The opioid crisis in Canada provides physiotherapy with a new opportunity to demonstrate our value in the health care system. Other professional groups are ready to step up and say they have the answer to this health crisis. Yet, as physiotherapists, we might feel as though we do not need to step up. We already know the important position physiotherapy holds in the effective treatment of people with chronic pain.
- Two of the most effective and evidence-based treatments for people in pain are the foundations of our expertise – education/awareness and exercise.
- Physiotherapists are an integral part of the best pain management programs.
- We have the clinical assessment skills to identify musculoskeletal, sensitization and psychosocial factor involvement in a person with pain.
- Given physiotherapists’ expertise, we should be considered an integral aspect of this health crisis. Yet we have some significant barriers to overcome in order for our interventions to be considered as effective adjuncts in pain management.
1. As a profession, we have been slow to effectively translate pain science education into our practices1, 2, beyond one-to-one education. Specifically:
- Most physiotherapists are not receiving education that informs or instructs them how to integrate recent advances in pain science into their current treatment processes. Often, there is no focus on the importance of consistency between the language of pain education and the language used when providing hands-on therapeutic techniques to patients. In other words, physiotherapists often view this education as a stand-alone intervention, as if it is somehow disconnected from other treatments.
- Many physiotherapy clinics do not offer group pain education sessions to their patients, even though doing so is an effective strategy with which to differentiate the clinic, and to decrease clinician stress by creating a common language to support our vital one-one education. One-one education will take much less time, and might just be more effective if there is also group education.
- Physiotherapists have almost uniformly reported to me that the education doesn’t work well when they first apply it Their patients complain during this initial skill acquisition stage that the physiotherapists is just one more person telling them the problem is all in their head. Strangely, when we learn acupuncture, IMS or other hands-on skills, we clearly identify them as skills, and realize expertise takes practice. Similarly, it takes practice to become good at educating those with pain.
- Some believe their education is only of value for people with complex chronic pain, and that the majority of the people they treat have acute pain, even though the majority of private practice patients only show up when the pain doesn’t go away.
- Pre-licensure education and clinical placements are dominated by a Cartesian dualistic perspective3 of pain, regardless of the efforts of many to train new physiotherapists with a truly biopsychosocial understanding.
- Some physiotherapists complete pain courses without clear ability to translate this new information into their clinical work.
2. Most of the exercises prescribed by physiotherapists, and the majority of research studying the impact of exercise on people with chronic pain, are not consistent with our current understanding of pain and of people in pain.
3. Some physiotherapists might not be interested in or feel capable of working with people with chronic pain. Recent research has shown that physiotherapists are likely to stigmatize people in pain and feel unprepared to treat them.
Then, given all these barriers how can we ensure we are part of the solution to the opioid crisis?
First though, are we ready? I will emphatically state that ready or not, it is our professional responsibility to step up. I hope that more of the twenty percent of the population with chronic pain, and in need, will demand our help, and that health care agencies will demand that we share our expertise. That’s my bias.
Solutions – so we can start to be viewed as part of the solution to the opioid crisis
1. Recognize that many of your patients learn best by doing/moving rather than listening to a lecture – possibly this is different from the way you learn. Plus, changing cognitions does not always change behavior. For many, their own physical experience is the best way to reconceptualise pain, and the best evidence that pain is not an accurate indication of what is happening in the body, that pain is changeable, and that they have a role to play in recovery. So maybe provide patients with a mechanical treatment or a movement that creates (patient-reported and demonstrated) change, then explain this from a science rather than tissue perspective instead of telling people about pain science first.
- Or ask a person to rest comfortably for a few minutes while you guide them in slowing their breath, and releasing excess tension in their body. Then ask the person to imagine moving their body with more ease and less pain. Then ask the person to perform that movement while they do their best to keep their breath calm and body tension low, and in a way that feels safe, and not so likely to make them regret the movement later. Once the person understands how to do this, and is able to try it with some success, then tell them that this is an important part of their treatment – that repeatedly practising movements that feel good will calm the sensitive nervous systems down and eventually let the person move enough to get the body tissues healthier again too.
2. Shift your current explanatory models, the ones you tell your patients, to include what we know about pain. Here’s some examples … Don't worry about the exact wording. Find your words to explain that persisting pain is not all about the tissues, and that recovery is as much about moving with ease as optimizing the health of the tissues.
