Brent Anderson PT. Ph.D., OCS, NCPT, and Adriaan Louw PT, Ph.D. discuss how to practice presence when listening to our clients’ history and pain. Watch #PilatesHour episode 113 “All Things Pain” here.
Listening To Our Client’s Stories
BA: How do we learn to listen as practitioners? In the interviewing and questioning area, what are some tips for listening?
AL: You’re throwing some tough ones at me today! There is eye contact and eye level and all of those things, but I think there is more to it. When it comes to chronic pain, which is the area that we tend to specialize in, there has to truly be a desire to get to know the patient, empathy, and compassion. I know this is a very hard thing to wrap our minds around today. All of us say “I care”, but I don’t know if we do.
I’m listening to your story today and I’m thinking, I didn’t even know a lot of these things existed in my first 5 years of orthopedic practice. If my patient came in and said “my pain is worse because I’m being punished by a deity” I would say “yeah right, get out of here, I have another patient at 2 o’clock”. We’re all on a journey in our professional lives, and luckily as you get older you get more experience and things come to you.
The therapists that really get to know pain and how pain works, that truly start seeing how complex human pain experience is, are more intent on listening. They think “tell me more, I want to know more”. There is a real interest and desire to know.
As we get more of a human pain experience there is almost an innate wanting to know more. And as you see more complex pain patients, things sometimes don’t make sense – how does this work? We’re becoming more aware of the things we don’t know, so we ask more questions.
Be There And Be Present At The Moment
An interesting thing that we have shown is that outcomes have nothing to do with time. I think this is important because every person listening today is thinking “you have to spend more time with your patient” and the answer is no. There’s no data to prove it. We did a study where patients came in and we measured a bunch of “stuff”. We then sat and interviewed, heard their story, and had a therapist time how long they sat with them and measured this “stuff” and some physical exams as well.
People had 25% better outcomes before we even started treatment. It had nothing to do with time. So what I tell students often is “be there and be present at the moment”. Other data showed that we trust in less than 1 second. Trust is almost an instantaneous thing, but it’s about being there, being present, and wanting to know this person.
I’m going to very shameful share that when I was an OMT I don’t think I wanted to know people. It was just a joint or muscle that I had to manipulate to get them out and get them better. This is no disrespect to my instructors, they were amazing.
BA: It’s how we were trained.
AL: And that’s ok. As I worked my way through, I learned more about pain. The more I learned about the neuroscience of pain and how complex pain is, the less likely I was to cut people short or interrupt them or explain things to them because I don’t know yet. I have to think, “that’s interesting”, I should go learn more. We become vulnerable and remember that the patient is the expert in their pain. “Tell me your story – what brings you here?”.
BA: I think the keyword is “present”. One of the things we talk a lot about in Pilates, Yoga, Tai Chi, and Feldenkreis, is being present. Be mindful and understand that there’s something important happening right now. Right now I’m fully interested in sharing information with you and learning from you and I’m present, writing notes down!
I see this often with students who are in my class. They are on their cell phones doing things and I know they can’t be present and be on the cell phone at the same time. Or they are present with their cell phone but not present with me.
I think it’s a great question, and one of the dilemmas we present to students sometimes is that you have to document. So you have your computer there documenting what you’re doing, but the documentation is taking away from the contact you’re talking about. Eye contact, same level, body language, being present, listening, appearing to listen, and building that trusting relationship.
As we mature in the practice we start to realize that we don’t have all the answers. We end up getting more complex clients, that have more complex issues. More comorbidities, and more psychological and social-emotional issues, are tied to the physical manifestations. What I have learned as well is that the patient knows what’s wrong with them, but they often don’t know how to articulate it. If we can listen and ask the right questions, we can get the information we need to help them walk out the door.
The Problem Of A Lion
BA: Regarding centralized pain, I want to mention how you talk about the “Lion”. How the lion increases, anxiety, fear, relationships, finances you name it – and can sensitize the interpretation of pain. I think this is so important!
AL: To put it into context, one of the metaphors we use to teach people about pain is a lion metaphor. This story works with people who talk about fatigue or problems sleeping. Let’s first take a half step back. The patient walks in and I say “since you have developed fibromyalgia what’s the biggest thing you struggle with”… “Well I’m always tired, exhausted, and cannot sleep at night”.
We develop different stories based on problems people face based on their underlying biology. We may explain this and turn to the patient and ask them “has anyone explained to you why you are so tired, or why you can’t fall asleep?”. In 99 percent of the patients, the answer is no, no one has explained this pain to them.
