To explain pain in an understandable way is one of the most challenging aspects of being a therapist, but it is likely to be extremely valuable and rewarding if done well.

This post is a result of a seminar about pain education at the Master of Musculoskeletal Physiotherapy,  University of Queensland.

Myself and Sunny Chhokar got an assignment to explain pain to a patient with a specific disorder, performing it as a role-play. It is as an attempt to explain the patient about the physiology and purpose of pain in 10 minutes, without going into depth too much due to the time limit.

The text is greatly influenced by the great work of Adriaan Louw, David Butler and Lorimer Moseley (Explain pain).

The patient:

«A 65 year old retired woman with (R) OA knee, who is going on a hiking trip in Tasmania where the track is slightly hilly and in some place quite rough»

Our main aims were to explore the beliefs and attitudes of the patient, address the concerns, and explain how one might benefit from knowing more about pain and how this can change the experience and management of pain.

There is not one universal way of explaining pain and it must be individualised to each patient, but hopefully this post may give some tips on how to use pain education in the clinics.

Role-play

Therapist (T):  So what brings you in today?

Patient (P): Well I was at my doctor a few days ago, and he told me I have OA and that my knee is worn out, and maybe physio would help

T: Okay. So what do you think it means to have knee osteoarthritis and a worn out knee?

P: I know that Arthritis is something that you get as you get older, both my brothers have arthritis and they complain about their knees all the time.

I used to work on the farm for many years and I guess I have been pretty hard on my knees.  The doctor told me it was almost bone to bone and that’s kind of the way it feels to me, sometimes it sounds like my knee is clicking or grinding when I’m moving around.

I guess I view arthritis as something I was eventually going to get anyways, I was just hoping it wasn’t going to be as painful as it has.

T: OA is associated with different changes to a joint, specifically the bone and cartilage.  OA is not only found in older people, it’s actually found in a lot of younger people as well.  

We know from research that the amount of changes in your knee is not associated with the pain levels you are experiencing.  For example, a knee may be very painful but show small changes, and a knee may feel fine even though a x-ray shows it is almost bone to bone.

P: Well, my imaging shows my knee having significant changes and I have pain during my activities. So why do I have so much pain when I try and perform my activities when others don´t?

T: Even though you have changes to your knee, which was shown on your x-rays, it is important to know why our bodies experience pain. Let me explain.

If you stepped on a rusted nail right now, would you want to know about it?

P:    Of course.

T:   Why?

P:  Well; to take the nail out of my foot and get a tetanus shot.

T:  Exactly. Now, how do you know there’s a nail in your foot? How does the nail get your attention?”  “The human body contains over 400 nerves that, if strung together, would stretch 45 miles. All of these nerves have a little bit of electricity in them. This shows you’re alive. Does this make sense?

P:     Yes.

T:  The nerves in your leg are always buzzing with a little bit of electricity in them. This is normal and shows….?

P:     I’m alive.

T:   Yes. Now, once you step on the nail, your alarm system is activated. Once the alarm’s threshold is met, the alarm goes off, sending a message from your foot to your spinal cord and then on to the brain.

When the brain gets the message, it may give you the experience of pain. The pain stops you in your tracks, and you look at your foot to take care of the issue. Does this sound right?

P:      Yes.

T:   Once we remove the nail, the alarm system should?

P:       Go down.

T:   Precisely.  Over the next few days, the alarm system will calm down to its original level.  Your foot may still feel sore  for a few days. This is normal and expected.

Here is  the important part. In one in four people, the alarm system will activate after an injury or stressful time, but never calm down to the original resting level. It remains extra sensitive. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, it is normal to think that something is wrong.

P: Why is this alarm system so different between people? Shouldn’t it be all the same?

T: Pain is a multifactoral experience which means that it is not just messages from the joint which is causing the pain. The pain experience can be affected by your current and previous thoughts, feelings and emotions.  Our thoughts and feelings are highly influential in how we experience a certain situation and how we experience pain.

P: So, if I just thinking happy thoughts all day, my pain will go away?

T: Not necessarily, although it is important to have a positive outlook on your condition. When a part of your body has been painful for a while, you can say the body becomes very efficient in experiencing pain.

Our body is doing a great job of protecting itself, but sometimes it is doing it excessively, almost being too good at it. In some cases the pain might be counterproductive as it is actually overprotecting that joint.

