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

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What’s the Big Deal if I Crack My Own Spine? – Stop Everyday Pain

What’s the Big Deal if I Crack My Own Spine? – Stop Everyday Pain

Is this you when your back feels stiff?  Looking for relief from stiffness or pain by twisting it out?  Hoping for that crack that feels like what you get from your chiropractor?  It’s not the same.  It’s more dangerous to do this yourself and you should learn about why this is.

 

Read more from the original post and early book excerpt by following the link below: “When the jammed-up joints are properly released, then the hyper-mobile joints – the ones that are cracking all the time – should not feel the need to do so much of the work anymore”

It might be that you’re noticing cracks and pops with regular daily movement or you are making your joints do this repeatedly throughout the day in the hopes for relief from pressure.  In both cases you should learn more about what’s really going on, so you make informed choices…

Source: What’s the Big Deal if I Crack My Own Spine? – Stop Everyday Pain

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Your Pain is Not Because You’re “Fat”

Your Pain is Not Because You’re “Fat”

What do I know about the struggle to lose weight? Not much and I don’t pretend to. That is a genetic “crap shoot” that I came out on the lucky side of.

What I DO know is that pain does not happen to overweight people alone.

The other thing I know and hear about more often than I should, is how doctors of all specialties commonly and unabashedly display extreme prejudice against people who are overweight.  Numerous patients of mine tell me similar stories about reaching out for help with their pain and being met with a host of physician encounters that leave them feeling judged and ashamed.  So many doctors are quick to blame the weight and slow to investigate past the fat.

Anyone in this day and age knows about the correlation between obesity and disease and mortality.  I’ll go out on a limb here and suggest that the majority of overweight patients know that it’s not ideal to be on the heavy side.  The last thing they need to hear is that everything wrong with them is because of their weight. First of all, that’s just not always true and more importantly, blaming their weight is certainly not something they need a doctor’s help doing.

When has fat-shaming ever helped anyone make positive lasting change? Being judged by careless strangers is one thing but by your own healthcare provider is quite another and shouldn’t be allowed.

If someone has been steadily on the heavy side for the majority of their lifetime and there hasn’t been a sudden recent change in weight, then the skeleton – while perhaps stressed in ways that lighter people aren’t – has had years to adapt.  Our bodies are pretty amazing that way and given years to slowly get used to something, we just do.  The likelihood that suddenly the weight is the main problem is unlikely for this sort of scenario.
I see plenty of lean and “fit” looking people who just wake up one day in pain and have no idea why.  We don’t say to those people: “Well it’s obviously because you’re too skinny.  Come back and see me when you’ve gained some weight.”

Here’s another problematic drawing of parallels that seems to happen quite a bit…

Any sized woman who experiences a 9 month gain of pregnancy weight should never be compared with someone who is chronically overweight.  It is completely different. Not only do most overweight people not gain that quickly but they also aren’t experiencing the unique destabilizing and mechanically disorienting effects of massive hormonal and blood volume changes.

If weight is legitimately suspected as the cause for pain, then the last thing you should do as a doc is dismiss the patient with a sweeping prescription for exercise and calorie restriction when the more likely chronic weight-related risk is cardiovascular.  If anything, this person needs to have a heart health check first.

When a patient feels alienated from their physician due to the shame over their weight, it creates a dangerous  barrier to receiving true healthcare solutions.

I hear first-hand from patients that they will simply not return for care when they feel unfairly judged and dismissed and this can be more dangerous than the weight itself.

We do need to be clear with our patients about the facts:

But facts can be shared without judgment and blame. Higher body fat percentage is a real health risk. Abdominal fat is the worst. It predisposes us to higher levels of chronic inflammation which can manifest in many ways – not just through pain.  Evidence shows that it’s inflammation that is the huge risk factor and linked with a host of diseases.

Doctors and patients alike need to be aware of the cold hard fact that body fat percentage can be dangerously high in underweight, average weight and overweight people.  This is why everyone of absolutely any size, needs to avoid being sedentary, eliminate inflammatory foods and care for their stress levels and stress coping – all of which have been shown to play a role with inflammation which is the ultimate killer.

It’s never just the weight alone.

