A person with low-back pain goes to a fascial-distortion therapist and gets a fascial focused intervention. The person with low-back pain then goes to a manual therapist and gets a manual “issues with the tissues” therapy intervention. The person with low-back pain then goes to a movement “dysfunction” therapists and gets a “dysfunction” correction intervention. The person with low-back pain then goes to a medical doctor and gets an opioid prescription. The person with low-back pain then goes to a dry needling therapist and gets dry needling. The person with low-back pain then goes to an MDT-therapist and gets a and gets an MDT focused intervention.
Do you see a pattern here?
Not one of the therapists did use a patient-centered approach. A therapist’s choice of intervention should be based upon the patient’s representation, not what the therapist prefers, or what they learned in their latest CE-course. If the therapist’s choice of intervention is based upon what he prefers, what he does is clinician-centered, our care should be patient-centered.
Only after taking an extensive multifactorial pain anamnesis can a patient-centered intervention be generated. The pain anamnesis should be trying to cover all aspects and dimensions of the patient’s pain experience.
A question I often get asked very frequently when teaching my course, or on social media is “well, let’s say you have a person with knee pain, how do you treat them?”
Firstly, here we already start off on the wrong foot; even two people, both with knee pain, can have drastically different representations, beliefs, needs, and goals, even if they have pain in the same location. An exploration into the differences of the pain experience (with the same location) is documented in O’Sullivan et al. 2018.
Secondly, the idea of simple “intervention” that can be shared on social media or quickly explained can somewhat be seen as a symptom of the lack of understanding of the complexity of pain and the basic nature of patient-centered care.
My typical answer to the questioner, is to answer the question with a question: Did you do a thorough and multifactorial pain anamnesis trying to cover all aspects and dimensions of the patient’s pain experience?
The typical answer is no; they did not do a thorough and multifactorial pain anamnesis.
The real losers in this sad situation are our clients. After the person with back pain has been to see the seven different types of “modality” therapists (that all use a clinician-centered approach), they will now think, that they will never get better, and nobody can help them.
The patient has now, due to having to shop around from therapist to therapist, been told a lot of stuff is causing the pain. The patient now thinks he has a “fascial disfunction”, his tissue are restricted and needs mobilization, he has several movement “dysfunctions”, he needs to start on opioids, he also needs three more sessions of dry needling, and he has something called “derangement syndrome”.
A rehabilitation program should look at and consider the representation, goals, and needs of the person with pain. Dogmatically adhering to a particular modality or specific intervention, is not providing patient-centered care. Unfortunately, many therapists become blindly enslaved to their own favored choice of treatment.
The successful pain management professional understands that their job is to serve as a multidimensional rehabilitation specialist. Not as an expert in using only one unifactorial modality (adapted from Nick Tumminello).
Thanks for the inspiration to write this article to Ben Cormack and Nick Tumminello.
O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018;98:408–423.