If you haven’t read the previous blog on chronic pain, read it, ask me some questions and then read this article in succession. There will be many of you that feel I don’t empathise with you. You may be thinking, “it’s not as easy as that” or “this physio doesn’t feel what I feel, or even understand my pain”. Some of you might have been in pain for a year, five years or over 30 years and can’t fathom the idea of starting to get rid of it. Most of you have been in pain for so long, you don’t remember life without it. The thought of being out of pain actually scares you because it’s become part of who you are! Now is the time to take your life back and start doing the things that you haven’t been doing because of that chronic shoulder pain that you sustained when you crowd surfed without a crowd during your 40th birthday party, or that chronic neck pain that you have been putting up with since you thought it would be cool to impress the girl next door with your unicycle skills, before falling into the hedge.
Let me tell you now that managing chronic pain is achievable for every single one of you!
In assuming you’ve all read the previous blog (Seriously just read it. You’ll learn something extraordinary and no doubt you’ll be able to use the information to help someone you know), we know that it takes an enormous amount of effort to even start to manage chronic pain.
Let’s take two different people, Jack and Jill. Jack has a chronic back injury, which he sustained falling off a ladder at work 12 years ago. He has a physiotherapist who he sees for strength and conditioning twice a week (and for any hands on treatment he rarely requires), he’s back playing soccer every Sunday afternoon, (followed by a sneaky pint at the pub with the boys) and he’s back working full time. He understands the importance of keeping mentally and physically healthy and asks his physio questions as they arise.
Take Jill on the other hand. Jill fell off a ladder at work 12 years ago (in a different work scenario, otherwise I’d definitely recommend an auditing of the ladders!). Unfortunately, Jill was given some pretty poor advice soon after her injury and took time off work, only to lie in bed for quite some time (Note: bed rest is not cool and very rarely recommended after a back injury – remember to talk to your physio about how best to go about treatment at this stage). Jill has lost faith in medical professionals, can’t see an “end” to her injury and, as a result, has developed some poor habits.
Jill has effectively given up. She’s not bothered about getting herself better because “nothing will help” and she has “tried everything”. She now resides to the fact that she “has to live with this forever” and becomes defensive when others offer help. Her injury becomes part of her. Jill is now known as “the Jill with the back pain” and she is scared to try to get better because she has forgotten what life is like without pain. Jill is in denial that anything can be done and tries to “get on with it”.
What if I told you that both people could self-manage a pain free life?
These two people, who sustained the same injury, by the same mechanism at the same time are on two completely different recovery paths. This is because they are in different stages of change.
This is known as the Transtheoretical Model of the Stages of Change.
Almost 20 years ago, two well-known alcoholism researchers, Carlo C. DiClemente and J. O. Prochaska, introduced a six-stage model of change to help professionals understand their clients with addiction problems and motivate them to change. Their model is based not on abstract theories but on their personal observations of how people went about modifying problem behaviours such as smoking, overeating and problem drinking. Let’s discuss how these stages pertain to chronic pain and how we as physio’s can help you, your friends and your family through a path of recovery.
The stages are pre-contemplation, contemplation, preparation/determination, action/willpower, maintenance and relapse.
Try to decipher which stage of recovery you are in with your recovery and, after reading the information, try to think about how to take action to move you that next step towards achieving a full recovery. Remember, over the course of a day, you can move up and down between stages so go easy on yourself!
Stage 1: Pre-contemplation
If you aren’t thinking about changing your habits, are not interested in any kind of help and find yourself defending your bad habits, as you don’t feel they’re a problem, then you’re in the pre-contemplative stage of change. You might have a mother who becomes quite emotional about how she can’t lift her grandson up due to her nagging shoulder pain but, when you suggest she seeks help, see employs the “ignorance is bliss” attitude.
As physio’s, it’s hard to optimise our treatment with patients in this stage. We must validate their lack of readiness and clarify that the decision to change in theirs. We might encourage the re-evaluation of their current behaviour and encourage them to discover why they have certain roadblocks that are inhibiting change. We may encourage self-exploration and to seek help from other allied health professionals to help encourage a more optimal mindset for change. Jodie, who injured her back water skiing last summer, has been advised by her best friend that because her best friend’s back has never recovered from a water skiing injury, then Jodie’s back will be the same. Jodie unfortunately settles for the fact that this is the truth and doesn’t realise a full recovery can be made.