I ask the patient, “if a lion jumped in his room right now, what would you do?”. Then you stop, you don’t talk. We have a marker and dry erase board in the room and the patient writes down what they would do. They will write things like scream, run, freak out, or whatever they may think of. Then I systematically go through a list of biological processes. “Suzy, if a lion jumped into the room is it time to take a nap? Yes or no”… “Well, no”.
They know the answers! If a lion jumped in, is it time to save energy for the winter or time to use energy? “I need to use it”.
We go through their system and use big muscles and small muscles working our way down. Then we ask them “what does this have to do with you today?”. And we know what they are struggling with. They have seen 2 podiatrists, nine PTs, and three orthopedic surgeons. They have bills and co-pays, (and we start writing these on the board), and all the things they are dealing with like stress, anxiety, life, and relationships. All of these are the problem of a lion.
From the moment you wake up, there is a lion in your life, and your system shunts. When a lion jumps in you freak out, and your fight and flight systems begin, the sympathetics. Then when the lion gets pulled out you sink back in the room and think “that’s the third lion attack today, this better stop!”. Our system is designed to ramp and calm. But for Suzy, this lion has been in her life for 5 years or 7 years. Her system shunts constantly and she never saves energy.
They know we are using a simple analogy, so the questions come about what we can do about it. “Suzy, how do we make the lion smaller?”. We talk about nutrition, sleep, mindfulness, relaxation and movement. This is all the cool stuff that can make your lion smaller and smaller and when the small lion enters the room we don’t freak out. We go “Awww a little baby lion”.
I know this sounds silly, but it’s the latest neuroscience, and in a simple way the patient says “this makes so much sense”. We have systematic reviews and meta-analyses to show this really works!
BA: I love the analogy! One of the products that you’ve put out is the fibromyalgia workbook and I’ve used that a lot with many of my patients. We go through the lessons and we take one lesson a week if they can handle it. Going through each of the lessons helps them and they go home and think about it and work through it. I use the workbook with anyone with chronic pain. It works great with people with fibromyalgia diagnoses, why is that?
AL: Fibromyalgia is obviously a complex condition that affects millions of people. We wrote a paper a few years ago, “treat the patient not the label” because their labels change all the time. Between chronic Lyme disease, fibromyalgia, IBS, and chronic fatigue syndrome, the list can go on and on. The underlying biology is absolutely intriguing.
The current thought process in the neuroscience world, in the condition you and I would label “fibromyalgia”, is that the immune system plays a significant role in sensitizing the peripheral and central nervous system. We understand the mechanisms better, but that doesn’t help the patient. The patient came to me with their fibromyalgia. If I take that label away from them, I might as well cut their body in half. With patients, we validate them by using their labels.
Pain is an individual human experience and we need to be careful about labeling. Fibromyalgia tells me nothing that is happening under their skin, in their system, in their brain, in their amygdala – but that’s what the patient has chosen to call it and be labeled as. You and I know the underlying mechanisms of all of these are very similar biological processes.
BA: I want to go into these stories you created with your team and through the years what I find most important is looking to match a story. Having a story that a client can relate to and understand just like we talked about the lion.
Understanding Pain
AL: It started way back when we interviewed a lot of people with chronic pain and what the most common struggles were. There are 6 of them: persistent pain (pain that does not get any better), pain that spreads (pain that moves to different areas of the body), fatigue and sleep issues, odd pain (pain when it’s cold, pain when you are stressed), and a “fog” causing forgetfulness and lack of focus.
We went and studied the underlying biology to know when a patient comes to us. I ask them, “Since your knee replacement, what’s the biggest thing that bothers you?”. They respond “when it’s cold I feel my knee pain”, and I ask if anyone explained this to them and the answer is often “no”.
We can use car sensors as explanations. A car sensor goes “hey you need gas”. Is there something catastrophically wrong with your car? No, you just need gas. There are sensors in our body that tell us how cold it is today, or if we are stressed. They are all balanced and when there’s a cold front coming, the temperature sensors will tell us “hey it’s cold out, make sure you put on long pants”.
These stories are designed to de-threaten the pain experience so the patient understands “oh, that’s what’s going on”. We have studies to show that fear avoidance and catastrophization positively shift and that then makes your candidate for movement.
People who are not as afraid of their pain anymore are now prime candidates for the most powerful thing to change pain, which is movement. People in pain are afraid to move. They fear that they will undo their knee or hurt their back and their alarm system is on full alert while the back is healing. Tissues heal, right? It’s the education model designed to facilitate people to move that is where we really want to get them, that’s where the therapy happens. They are just afraid to move.
Watch the #PilatesHour episode 113 “All Things Pain” Here. Learn more about Adriaan Louw and Evidence in Motion here.
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