In Louis Gifford’s Aches and Pains
book Graded Exposure Section 4, he shares thoughts about what he termed his
‘Shopping Basket’ approach to care. He details all the different compartments
to consider in one’s care for an individual in pain (Biomedical, Psychosocial,
Disability/functional restrictions, Impairments, General health, and Pain). I
have stretched this metaphor into my interventions to use when planning a
treatment for a person with persistent pain. During our Therapeutic
Neuroscience Education course we go through the various changes in the
output systems (immune, endocrine, sympathetic, sleep, etc.) of an individual
in pain and look at what interventions can we use to work on improving each of
those outputs. When we get done we are left with a list of 20 some different
treatment intervention options. So where do we begin?
Thinking of the shopping basket metaphor, I like to think of
going to the grocery store and getting the right ingredients for a wonderful
meal. First things first, I need to know what I’m cooking up. And the type of
meal is more dependent on my guest diner (the patient) then it is on me the
chef. I need to remember each of the interventions need to be about my guest
not me. Just because I like to make certain meals (using treatment
interventions that I’m use to), I need to be like Bobby Flay in “Beat Bobby
Flay” and cook what the other person’s specialty is. If someone likes yoga, then
a little yoga it is. If they are into meditation, then let’s work some
meditation and diaphragmatic breathing. If I don’t have the specialty in a
specific treatment then I might need to refer that out, while I continue with
the rest.
Next is getting the ingredients needed. The grocery store
has more things then I need, so I don’t need to buy everything. Just as the
patient doesn’t have to do every intervention on the list of interventions we
can come up with. As I try to instill in my students here at USD, more is not
better. More is just more – better is better and many times simpler is better.
Pain is complex and when we can move through to the simple side of that
complexity it often times goes better. Also we need to consider that some of
the items the person may have at home already. Often times they are doing some
of the treatments on the list. We just need to check to make sure they are up
to date and they know how to use the ingredient properly and not for an
inaccurate reason. (Core stabilization exercises may be okay exercises to do,
but not necessarily because the person’s core is to weak and causing their
pain). Another potential is that maybe they are using an intervention and don’t
really like it, but they are fearful if they don’t use they won’t get better.
Then we can either show them some appropriate substitutes to use and see if
they like them better or educate them that they can get rid of some ingredients
and the end recipe will still be fabulous. Using ingredients (interventions)
they already have and enjoy can be important when it comes to compliance. We
tend to do what we like and enjoy. The best meal in the world that doesn’t get
eaten is of little use. Just as the best intervention program that is not
performed by the patient is of little use. You will get better results with a
bad program that is used by the patient then a great program that is never used
(obviously a great program that is used is
best).
After figuring a bit more about what meal might be
appropriate and what ingredients they already have and want to keep, it is time
to start filling up the shopping basket. I think as we look to add ingredients
again it is important to ask if it is an ingredient that the patient might like
or not. While the recipe might need some chopped greens we can vary what that
is (maybe substitute kale for spinach). Also where does the patient want to
start with the shopping of ingredients to add? Let them pick which
interventions to start with. While we might be use to a specific order when we
go through the grocery store, we may need to allow some flexibility based on
what the patient is willing start with. We may think they need some spices
early on, but we may need to get to those later once they are liking a taste of
the recipe and ready to then “kick it up a notch”.
One thing we need to remember is that every meal has to have
its staple ingredients. Based on my interpretation of the evidence and clinical
experience there are four staples of interventions that need to be included for
people with persistent pain: Pain Neuroscience Education, Exercise, Sleep, and
Goal Setting.
Pain Neuroscience Education
|
Goal Setting
|
Exercise
|
Sleep
|
·
Pain Neuroscience Education: Obviously I may be a bit bias when it comes to PNE, but I think there is pretty good evidence that a person has to understand why they hurt and that pain is not always injury.
Exercise: When a Cochran Review gives you the “Gold” level of evidence stamp of approval, I think we should be using it. Which type of exercises, that gets a bit more debatable and in some cases may not matter, pick the chopped greens the person likes and dose it appropriately.
Sleep: Most people in persistent pain are not sleeping well (if they are then this staple is already at home and have them continue to use it). We need to address it and help them create better sleep hygiene to improve their sleep.
Goal setting: People with persistent pain need to have goals to work toward. Many of them have none or they are poorly defined. To improve motivation and self-efficacy we need to help them generate realistic objective goals based on their values and then achieve them. By helping them achieve these goals we can get them to move out of learned helplessness state and see that positive change is possible and that they can get their life back and provide a sense of hope so many of them are lacking. These goals need to be based specifically on the patient’s values (not ours) related to improved function, measurable, agreed upon, realistic and have some time base to them.
ter these staples are in the shopping basket we can continue gradually putting more things in or maybe that is all the recipe needs. That is what the diner (patient) and chef (PT) need to figure out together. Also remember as the chef, part of our job is to teach the diner how to eventually cook this meal on their own.
Pain Neuroscience Education: Obviously I may be a bit bias when it comes to PNE, but I think there is pretty good evidence that a person has to understand why they hurt and that pain is not always injury.
Exercise: When a Cochran Review gives you the “Gold” level of evidence stamp of approval, I think we should be using it. Which type of exercises, that gets a bit more debatable and in some cases may not matter, pick the chopped greens the person likes and dose it appropriately.
Sleep: Most people in persistent pain are not sleeping well (if they are then this staple is already at home and have them continue to use it). We need to address it and help them create better sleep hygiene to improve their sleep.
Goal setting: People with persistent pain need to have goals to work toward. Many of them have none or they are poorly defined. To improve motivation and self-efficacy we need to help them generate realistic objective goals based on their values and then achieve them. By helping them achieve these goals we can get them to move out of learned helplessness state and see that positive change is possible and that they can get their life back and provide a sense of hope so many of them are lacking. These goals need to be based specifically on the patient’s values (not ours) related to improved function, measurable, agreed upon, realistic and have some time base to them.
ter these staples are in the shopping basket we can continue gradually putting more things in or maybe that is all the recipe needs. That is what the diner (patient) and chef (PT) need to figure out together. Also remember as the chef, part of our job is to teach the diner how to eventually cook this meal on their own.
What say you? How do you fill your shopping basket for the
person in persistent pain?
Via Dr. Kory Zimney, DPT
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...
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