Abuse of Power in Pain Treatment

Abuse of Power in Pain Treatment

It’s been a 6 month hiatus since my last post.  Many micro projects are in the works at the moment.  It was time to re-focus on streamlining procedures to make time for writing and creating again.  I’ve recruited some behind-the-scenes administrative support which has granted me some much needed breathing room with a little bonus moral support!

In the meantime I’ve been keeping only a casual presence on social media with Facebook (FB) groups in the areas of chiropractic and pain.  These relaxed venues are a wonderful resource for me and I spend a great deal of time reading research this way and following professional debates about pain science within these groups.

The following post was originally geared towards practitioners because it was actually something I was preparing to post to a particular FB group.  Half way through writing, I realized it’s much too long and in-depth for a post like that.  It’s something that deserves wider readership and better scope (and may in fact need to be re-visited in the future.)

I have had concerns with the multidisciplinary discussions online about pain science

…and this week a patient helped me realize why.

My concern is specifically about how the rise in casual awareness of the bio-psycho-social (BPS) role in pain is affecting the way that non psychologically trained professionals handle the care of patients. An increasing number of practitioners are growing aware of the role of psychology and brain chemistry in pain…yet they are not trained appropriately about how to safely and effectively broach this topic with patients. They think that they can and should do so – based on the research.  This is a mistake – a potentially harmful one.

Don’t get me wrong – the rising awareness about the connection between pain and the brain is wonderful progress.   Increasingly the new supporting research is emerging online and at weekend seminars.  It provides strong support for collaboration between healthcare disciplines.  We are seeing that the answer to treating pain effectively is never solely via a mechanical fix (like with chiropractic, orthopedics or physical therapy.)  It’s not exclusively a dietary issue and it’s not something you can counsel your way out of by talk-therapy alone either.

The problem occurs when practitioners without mental health care credentials, try to incorporate their casual knowledge into treatment.  Without a deeper understanding of a patient’s emotional health history nor the training to safely handle someone’s full psychological burden, this ends up just being reckless and delusional behavior on the part of the practitioner.

A subtle boundary breach is serious

This week, my patient confided in me the reason she had to change physical therapy (PT) practitioners. She is someone who has a complex variety of PTSD and maybe some other combination of DSM-V diagnoses, but that is something I am not qualified to confirm.  The point is she, like many patients, is more than meets the clinical-eye.

For her to trust a new practitioner involved numerous emotional hurdles.  Under the care of this PT practitioner, as part of each visit, she found herself apparently continually pushed into the topic of deeper underlying psychological reasons for her current condition.  This probing was coming at her from someone unqualified to appropriately recognize the precarious nature of what was being forced to the surface. Then, once having re-triggered trauma for this patient, this practitioner was ill-equipped to handle the fall-out.

My patient believes that after declining numerous times to engage in discussions of her private psycho-social history, this therapist continued to press her on it and belabor the point.  While rightfully believing that this may play a role in the patient’s overall well-being – pain or no pain – it is EXTREMELY important to read your patients’ cues and realize that most people who seek the help of PTs OTs DCs LMPs LAcs are not giving consent- explicit nor implied – to discuss personal emotional matters.

What any of us healthcare providers need to do:

When we don’t get the response we’re looking for from patients – we all need to take the hint, just drop it and move on.  Meet your patients where they are at.  No one will benefit from being force-fed “insight” they are not ready for.

This patient who had to change PTs, did so – not because of a petty personality clash and not because of ineffective physical therapy, but because her emotional trauma was re-triggered and the PT’s probing was uninvited. Unfortunately this PT did not have the training, life experience nor the instinct to realize the gravity of what she was inflicting visit after visit. Any physical progress the patient could have made in regards to her pain was sabotaged.

It was no small feat to get this patient to reach out for treatment in the first place and this misstep could have been detrimental.  Luckily she has a psychiatrist and is getting the right kind of support through this glitch.

This should serve as a word of caution to all of us. It’s tempting to want to put into practice the full breadth of what we know, but it’s not always appropriate nor welcomed.

Perhaps for the BPS / pain-science educators at large it’s also a reminder to teach with this in mind.  Pain education when taught to professionals who are not adequately trained in mental health, absolutely must emphasize the importance of recognizing the need for referral to a qualified practitioner.

Practitioners: when thinking of putting your newfound knowledge to practice without extensive training, make sure that when sharing information about the psycho-social links to pain, that it’s done with kindness and not judgement.  When coming from someone who is not trained in mental health, it must be done from one human to another, in conversation and without the pretense of power differential between therapist and patient.

Working with an integrative approach and developing a robust referral network is key.  Please leave the formal psycho-social piece to the mental health professionals.

For the patients reading this: trust yourself.

Only you know what works for you and you know best what you’re ready for.  Don’t let anyone guilt you or pressure you into overriding your instinct and comfort levels.  If you feel emotionally violated or disrespected, there’s a reason for that.  You deserve to be treated with respect.  If you do your best to communicate your boundaries, then you deserve to have those respected.  Sometimes when others trigger us, whether that’s in a therapeutic relationship or not, it’s an important signal that we have some work to do within and remember, no one intends to be unkind or disrespectful.

