Education: Maybe We’re Missing The Boat

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Well, I wasn’t planning on publishing a blog on this topic until later, but it seems timely in light of recently published research (here.) Articles, books, courses, and even certificates/credentials, all exist surrounding the education of patients with persistent pain. I understand the noble objective of reducing catastrophic thinking, pain intensity, improved agency, and reduced disability through education. And I strive for this in my care model as well. But I do challenge the idea that because we think we are imparting objective information, that it will convince someone of something different. Patients hold deep beliefs about their pain. We assume that presenting facts will change someone’s mind. They don’t. I don’t think we understand the gravity of what we say to our patient’s experiencing persistent pain. It may seem like we are delivering unbiased education, but the reality is that it can be perceived as an affront to their suffering. It’s like trying to change the views of someone whose political beliefs are opposite of yours. Your attempts at convincing them only deepen their opposing thoughts. When it comes to beliefs, facts don’t matter. Scientific data is insufficient to convince someone of a differing belief. There is significant scientific inquiry into the how beliefs change. Emotion and value processing are integral to the process.

“To make a change we must tap into those motives, presenting information in a frame that emphasizes common beliefs, triggers hope and expands people's sense of agency.” -Dr. Tali Sharot

Read more about her lab and research (here.)

A recent patient was very focused on wanting another MRI to see if “xyz” was still going on in her knee. It was a topic she brought up every session. Arguing, I mean educating, her would only deepen her resolve that she wanted another MRI. So I didn’t try to persuade her. Instead I focused on the huge amount of ability she had gained in the previous month compared to years of disability following an injury. I then had an even better discussion of what vocation might look like for her and how we could help her feel more capable to perform tasks. This is huge. Life roles are now back on the table. That is more important than me convincing her that she doesn’t need another MRI. If she gets another MRI and it shows no change from prior reports, I don’t know that it will increase fear. It might. It also might not. What I do know is that she’s looking for vocational opportunities. She is self managing better, feeling better, and therefore doing more to build capacity.

In earlier blogs I’ve discussed pain as maladaptive neuroplasticity (here) and that we want to use strategies that foster neuroplastic change away from persistent pain (some strategies here & here.) I think the notion of didactic education on pain topics ignores the importance of the implicit process of neuroplasticity. How does explicit education achieve this? I’m not sure it does. I think my messaging is better received when I facilitate a patient’s discovery. Helping them experience “I can move and it doesn’t have to have a catastrophic result” no matter how distal to the primary site it is, or how tiny a movement it is. Meet them were they are. It’s not time to “poke the bear.” In fact, it is the opposite. It is to help change their implicit understanding of their fear of movement in the presence of all the other factors that still exist, through experience. My message to patients is “Let’s try something different, if it bothers you, we will stop, you are in control.” I don’t attempt this without strategies for self management being established first, as I want to reinforce that if a flare up happens, they have tools to help reduce it.

My approach consists of shifting focus from a pain score to a mindfulness of tolerance, helping patients tune in to baseline versus flare-up to understand that external (and internal) inputs influence their symptoms, and that therefore there is potential to impact them. Maybe we walk together, and even though they still experienced pain, they also experienced ability they may not have known they had. I tell them how many minutes they tolerated, or what distance they achieved. If the activity flares them up, then we know to grade it down. It’s experiential reinforcement of the message I want to impart. This is valuable for changing beliefs and neuroplastic change.

I can influence context throughout the entire encounter. I impart messages of tolerance, pacing, “sore but safe”, “hurt not harm”: “how do you feel, can you keep going or do you need a break?” I am consistent in my messaging every session when an opportunity arises to highlight what they’ve demonstrated. Education is vital, but it doesn’t have to be a curriculum. It’s about the patient proving it to themselves, not me trying to convince them. Implicit learning instead of explicit.

Since I take the stance that persistent pain is maladaptive neuroplasticity and a sensory processing issue. I do take some cues regarding patient learning from the body of knowledge of motor learning. The learning comes from doing, repeatedly.

Every session I review flare ups, what preceded them, and how strategies for self management impacted their symptoms. Thus reinforcing the idea that pain is not random, can fluctuate with outside influence, and there are things the patient can do to impact it.

Education is vital with patient's experiencing persistent pain. But every patient doesn't necessarily need a run down of everything you've ever read and every course you've ever taken.  Dosing and quantity are important too. If in the patient's narrative I hear that they believe they've been told "it's all in their head", I may wait awhile before I start talking about the brain and danger messaging. I may not go there with them at all, depending on how things evolve. In this scenario, I opt for education focused on identifying stressors and self management strategies. 

This is challenging stuff. You’re not a bad educator if you can’t seem to get the message of the “curriculum” right. Try helping them experience it instead.

Caneiro, J., O’Sullivan, P., Smith, A., Moseley, G., & Lipp, O. (2017). Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scandinavian Journal Of Pain17(1), 355-366. doi: 10.1016/j.sjpain.2017.09.012

Costa, D. (2016). Changing pain-related knowledge may or may not reduce pain and improve function through changes in catastrophising. PAIN157(9), 2141-2142. doi: 10.1097/j.pain.0000000000000617

Edelson, M., Dudai, Y., Dolan, R., & Sharot, T. (2014). Brain Substrates of Recovery from Misleading Influence. Journal Of Neuroscience34(23), 7744-7753. doi: 10.1523/jneurosci.4720-13.2014

Lee, H., McAuley, J., Hübscher, M., Kamper, S., Traeger, A., & Moseley, G. (2016). Does changing pain-related knowledge reduce pain and improve function through changes in catastrophizing?. PAIN157(4), 922-930. doi: 10.1097/j.pain.0000000000000472

Sharot, T., & Garrett, N. (2016). Forming Beliefs: Why Valence Matters. Trends In Cognitive Sciences20(1), 25-33. doi: 10.1016/j.tics.2015.11.002