It felt like he came back to shake my hand 5 or 6 times. Big smile. Effusive praise. He was clearly delighted. He was back on his bike. Confident about his future. Which was a big turn around from 8 weeks earlier. A young man (mid 30’s- I say young as same age bracket as me). He felt “his life was over”. He had been “getting worse and worse”. I’ll always remember him by his thick Kiwi accent. The subjective had gone longer than expected. He’d had episodic LBP for a long time. This episode after a long car journey. But it was taking less and less each time. He was now “conscious of his back all the time”. Even when it wasn’t hurting. This was interesting I thought. Should we be conscious of a body part even when it’s not hurting? I delved further to his history. Oh yeah and he’d had a lumbar fusion. Thought you’d pop that one in there last minute did you? Aged 19 a rugby injury lead to a spinal fracture. The surgeons decided to stabilise/fixate. This may have been the best treatment for him at that point. However what came next was the key to his case. “So what did the surgeon say after the op?”
“Well he said I needed to be careful, take it steady, that it was pretty severe, in fact he said if he’d known how severe it was he would have used a stronger fixation device!”
“He said WHAT?!?!”
“The physio then advised on lots of bracing techniques, log rolling in/out of bed, lots of core stability, but now every time I bend it hurts”
“So you’ve basically avoided bending for a lot of years and now when you have to it hurts? Is that a surprise to you?”
If we are taking a history we need the narrative. Otherwise we are taking a questionnaire. Skimming data from detail. One of the first stones to be turned is previous healthcare experience. Have they been referred by another practitioner? Have they consulted anyone else? Usually for me it is a GP referral. So I ask them when they saw the GP “what did she say?” Trying to get it in their words. Rather than from the referral. Discrepancies are frequent.
Sticks and stones may brake bones but words will never harm me. This is true. This is false. It is a polemic for dissociating with harmful words. Words cannot directly cause physical harm. But words are powerful. The context they operate in help to load or unload this power (Naked physio blog illustrates this nicely). The surgeons words here hung heavy. But heavy as they lay equally they can powerfully free. If there is power in words we need to know what they are. Allowing people to use their own spontaneous language rather than words or numbers prepared by us. The poster below (from Gurpreet Singh) is an excellent example of qualitative research uncovering powerful words specific to people and cultures.
People in pain often face an existential crisis. Their existence becomes afflicted. Usurped. Consumed. Their world is hi-jacked. Their words insight into their turmoil. Words spoken require understanding. Words heard need to fit.
So what makes words powerful or meaningful? We can search ourselves for clues here. What are the words we remember. That stick with us. What are their characteristics? Are powerful words likely to be specific or generic? For a person or population? If we get an email/tweet/message are we more likely to respond if generic and to a group or if it is personal, specific to us and engaging. Obviously other contextual factors matter here. There is no absolute. As therapists are we repeating words we feel we should, or we have read, seen or that matter to us, or have worked before. Or are we trying to speak to the individual in front of us. Of course some of these things may be applicable. Sometimes I wonder if I recited information and advice hoping that something will connect. Now I wonder if this is why connection didn’t happen much!
So how do we make this connection? Well something I have been doing lately is recording verbatim. Not every word. But those about feelings, description of pain, possible maladaptive beliefs or behaviours. Anything that prods my conscious. I usually use a separate blank sheet for these quotes as often they come at inopportune moments. Like when the subjective is ‘done’ (fallacy). From a physiotherapy perspective how well do our SOAP notes (subjective, objective, assessment, plan) allow this? You may notice the quotation marks in the above case study. These were the elements I earmarked in this case. Then our job is about redemption. How can we free people from these. Robotic redemption is something I’ve yet to see.
In this case some reassurance and a graded reverse deadlift were the “only” intervention required. In much the same way I tell my son the best way to get it better is to use it. Those redefining ground include Dustin Jones (+ others, see above image) who are reshaping our approach to older populations, and Peter O’Sullivan, Helen Slater, Mary O’Keefe, Derek Griffin and Kieran O’Sullivan who are writing to powerfully change how people view back pain (see here and here).
Are we skimming data from detail?
Are we asking what their GP/surgeon/physio said to them?
What will they say to your family? (The Kieran O’Sullivan Test)
What’s the thing they remember most about physiotherapy? Important questions if you are patients are human!
Be more human. Be less robot.
Thanks for getting this far.
Lagerman (2015) http://www.thenakedphysio.com/?p=1866
Jones (2015) Redefining Old http://www.seniorrehabproject.com/products.html
O’Sullivan + Slater (2015) http://bit.ly/whatisLBP
O’Keefe, Griffin + O’Sullivan (2015) http://bit.ly/LBPeire