We are all imperfect and trying to figure things out and doing the best we can, but that doesn’t mean you should tolerate anything that makes you uncomfortable.  Your boundaries and limits don’t have to be the same as someone else’s.

If you are working with a PT, OT, DC, MD, LAc, LMP or anyone else in a therapeutic capacity, and he or she is pushing you to either talk about something that you don’t want to talk about, or making you do something that feels uncomfortable – let them know that you are not okay with it.  It doesn’t matter if this seems like something you “should” be okay with or others would normally be okay with.  That’s irrelevant when it comes to your well-being.

Too often patients/ clients abdicate their power and autonomy with the idea that the therapist/doctor/professional “knows best”.  That may work for some people but it only works because there is awareness and consent.  If you feel emotionally or physically uneasy and you’re not explicitly consenting to have your boundaries pushed, either speak up or move on.  Communicate your needs or find someone who will work with you on your goals in a way that feels respectful of your comfort zones.

Anyone worth their salt will happily hear your concerns and adjust their approach accordingly.


Image Credit: Wikimedia Commons By Pieter Brueghel the Elder

Save

Save

Save

Save

Save

Save

Save

Save

Save

Save

Advertisements
Pain Research – Someone’s Got To Do It.

Pain Research – Someone’s Got To Do It.

It’s abundantly clear to me after this weekend, that the folks at the Neuro Orthopoedic Institute (NOI) group in Australia have been busy doing exactly that.

img_6417My writing relies heavily on the hard research work of people like these and I am so happy not to have to be the one to produce it.  I have the utmost regard for the kind of mind it takes to do that sort of work.  I, on the other hand, much prefer bringing the information to real people for whom it has practical application in a way that makes sense to them individually.

This past weekend, I was able to attend part of the NOI group‘s EP3 West Coast version of the US edition on Friday at the Washington State Convention Center. Those in attendance were primarily physical therapists, some with doctoral PT training, a few medical doctors, a few adjunct providers – one other chiropractor, a couple of osteopaths, nurses and a some psychologists.

Axons and Dendrites and TLR-4 Cells Oh My!

tlr4What I love about this particular body of pain research presented by the NOI group, is the neuro-biology of it. While sitting in the conference and happily soaking up the neurological terminology familiar to me, I wondered how well the basic physical therapy education covers neurology in the US.  Chiropractors get extensive exposure to neurology with increasing detail through the progression of the 5000+ hours of doctoral level curriculum.  It appears that Australian physiotherapy schooling also includes a fair amount of neuro-physiology training.  As I looked about the room at the blank stares, I wondered if perhaps the American PT curriculum isn’t quite as rigorous in this area until perhaps the elective doctoral level? Something for the NOI instructors to perhaps become aware of.

The minds behind this approach to understanding pain via this group out of Australia, is headed up by the two Australian educators who created the book behind the tour. One is a clinical and research physiotherapist and professor of clinical neurosciences at the University of South Australia . The other calls himself a “freelance educator” and sports the suffix EdD, also a physiotherapist who holds a graduate degree in “advanced manipulative therapy” which I believe is the Australian preference over chiropractic although it seems there is significant overlap. As with many different regions in the world there are political reasons that one profession is regarded more highly or accepted more widely.

This weekend they were joined by a local talent, editor-in-chief of the Journal of Pain and University of Washington professor in the Department of Rehabilitation Medicine.

Guess What? “Sh*t” Happens and That Same “Sh*t” Matters When it Comes to Pain.

statue_trippingWhat tickles me about the NOI group research – at least as presented by the neuro-literate educator of the group – is that it is finally providing scientific evidence of things that we all as humans at some level already know.  Life experiences affect our relationships with pain.

Happy or sad, the things that happen to us as we navigate life, impact us in ways that can cement in time, our cellular reality. Our neuro-physiological responses to pain are significantly dependent upon the molecular patterns set up by a wide array of events and can set us up to experience recurrences of pain more easily or keep us from being able to find our way out of pain.

I was pleased to see that the substance of their work corroborates what many of us who work extensively with patients in pain have always known, and that is the practical reality that pain is often independent of tissue damage. Long after a legitimate tissue disrupting trigger has passed, pain can linger. Pain can also return in the absence of proportional local tissue damage and this is where things get quite fascinating.

The entire premise of my book series about everyday pain is that helping patients grasp the reasons behind their pain and helping them see that they are not irreparably damaged, massively speeds recovery from pain and keeps relapses to a minimum.

Teaching the Teachers

landaff_1940sThe most lovely thing about these three clinical research masterminds is that they have uncovered and provided the science and research behind the validation needed to implement this pain education. The NOI group seems to be working to educate more clinical educators which is truly going to the source to effect change and I applaud that.

It’s extremely important to refine the professional messaging behind how we greet pain in the practice setting and it will go a long way to changing our pain culture. But what I want to do and am focusing on with my publishing project  these next few years but also farther into the future, is to bring much more of this directly to the patients – the everyday person.

