The Importance of the Patient-Provider Relationship When It Comes to Pain Management
Despite being originally proposed in the ‘70’s by psychiatrist George Engel, the “biopsychosocial model” of health (BPS) is the newest craze among healthcare professionals. This model contradicts the current “biomedical” model of health, wherein the amount of pain you perceive is theorized to be the direct result of a physical pathology or biological damage. This approach is seen by many, including us at Motus Strength Health Club, to be overly simplistic because it prioritizes a focus only on the physical aspect of health – which certainly exists, but is rarely the whole story. The BPS model, on the other hand, takes into account not only the biological issues, but the emotional, social and psychological factors that contribute to the experience of pain and illness as well.
I found the BPS model of health after stumbling across a 2015 systematic literature review by Brinjiikji et. al [1] in which they found spinal degeneration, via imaging, in high proportions of asymptomatic individuals is likely part of normal aging and unassociated with pain. The BPS model became increasingly more important to me when I started questioning why patients of mine were still in pain, even though I thought I was performing the necessary physical therapy they required. Instead of doing a thorough interview on how they viewed their pain from a multi-factorial perspective, I would pull out all of my muscle testing, special orthopedic tests, postural scans, and range of motion tests I knew, continuing to approach pain from the one-dimensional biomedical perspective. So instead of helping them with their pain, I actually solidified their belief that they had physical issues causing their pain, thus increasing certain patient’s perceived pain levels. I would then go on searching for painful spots and what I deemed as “tight” muscles to release and then send the patient away assuming all the work I just did was going to resolve their pain. I was working ON them, instead of WITH them. The relationship I was fostering was one based on the narrative that they had physical abnormalities causing their perceived pain that I could fix with hands-on treatment alone. The late William Osler said, “The good physician treats the disease, the great physician treats the patient who has the disease”. I believe this remains true for every healthcare professional that is working with patients, not just physicians. It is imperative that we help our patients manage their own pain through therapeutic alliance rather than relying on a healthcare professional.
So how does our relationship with our patients foster an effective way of managing pain? While understanding the importance that psychosocial factors can have in those receiving treatment from a healthcare professional, the relationship between the therapist and the patient has the potential to strongly influence the outcome – whether it’s negative or positive. This relationship should be based on a host of factors in order to truly help patients manage their pain – trust, empathy, communication, active listening, mutual goal setting, and patient education, just to name a few. When you gain the trust of your patient, they are more likely to open up about their pain and how they perceive their own physicality. Also, your patient will hopefully trust that you can treat them as effectively and efficiently as possible, which is crucial for positive outcomes.
Let’s further examine why trust is important. A person walks into your clinic, most likely a complete stranger to you. Somewhere in between the moment they walk into your office and walk out, they will likely have gotten undressed to a certain degree. It’s important to develop a relationship early to ensure they are comfortable with another person’s hands on them so they can fully benefit from the biopsychosocial effects and, specifically, placebo effects that massage therapy can offer. I believe this boils down to the most basic of human interaction – treat them as a person rather than your next task at work.
Showing someone empathy can be the perfect way of shifting your patient from your next task to an actual person. Empathy will help take your relationship with your patients to the next level. It shows that you actually care about the well-being of your patient. I hope you all remember the mantra that was (hopefully) preached at you throughout massage school; Patient Over Profit. Gaining empathy requires communication and active listening. Instead of listening to respond, listen to understand. In my experience, patients will usually tell you exactly what they think is causing their pain and what they think is going to help them. This is when you can use your evidence-based knowledge to explain what may be happening to cause their perceived pain and dysfunction. Howick et. al. [2] found that practitioners who expressed empathy and delivered positive messages are more likely to bring small improvements to a range of psychological and physical patient conditions, in addition to improving overall patient satisfaction with care without inducing any harm. This begs the question – why not use positive terminology rather than fear-inducing words like “dysfunction”, “disorder”, and “syndrome” if they aren’t appropriate? This could certainly negatively affect the pain-inducing factors involved with the BPS model. Shouldn’t we be reminding our patients that their bodies are remarkably designed to be highly adaptable, rather than instilling the belief that their bodies are fragile and in need of constant maintenance from a healthcare professional? Preach resiliency, strength, and that pain is a normal, inevitable and necessary aspect of life.