When there is pain, the pain chemistry needs to be addressed first and foremost.  Yes, fat cells contribute to inflammation which can stack the deck against us and cause pain, but every person’s situation is unique.  Look at the mechanics.  Consider individual body chemistry.  Inquire about psycho-social factors.  These are the inroads to better, more compassionate self-care which is where weight loss can begin if indeed that is appropriate for that patient.

We are emotional creatures first.  The physical body is a reflection of who we are.  All bodies need to be greeted with kindness and respect first before change can be made.


image credit: By Peter Paul Rubens – The Prado in Google Earth: Home – 7th level of zoom, JPEG compression quality: Photoshop 10., Public Domain, https://commons.wikimedia.org/w/index.php?curid=22620913

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How Does Self Image Affect Your Pain?

How Does Self Image Affect Your Pain?

An excerpt from my book as seen over at InnerSelf Publications website.

Timely for the season of self reflection and internal work.

 “by Ya-Ling Liou, D.C. If you’ve only ever seen yourself as unsure and perhaps your self-esteem is not strong, you may be more vulnerable to becoming overwhelmed by fear—stressed by the worry that your pain might devolve into a worst case scenario of unknown proportions.”

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Meeting Dr. Joseph Pizzorno

Meeting Dr. Joseph Pizzorno

Last month I was in San Diego attending a week long conference of the Academy of Integrative Health and Medicine (AIHM). What a refreshing gathering of so many different health specialists and generalists, truly representative of my ideal in holistic and integrative care of patients.

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Dr. Joseph Pizzorno at the AIHM conference 2016 – Looking dapper as ever despite three consecutive lectures without break!

One of the highlights for me was to attend a set of lectures given by Dr. Joseph Pizzorno and then to meet him for the first time. He is one of the founders of Bastyr University. I’ve been in touch with him for the past couple of years now because of his kind willingness to pen the foreword of my first book in the Every Body’s Guide to Everyday Pain series, Volume One – Put Out the Fire. Until now we had only corresponded remotely and so this was the first chance I’d had to meet in person this man I’m so grateful to.

I was in disbelief for quite some time that this natural health care giant was willing to associate his name with a project like mine – very much still in its infancy.

What I’ve learned about him during the process is how generous, gracious and humble he is and all of this was just confirmed by our in-person meeting in San Diego. He was practically mobbed by eager attendees after his lectures and despite being worn out from travel and an unusually long consecutive series of lecture hours without a break, he responded with patient kindness to everyone’s questions.

The topic of Dr. Pizzorno’s most recent research and writing work is environmental health.

The area of study referred to as “environmental health” concerns itself with the effect that inorganic compounds in our environment  exert on our overall well-being, whether those be naturally occurring or human-made.

It is an essential piece to the puzzle when considering the three possible triggers of everyday pain.  Exposure to these compounds can be one of the significant influences responsible for triggering an imbalance in our biochemistry – the precise factor that can add to our inflammatory toxin load and set us up for pain.  When chemistry is out of balance it can profoundly change our emotional coping and in turn our mechanical stressors as we translate emotion into posture.

Environmental toxin exposure is an awesome topic demanding supreme command of the research which Dr. Pizzorno clearly has with unique affinity.  He is in the process of preparing for the release of a new book on the topic:

The Toxin Solution: How Hidden Poisons in the Air, Water, Food, and Products We Use Are Destroying Our Health, and What We Can Do to Fix It

And there is another book in the works for a few years down the road of a more didactic nature.  I’m very excited to see both and will be heavily referencing this work for Volume Two – Fix the Fire Damage of my pain book series.

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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.
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Do You Know How to Name Your Pain?  Here’s Why You Should:

Do You Know How to Name Your Pain? Here’s Why You Should:

The_Cluster_HeadacheWhen I ask patients about pain, I’m always intrigued by the amazing variability in terminology or often the complete lack thereof.  Maybe it’s because of growing up in a multilingual environment that I have a personal fascination with words and language in general.  What’s particularly interesting to me is how inadequate words can be for all of us when trying to fully convey pain and sensation.