- “There is a medicine cabinet inside you. Let’s find some ways to open it up to help you out of this.” (I attribute this language to David Butler, who states he cannot remember from whom he borrowed this.)
- “All pain has to do with what is going on in the body tissues and how information from that part of your body is being dealt with. So we need to work on your body, and the nervous systems to help you improve.”
- “Wow, if your pain changed from this treatment, that is great. It means that your pain is changeable, and that’s not always the case. Now I need to “this – fill in blank” and you need to do “this – fill in the blank” to get these changes to stick.”
- “This treatment I am giving you is to help you move better. If it does not, then we need to change it. Moving with more ease is a big part of getting better.”
- “When you complete these home exercises, it is important that you do not regret it later. You don’t want the protective systems practising. So let’s find a way to make these movements/exercises feel safer.”
3. Provide pain education sessions in your clinic, once each month for your current clients.
- Market these sessions in your community as a public service.
- Provide these sessions for your local public health authority or in a community centre.
Find primary care groups to whose patients you can offer this education for free. We’ve had great success doing this right in waiting rooms to small groups – with the doctor primary care provider present for added credibility and so the doctor or nurse practitioner can learn how to talk with their patients about pain.
4. Join community groups who are bringing pain care to the community. In Penticton, British Columbia, we’ve created a health care team, and have started research of a community based program for people with fibromyalgia. On Vancouver Island, Carley Grigg has spearheaded a program with Pain BC to bring a recurring six-week education through gentle movement program to the community.
5. Practice delivering pain education. Expect these things:
You will make language mistakes. People will claim you are saying the pain is not real or in their head.
At first you will be so focused on education, that you may not do a great job of facilitating, or noticing whether people are with you or not.
You will try to change everyone. Not everyone is ready, but of course we know that when people are pre-contemplative education remains one of the most impactful interventions. Plus imagine the potentially positive impact of watching others ‘who are getting it’, when you as the educator are offering the information for others to consider rather than forcing them to change.
You will resist asking the experts for help. However, help is readily available. For example ISPI, NOIGroup and Life Is Now Pain Care all have resources to assist you in educating your patients.
Over time, you will know that people experiencing pain need to be educated in multiple formats – one-one, kinaesthetically, books, group lecture, online, watching others – and considerable repetition is often required. Think about what it takes to change your paradigm.
When we help other health professionals, by teaching patients about pain, we are offering more than exercises. When we offer effective and multiple options for providing pain education, including options that serve those who need it most and typically have least access to physiotherapy/ists, this will change the external view of physiotherapy’s role in pain management. And when we use movement as the educational conduit, others will understand that physiotherapists, and what we have to offer, are viable, practical, upstream solutions to assist with the opioid crisis. Opioid prescription for pain is based on the idea that the only way to deal with pain is to cover it up. Conversely, physiotherapy helps teach patients about the nature of their pain, how to deal with it, and how to move with more ease through it.
About Neil Pearson PT, MSc, BA-BPHE, C-IAYT, ERYT500
Neil is a physiotherapist, Adjunct Professor at UBC, yoga therapist, and a faculty member for international yoga therapist training programs. He is the founding Chair of the Canadian Physiotherapy Pain Science Division, developer of an online pain self care curriculum, and author of ‘Yoga Therapy’ in the 2016 book Integrative Pain Management. Neil is the recipient of national Canadian awards in pain education, and in physiotherapy pain management in BC. Neil’s pain education book and Overcome Pain Gentle Yoga DVDs have been helping people in pain since 2009. He is a past Director of Pain BC, and was hired by the Doctors of BC to develop and implement their post-licensure clinical pain management education. Beyond teaching and building a website with ever-growing resources for professionals and people in pain, Neil now assists local community groups facilitating improved team work, and movement classes for people in pain.
Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy 61: 68–76
Overmeer T, Boersma K, Denison E, Linton SJ. Does teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes? A randomized controlled trial. Phys Ther. 2011;91(5):804–819.
Mehta, N (2011) Mind-body Dualism: A critique from a Health Perspective. Mens Sana Monogr. Jan-Dec; 9(1): 202–209 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115289/
Follow Neil: @lifeisnow1
Pain BC - Jamie@painbc.ca