having a hard time sleeping. Do you think that if you sleep better you would feel better?” It is very critical to engage the patient to facilitate changing their own behavior and assessing what activities may be beneficial to the healing process.
Technique No. 2 – Establish moving safely.
Will movement be painful? Probably, but the patient gets to define what is tolerable.
Teach them breathing techniques such as straw breathing that help decrease pain.
Teach them that if pain increases during movement it’s ok as long as it recovers quickly to baseline after stopping an activity.
You may also want to teach them that flare-ups due to overexertion may occur.
Then teach what they can do to help control their pain again.
Technique No. 3 – Graded motor imagery and retrain the brain with graded exposures.
Jim suggests three steps:
Identify the right and left images of the pain area. Research shows that people with pain are less able to distinguish right and left limbs and less likely to correctly identify if the neck or back is moving to the right or left. For example, if a person has right shoulder pain they would be less likely to correctly identify a picture of a right or left shoulder.
The second step in graded motor imagery is an imagined movement. Mirror neurons in the brain are activated when we imagine or watch someone perform a movement. This allows the patient to think about the movement without actually causing any pain.
Use mirror therapy. A mirror is used to watch the non-involved limb perform a pain-free movement as the brain interprets the movement as the involved limb.
4th Technique – Mindful Movement.
The last tool Jim presented is mindful movement based in the Feldenkrais method. He describes some patients respond well to identifying the smallest movement they can do without an increase in pain. The goal is to grade the exposure that the patient begins to feel little movements that they were unable to feel before. The therapist can provide tactile feedback to facilitate correct body mechanics that increase body awareness of the movement.
In review, Jim describes the first step is identifying an action step that the patient can take to begin to control his or her pain. Second, teach the patient the movement guidelines to limit exposure to pain based on their own guidelines. Third, use guided motor imagery right and left limb pictures, visualizing movement and as needed mirror imagery techniques. Lastly, Feldenkrais may also prove effective with having the patient focus on small guided movements.
As we wrapped up our time together I reflected and said to Jim, “I wish I would have been taught this before, I believe I may have been able to positively affect more of my patients!”
Jim responded with a quote from Maya Angelou:
“Do the best you can until you know better. Then when you know better, do better.”
Now that we know better, may we all “do better” with our patients.