P: Hmm…so my emotions can have an impact on my pain, this is all new to me. I always thought if you have something wrong with your body, you get pain, simple as that.

T: Lets use an example of how previous experiences and emotions can affect a situation. Have you had anything stressful happen to you recently?

P: Well I was in a small fender bender last year,  I was driving along and the car infront of me suddenly slammed on their breaks, so I also breaked and all I remember is hearing a horn and then getting hit from behind.

T: hmm, so have you heard a horn since you had that accident?

P:  Ya, here and there, I live in a pretty traffic heavy area.

T: When you hear a horn now, how does it make you feel?

P: Oh I get so worried, Its like I’m preparing for someone hitting me each time it happens.

T: Was this how you felt prior to the accident when you heard a horn?

P:  No, not at all, I would hear it and get annoyed.

T: So your knee pain may work in a similar way. The fender bender has changed your experience when you hear a horn similar to how your previous experiences with your knee has changed your alarm systems response to activity.

P: So, your saying my alarm system is being set off by activities that previously did not cause it to be active and this is part of the reason I get pain. Is there a way to change this? Or is it permanent?

T: Well, research shows that our body is really good at adapting and that the pain can be decreased if it is given the right tools. To date, what have you done for your knee pain? When did all this start?

P: My pain started 2 years ago. I went to a physio for 3-4 months, doing exercises, but they hurt, so I stopped doing them.

T: When would your knee hurt? Was there something specific that hurt your knee?

P: No, it was usually after, it would get very sore, I was afraid I was damaging it further.

T: Did anything else happen in your life at the time?

P: Well it was around the time I was retiring, and I was really worried if I had saved enough financially. It was very nerve wracking to go from earning a paycheck every few weeks to not making anything. So I would say I was very stressed at that time.

I was also exercising regularly with an exercise group and my knee began to ache, and it just seemed to get worse with all that was going on.

T: And how was your knee then compared to now?

P: It’s the same, but that is when it started.

T: Hmm, with all that we said about how your brain and feelings can affect your pain, would you say your stress at that time was related in any way to your knee pain?

P:  Well, I actually think it was now that you mention it.  I was very stressed about retirement and I noticed a few changes.  My knee pain was getting worse, I was not able to eat as well as I wanted, I gained a few pounds.  It was a tough situation all around.

T: Are you still dealing with the same stress ?

P:  The retirement concerns are gone, I am now just concerned with my knee. I am worried I won’t be able to go on this walking tour and I am in my retirement. I have so many other travelling plans that I would like to do.  So yeah, I am very worried.

T: So in a way, your stress levels actually might be the same, but the reason for it is now your knee pain.

P: Yeah, that could be it.

T: If your body is in a worried and stressed state, it will make it more important to protect itself by making you avoid certain activities which it thinks may be harmful. The most efficient way our body can do this is by giving you the experience of pain to make sure you rest and relax.

In the short term this might be beneficial, but in the long term we know that being inactive will make things worse.

P: Yeah, because I have been resting, and it´s not getting better.

T: So, do you feel more confident in what is actually happening with your body and knee now?

P: Yeah, it makes more sense now. I feel if I can just  get this knee pain under control , it’ll improve a lot of my stress. So, what can I do to decrease my pain?

T:  I believe a part of your pain is due to an extra-sensitive alarm system. So, instead of focusing of fixing tissues, we will work on a variety of strategies to help calm down your alarm system, which will steadily help you move more, experience less pain and return to previous function.»

We know from research that understanding pain may change the way you think about pain, and improve how you can manage it.

P: So your saying the more I understand my condition will help my ‘alarm system to settle down’ ?

T: Understanding of pain is one of the steps towards getting better and there are no guarantees. Other steps we need to take are around getting you to do activities without flaring up, and progress until we get you closer to where you want to be.

Would it make you happy if you could do all your activities with certain modifications, like rest breaks?

P: I don’t mind rest breaks, as long as I can be active with my walking and perhaps going to exercise classes a few times a week, I will be satisfied

T: Good. It will still be important to get proper movement in the knee, do strengthening exercises and improve control and your overall function. Your joints enjoys getting movement and it is essential for them to function properly . We just need to start at the right level and then build from there. Sounds good?

P: Yeah, absolutely.

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