Not only is there an endless variety of quality and severity, people who make a habit of “toughing it out” in the face of pain, actually lose their language for pain.  Depending on modeled pain behavior in your childhood home, it’s also possible that this language was never even allowed to develop .  Based on what I see, I believe firmly that it’s only through the re-learning (or learning anew) of how to speak about our physical pain that allows healing to begin.

First of all, on a simply practical level, if you cannot describe your pain with any convincing accuracy, someone like myself who is interested in learning about your pain in order to help you troubleshoot it and get rid of it, is working with hands tied.  It’s not until I spend time with someone who has no language for their pain that I am reminded of how important it is to the successful outcome of any bodywork treatment.

Secondly for yourself, how can you forge ahead successfully towards a cause – in this case eliminating your pain, if you don’t even have a name for it?  For many people pain conjures up fear.  The first rule of thumb about conquering fear is to name it and face it.  If you say to yourself you’re unhappy, don’t you need to know what it is that you’re unhappy about before you have any hope of being happy again? Same thing with pain.  Get specific. Dig deeper.

I notice that the people who are the most conflicted about using the word “pain” tend to be the chronic pain sufferers – the people with high pain tolerance.  (A topic for a separate blog post: people with a high tolerance for pain often are the ones who end up in chronic pain because of their inability to register the early warning signs – and yet they seem to be the ones who worry the most about being pain-“wimps”). These are the people who hesitate and insist instead on using a different, less loaded word because “pain” sounds too serious compared to their perceived discomfort.

It’s okay if you don’t want to refer to your discomfort as “pain”, but you should know that by repeatedly dismissing the idea of pain you lose the ability to describe any aspect of it.  For example, “pins and needles” is an important sensation that leads to very different approach in treatment than “stabbing” sensation.  An “ache” can be very different than “stiffness” and both are significant to me but will change how I treat it.  Sometimes the sequence and timing of sensation is meaningful and sometimes it’s the combination of sensations that points to the cause.  Everything and anything that you notice is significant – even if you don’t want to give it any weight.

I believe this widespread issue of inadequate command of and connection with our language for pain, is what causes some physicians to quickly dismiss complaints as fabricated or baseless.  If you are someone who is unable to describe your pain as anything other than “it hurts”, your concern will most likely be dismissed and you’ll be urged to  medicate it away because no one has the words to understand it.

If you’re like any reasonable person, after years – or even just weeks – of pain, certainly you would like nothing more than to distance yourself from it. Why would you choose to dive deeper into your awareness of it?  Well this is exactly what I’m asking a lot of my patients to do and yes it can be a frustrating process.  But it is an important step to solving the puzzle and taking control of what is within your reach.

Start with basics like: “sharp”, “dull”, “burning”, “throbbing”, “grabbing”, or “stabbing”.  If you’re still having trouble coming up with words that seem right, try thinking of how you can compare your pain or discomfort to other sensations you’ve had in your life like: a tooth ache, a stomach pain, stubbing your toe, catching your finger in a door or a drawer and other things like that.  Those are all good starts and you will probably find that once you start the conversation the words will come to you more and more easily.

I would venture to guess that at least half of the failed outcomes in physical medicine with any given practitioner has to do with how accurately the practitioner was able to interpret the patient’s pain language.  I certainly have failed my share of patients in the past when there’s pain that I don’t know about or fully appreciate, which is why I’ve learned to ask so many questions about the “pain”.  I will probably never seem alarmed by a sensation you’re describing but that is because most pain and discomfort makes sense to me.  What doesn’t make sense and worries me more is when something I know should be hurting, is instead shrugged off or does not even seem to register.

Start talking about your pain. Be creative and daring; find your pain-language. It’s personal, unique and valid.  There’s a good reason for your pain and it’s not out of your reach to figure it out and with some help to put an end to it.

Above all, be patient with yourself.   Pain is your ally not your enemy.  It’s an important message to you about something that needs your help and attention.


Practitioners: How does pain language affect your practice?

Patients: Have you encountered this language barrier with your practitioners?

Don’t be afraid to share your thoughts below…

 


Image Credit: Wikimedia Commons: By JD Fletcher (http://arowmaker.tripod.com/AROWMAKER/id6.html) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)%5D, via Wikimedia Commons

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