This brings us to our next factor, and possibly most important – patient education. As health care professionals, we hold a lot of merit in our patient’s minds with the words we use. We owe it to them to provide education using current evidence-based science. In a 2013 study from Darlow et. al. [3], they found that a number of factors influenced the participants beliefs about what was the cause of their pain, but the actual clinicians appeared to be the most important influence. This further drives home my point of the importance of the BPS model when it comes to the multi-factorial nature of pain. Patients will look to you for guidance and will generally assume that what you’re telling them is true. This is where we see the “social” aspect of the BPS model come into play. Patients will likely deem you as an expert and as such, will hold what you say in high regard. If you induce fear, suggest they may have XYZ diagnoses, or make them reliant on you to manage their pain, then you have done your patient a great disservice. Make sure you leave them with a takeaway that will empower them to manage their own pain via lifestyle changes, physical exercise and education about what factors influence pain. This truly makes the patient-therapist relationship absolutely crucial when it comes to pain management.
Lastly, we have mutual goal setting. Most patients come in to your office seeking immediate pain relief, but depending on the severity of their pain and issues that may not be realistic. It’s important to educate your patients about what you believe is going on and provide them with realistic timelines for the agreed-upon goals you’ve set. It’s a much less daunting task to get your patient to be able to put a cup into an overhead cupboard without pain compared to getting them to overhead press 135-pounds again. Considering, at this point, you’ve established a positive, trusting relationship with your patient, it will be easier to work together to find ways to manage pain over the long-term.
Understanding that managing pain is more complex than just simply giving a hands-on treatment, we can start analyzing what factors the biopsychosocial pain model offers that can be useful in achieving pain relief long-term. We can achieve this by doing a thorough subjective interview to get a better understanding of how our patients view their pain, emotions, social standing and physical performance. This should help you choose the appropriate techniques and home care that would be most beneficial for that particular patient throughout their pain management journey. For example, I’m sure you can all relate to having patients that are stressed beyond belief. Their stress levels will likely correlate along with their perceived pain levels and tension. In my opinion, those patients would benefit from self-stress management techniques. And while massage therapy can definitely be one factor in managing their pain, other interventions can and likely will be beneficial as well. For example, I’d give these types of patients an easily digestible task. Such as incorporating more steps into their day, or 10-minutes of daily meditation/yoga so it doesn’t negatively perpetuate their current mentally overwhelmed-based pain perception. Recommending positive long-term solutions that empowers the individual and gives them back control and confidence should be first and foremost before relying on passive modalities that can perpetuate sensitivity and hyper-vigilance to pain.
Ideally, your patient should trust you enough to believe in whatever homecare or remedial exercise you recommended to them. This should also ensure adherence to the proposed homecare so that they understand they can truly help themselves and not have to over-rely on others to manage their pain.
Here are a few of my suggestions when it comes to developing a relationship that will ensure efficient pain management;
Find out what they TRULY want the pain relief for; ie, being able to play with their kids, continue playing the sport they love, etc. and remind them every session.
Find activities they can do relatively, if not completely, pain-free and encourage them to do them as much as possible. Bonus if said activity is a physically active one.
Change terminology – instead of dysfunction, say temporary change in your normal mechanics. Instead of this muscle is very tight, say your tissues are just sensitive right now. Instead of bad or improper form, say less ideal form for you RIGHT NOW. Instead of unstable and weak, remind them instead that we’re adaptable and resilient. Better yet, some things may are better left unsaid if possible.
Encourage them to reach out via phone, social media, or e-mail if they have additional questions. This is a good chance for you to monitor their progress and make tiny tweaks to their pain management objectives if necessary.
Encourage them to do strengthening exercises. Resistance exercise should increase self-efficacy, promote resiliency, and hopefully change perceptions of weakness and dysfunction.
In conclusion, it is important that we analyze the therapeutic relationship we build with our patients because we can play a huge role in the successful management of their pain. Steering them away from overly-simplistic fixes that perpetuate the harmful notion of fragility and brokenness, and instead, encouraging in them a perspective of self-confidence and resiliency as part of a positive long-term solution. We should instill a sense of trust and empathy, as well as foster open communication, evidence-based patient education, and goal setting and let’s continue to watch this profession grow into something spectacular.
References
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., … Jarvik, J. G. (2014). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American journal of neuroradiology, 36(4), 811-6.
Howick, J., Moscrop, A., Mebius, A., Fanshawe, T. R., Lewith, G., Bishop, F. L., Mistiaen, P., Roberts, N. W., Dieninytė, E., Hu, X. Y., Aveyard, P., … Onakpoya, I. J. (2018). Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. Journal of the Royal Society of Medicine, 111(7), 240-252.
Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of family medicine, 11(6), 527-34.
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