Why going to a Pain Clinic can be a really good step to recovery

When the physiotherapist mentioned going to a Pain Clinic, everything about it that I could find suggested to me that this was a last resort – a place that you go once you have lost every last vestige of hope that you can get better and just want to manage the pain to try to find a way to get through the minutes and hours of an agonized existence. And talking with a number of other people in pain, this perception is very common, and none of the things that I could find online change that view.

However, the reality was so very different, and this is why I wanted to write this to help others to get the help that they need faster.

They never dismiss your pain

I can imagine that one of the challenges for Health Care Professionals is when they have to admit that something is complex and they don’t really know the answer. The downside of this is that thousands of people every year are dismissed by comments and inferences that imply that the pain is ‘all in their head’. You only need to take to Twitter or patient forums to hear the things that people have been told (or at least how they have interpreted comments from Doctors and Physiotherapists).

At the pain clinic, dealing with serious pain is their ‘thing’ and they are overflowing with compassion, knowledge, support and genuine interest in your pain. This alone is a huge relief, when you have been spending months battling to get people to listen the symptoms and take them seriously. It feels like getting into a comforting, warm bath! Plus they have models and simple explanations that help you to make sense of how your life is unravelling and what you can do about it.

One model that was enlightening for me was the ‘pain triangle’ that they said was universal in serious pain – where the relentlessness and intensity of it makes you feel helpless and hopeless, and your incapacity and reliance on others then drives feeling worthless. Then each point of this ‘helpless, hopeless, worthless’ triangle reinforces the other points, dragging you lower and lower until you can find something to break out of the vicious cycle.

They really want to get to the root cause

The next bit of brilliant news at the pain clinic is that they profoundly believe that your pain has a cause and that with work, they can find it. I felt that there was almost a detective vibe – where they are searching for the cause with different clues, hypotheses and points of evidence. They listen intently to every clue that you can give them, weighing it and thinking about what it could mean in a medical sense.

The pain clinic felt different. How? Well, I sometimes joke that when you see a consultant, they only have the 3 N’s (kNife, Needle or Nothing) and physiotherapists only have the 3 P’s (Poke, Push or Pray). This is of course brutally unfair and negates all of the knowledge and complexity of what they do, but as a patient it can reflect the outcomes and the lack of transparency in the process where they have the knowledge and you are just left with the problems. But, in the pain clinic, it felt like there was a logic in the way that they assessed the total body and looked at the interactions of different body parts. This is especially important when there are different body parts involved or overlapping conditions that come under two different surgical specialties because it leads to a lack of clarity about where the leadership and ownership sits between the different specialties once you are an out-patient. Whereas in the pain clinic it is all assessed together and at the same time (almost like you are one person with all of the parts of your body connected!)  

They take a multifunctional approach

The other brilliant bit is that all of the different disciplines work together and talk to each other in the pain clinic. This is so different from life as an out-patient and even as an in-patient, when even when you try to get the physiotherapy and surgical side to align behind one treatment plan and talk with each other, one party always resists it (even if you promise to sign GDPR releases, volunteer to manage the phone call within your appointment and volunteer to step outside if there is something that they want to discuss without you present).

At the pain clinic they have a common goal to reduce and eliminate your pain, and they each bring their own specialist skills to this team goal. It feels like a sports team, with everyone rooting for each other and working hard to get a result. As a patient, you feel in good hands.

This team support is important. If there was one tip that I would give to Physiotherapists in the out-patient context it would be ‘don’t comment at all on any previous physio that the patient has had’. I have seen nine different physio’s through the path of my pain and universally in the first stage (when they ask you lots of questions about what has happened and what you have done before), every single physio has critiqued what the previous physio has done with very negative tones and criticism. This really does not help! We cannot turn time back and I have already decided to change physio to see you, so there is no need to justify why you will be better. It makes me (as the patient) feel vulnerable and scared, because it makes me wonder if I allowed the ‘wrong’ treatment to be given to me (even though there was no way that I could have had the knowledge to make this judgement). And when you have seen as many as me, you start to build a picture that there is no common view of best practice and that there may be a lot of snake-oil sales people in the physiotherapy profession who maybe have not kept up-to-date with best practice. I hope that this is not true, but is a clear impression that the criticism of others can generate.

So my advice for patients is to seek out a group who work together across functional boundaries with your wellbeing as a patient as their over-arching goal.

When should you go to a Pain Clinic?

There is not really a clear view on when to go to a pain clinic, and again you can get a lot of contradictory advice. The textbooks says that pain is considered to no longer be ‘acute’ and to have become ‘chronic’ after 3 months, although many GPs seem to operate on 6 months.

I also think that there is a lot of pressure on the resources of the pain clinic (and there is a really long waiting list for it – over 9 months in our area). My hunch is that this leads to a tendency to hold off from a referral to the pain clinic until it has been a very long and serious issue. If you have health insurance, there are also private pain clinics, although you will need to have a look at the terms of your policy to see whether this is covered and what the referral process is.

I would suggest that for the reasons above a pain clinic may be especially helpful if:

  • You have overlapping conditions that make you feel that you are falling through the gaps
  • You are not making any progress and need a different approach
  • You are reaching a point of despair

I wish you the very best of luck – you are not alone, and there is a brilliant team somewhere who can help you! Stay strong in order to find them and start to move forward.

How do I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

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