Pay to Play – Healthcare as Usual?

dandy_pickpockets_divingI learned that it was primarily a few local larger medical institutions that brought this conference to their employees by virtue of allotted benefit dollars that provide them with reimbursement for continuing education. The cost of the conference was unfortunately prohibitive to anyone not affiliated with an organization with deep pockets.

The financially prohibitive nature of these conferences (geared specifically to the mainstream medical institutions) presents a discriminatory challenge to equally qualified and information-hungry solo (or small practice) practitioners from a wide variety of relevant specialties. Nevertheless I must applaud the forward-thinking by these health care organizations and hospital groups for embracing the reality and changing attitudes towards the psycho-biology of pain.

It is a changing world and there is hope.
Continue reading

What IS “Integrative” Healthcare?

What IS “Integrative” Healthcare?

By The U.S. Army (2012 Warrior Games) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

“Integrative medicine” is a term that has become very trendy in the health and wellness industry.  It’s an approach inspired by some of the leaders in the Functional Medicine movement.  As soon as it became evident that patients demand it which means there are big dollars at stake, even mainstream medicine is coming on board.  Cleveland Clinic has opened a dedicated wing for Integrative and Lifestyle Medicine  as has Johns Hopkins with their Integrative Medicine and Digestive Center.

So, what is it exactly?

It’s healthcare designed to treat the whole person (shocker). Many of us in the natural healthcare industry who have been practicing with this mindset for decades can’t help but roll our eyes a little bit at this “new” movement, but it is one to celebrate.

It feels to me like the general public is just catching up with how I’ve been living for most of my life personally, and now professionally for close to 25 years.  What we see in the integrative circles of healthcare is a coming-together of East and West, an acceptance of the interdependence of both sides.

“Integration” refers to the coordination of care between mainstream Western medicine and traditional or “alternative” methods including but not limited to acupuncture, chiropractic, massage therapy, yoga, meditation and other lifestyle modifications. You can find “Functional Medicine” on Wikipedia defined as: medical practice or treatments that focus on optimal functioning of the body and its organs, usually involving systems of holistic or alternative medicine.  

The functional medicine movement was started by a chiropractor with a PhD in biochemistry – Jeffrey Bland.  He bravely championed the long held old-world wisdom of viewing health and disease not as a linear process between one cause and one effect, but rather a complex symphony with multiple orchestral sections that all depend on each other for harmony.   Now people like Mark Hyman MD and a slew of others, straddling mainstream and traditional methods, have embraced this much needed common-sense approach.

Integration? Or Collaboration?

What we are seeing and hearing increasingly from numerous medical centers and hospitals, as many of them move to offer these kinds of approaches under one roof, is validation of this kind of wisdom-medicine for use in the Western model.

This week’s national news headlines on ABC’s GMA morning programming included a story highlighting the benefits of integrative medicine for cancer patients at all stages of care.  The use of acupuncture, movement therapy like yoga, massage and meditation were given as examples of treatment methods used to address the emotional, spiritual and physical needs together.

Some of you who follow this blog know that, just a few weeks ago, I attended a conference held by the Academy of Integrative Health and Medicine (AIHM) where I met medical doctors, physician assistants, nurses, naturopaths, acupuncturists and other chiropractors.  All of us together acknowledging the role of each other’s specialties in the full care of a patient while remembering to also live the path that we advocate for by indulging in some reflective self care.

In conversation with someone over breakfast at this AIHM conference I shared that I am a chiropractor in solo practice. I was met with “So you don’t actually practice integrative medicine…”

This took me aback a bit because I believe I actually do the ultimate integrative practice.   This exchange made me consider that perhaps the confusion is with the concept of “collaborative” vs. “integrative”.  Solo practice means I run a one-woman-show but does not preclude my patients from receiving collaborative (or “integrative”) care.  In my opinion collaboration is essential to integrative approaches.

This meeting of two worlds, in my opinion, can happen just as effectively in a more expansive community setting and not just under one roof. Successful collaborative care for the whole person is much more about the attitudes of providers than a physical facility with a name. I see my job as more of a healthcare traffic cop of sorts.

With the training that every chiropractor receives – to serve as a primary / portal of entry provider  – we are charged with the responsibility of knowing when chiropractic will serve our patients and when other modalities are more appropriate or needed in conjunction with our work.  Who better then, to assess and help patients prioritize treatment methods and direct them to the right practitioners?

I am extremely comfortable with my limitations as a practitioner and for true whole-person healthcare I think it’s essential to beware the delusion that any one of us can be everything to everyone.

For patients who don’t yet have a healthcare team, I regularly bring their attention to physiatry, physical therapy, massage, acupuncture, psychotherapy, and whenever needed, direct them back to their mainstream medical provider or any  number of medical specialists.

Do you have a healthcare team of alternative and mainstream providers?  Are you enjoying the integrative medicine movement?  You deserve to.  Status quo is changing.  Expect more.