Stage 2: Contemplation
Contemplators are forever weighing up the pros and cons of modifying or quitting their behaviour. They think about the negative aspects of their bad habit and the positives associated with giving it up and may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. This stage may take a few weeks up to a lifetime! If you’ve read my previous blog, you’ll know I haven’t been the best at rehabilitating my plantar fasciitis. We’re physio’s. We’re human. We break too. I was immensely stubborn about putting a pair of orthotics inside my shoes, to help treat my heel pain. As a physio, my stubborn physio brain thought, “I can strengthen my muscles to support the arches of my feet! I don’t need an assistive device to help get me better!”. Even my wife, who is not a physio, gave me the ideal physio advice, but I didn’t take it. Eight months later, I decide to buy a pair of orthotics. This leads me to the next stage of change, which we’ll talk about in a moment.
As physio’s, for contemplators, we must once again validate a patient’s lack of readiness and clarify that the decision to change in theirs. We can talk about the pros and cons of change and try to identify new and positive outcome expectations. A patient came in with a ten-year history of knee “stiffness” without pain. Her friend advised her to come to physio and, as this patient wasn’t experiencing any pain, the associated stiffness did not stop her performing any of her day-to-day activities. She had no motivation to eliminate the stiffness. As we dove deeper into conversation, the stiffness and hence weakness in her knees stopped her keeping up walking pace with her husband, hence she felt like she was letting him down. As they had an overseas hike planned for the end of the year, we got into some strength work!
Stage 3: Preparation/Determination
Here, patients have now made the decision that they want to change. This is a great stage where we as physio’s can intervene as patients have some experience with change and have realised that there are benefits to their good habits. Patients realised that they have to make a change. Maybe their restriction has hit them on an emotional level (the knee lady above!).
“If I don’t get this shoulder right, I won’t be able to hold my grandchild?”.
“I’m going to hike a mountain next year and I don’t want my knees to hold me back.”
“My husband and I used to go dancing, but we don’t anymore because my ankles are so unstable.”
Thoughts ruminate like this and people reach the point of realisation where a change needs to be made. People are seeking information on how to make that change and actively try to find out what strategies and resources are available to do so.
As physio’s, we can help in problem solving and talk to you about what is blocking you from taking action. We encourage social support at this stage to prevent regression and ensure that the “environment” is right for the behaviour change. Jack, who was mentioned earlier, who fell off the ladder, now has the social support of his soccer mates to keep him active. The key at this stage is small steps. Commonly, people skip this stage, wanting to jump straight into the next stage. It is likely that if people do too much too quickly, they become overwhelmed and may regress. Cheryl, who has been experiencing right knee pain for ten years when she runs does her research. She seeks help from her physio and realise that’s it’s not the artritis in her knee that’s causing her knee pain, but a mild tracking issue with her kneecap. After a few weeks of physio treatment, she is pain free and her knee is feeling the best it has in ten years! She decides to double the length and speed of her runs because she feels so good. Her knee becomes inflamed and the pain is now the worst it has been in ten years! She drops back to the pre-contemplative stage and suggests to herself that there’s no hope! This is why it is important to recover, like you would build a house. Brick by brick by brick…
Stage 4: Action
This is the stage where people have started their good habits to rehabilitate their injury or to attend to their chronic pain. This is a stage where people depend on their own willpower and are successfully making the effort to change. Usually, they have made a plan on how to deal with personal and external pressures of relapse. As physio’s we encourage using short-term rewards and analyse your behaviour change efforts to enhance self-confidence. Gordon was involved in a motorbike accident 20 years ago where he dislocated his shoulder. Due to fear, he stopped riding, he quit his job as a plumber and he stopped playing basketball every weekend. His social scene fell away. Fast-forward 20 years and, with the help of his family, friends and his physio, he is back to playing basketball every weekend and just bought a new Harley Davidson! He consults regularly with a psychologist to manage his fear with being on a bike again but is back to what he loved doing.
Stage 5: Maintenance
This is where those good habits people have developed have become the norm. Habit loops have been created (see previous blog) where good habits now become reflex and, although the bad habits are hard to resist, people stay on track.As physio’s we often remind people how much progress they have made (remember, this is changing brain chemistry!). We’re also constantly reminding people of their “why” and what it is that is their motivation for change. Just remember, as the process is considerably difficult, it is normal to relapse (the unofficial sixth stage) and “go back a stage”.
As physio’s we consider ourselves lucky that we are in a position to help “coach” you through these stages. Often, in the initial stages, we need the assistance of a support network including family, friends, other allied health and most importantly, YOU! If you have a better awareness of what stage you’re in, then that will help you realise what you need to do to move towards a pain free existence!
Merry Christmas Everyone!
South Perth Physiotherapy