July 25, 2021
At the conclusion of each of the courses I teach at University of Otago, I...

At the conclusion of each of the courses I teach at University of Otago, I ask students the “so what” question. So what that we learned about neurobiology? So what that we discussed social constructs and how they shape pain behaviour? So what that we learn that thoughts and beliefs influence our pain experience? What does it all mean when we’re sitting with a person experiencing pain?

This last week I’ve been on a brief trip to the West Coast of the South Island of New Zealand Aotearoa. It is a wild and isolated part of our country. So wild that in parts the annual rainfall is over 6,000mm (see the map below!), and the wind blows so that the trees grow almost horizontally. For two days there was no power (and thus no internet, no cellphone cover!) and the gravel road to our campsite was closed until 7.00pm while the power lines were being replaced… I won’t talk about the sandflies and mosquitoes – the size of helicopters!! Well perhaps I exaggerate…

Taking a break from talking pain brings me to my “so what” question. Why do I spend my time trying to help people, especially clinicians, learn about pain? Why am I so focused on bringing a narrative that says “we can’t reduce or remove all pain” and at the same time “it’s possible to live well with pain”? What is my “so what”?

Stepping back from the crabby discourse I see so often on social media – like whether hands on or hands off is preferable, whether pain is sensation or perception, whether exercise should be this or that – I think my purpose is to remind everyone, and especially clinicians, that when we’re working with someone who has weird pain that hangs around our job is to find out what this person’s main concern is. And to remember that irrespective of how much we help someone change their pain, ultimately, they will go on to live their own life. Not ours. Theirs.

It struck me from time to time as I swatted sandflies (helicopter sized ones, of course), that many of us work within inflexible processes and systems that demand we identify goals after only just meeting a person. It struck me that the people who develop policy and who get involved in establishing processes are not engaged in public discourse, at least, not in social media where so many of “us” hang out. I pondered how it is that the collective weight of allied health – numbering far more than our medical colleagues – has not yet shifted our conversations about best ways to help people with pain away from symptom reduction, despite our lack of success when it comes to pain. How we continually fixate on “if the pain goes, the person will go back to normal”. How we tout exercise as The Cure despite such small effect sizes on pain intensity, quality and disability. And for exercise, we could substitute needles, manual therapy, taping, medications…. How we want simple recipes, algorithms that sort people into “responders” and “non-responders” while failing to acknowledge that so far we haven’t achieved this and besides these approaches assume that everyone wants the same outcome.

Taking a break from work offers me a chance to refresh my perspective. My pain, it must be said, doesn’t take a break. And that, folks, is the reality for so many people in our communities. Because persistent pain persists. When we’re at work, and when we’re on holiday. When we’re trying to sleep, and when we’re busy with family. And we all come from what was our normal lifestyle. And some clinicians think that if only we would – understand pain neurobiology, pace, exercise, eat right, use mindfulness, check our thinking and get rid of maladaptive beliefs… then life would be fine. But would that life be what I want? Would it look like my life? Would I be able to be ME inside that regimen of all those things?

Clinicians, we can often omit to ask “what’s your main concern about your pain?” And we often forget to find out what that person values in their life. Our goal setting turns out to be OUR goals, often based on pain reduction – or focused on achieving X, Y, Z. Doing this means attention is paid to the end point – but then the process of getting there is left out. And life is a process (OK a journey) not a goal (OK a destination).

As I approach my teaching this year, and my interactions online, I want to emphasise respecting the autonomy and strengths people living with pain bring with them. That a person’s life and choices are theirs to make – and if we try to change people, we’ll fail. We can invite people to experiment with, play with, test, try out different ways of being, but unless we understand a person’s values and work with them, we’re probably not going get more than superficial compliance. Let’s be respectful and honour the complexity of each individual we encounter – and let’s not treat them as part of an algorithm.