Pain talks: navigating the maze of chronic pain conversations with Dave Renfew

In this episode, Dave explains how he handles uncertainty in conversations regarding chronic pain. He shares some lines and analogies he uses with his patients to help with buy in, and to help communicate the complexity of what we do. He also presents some digestible take-home messages to share with your patients with chronic pain.

Dave Renfrew is the clinic owner of Newcastle Performance Physiotherapy in Newcastle West. He prides himself on the fact that his clinic bases all its treatments on scientifically proven diagnostic techniques and methodologies. Dave graduated with honours from the University of Newcastle and is also qualified as a Strength and Conditioning Coach and has been working within the field of Physiotherapy for almost 20 years.  

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Transcript

SPEAKER_01 0:00

How we feel about a situation is going to impact the decisions we make. Absolutely. So regardless of whether it's a positive or a negative or whatever framework of thinking you take into that interaction, if you are letting something about their history already push you in a certain direction, then I think it impairs your decision-making process.

UNKNOWN 0:30

Thank you.

SPEAKER_02 0:32

Communicating clearly and concisely and simply what we do is becoming harder and harder as we become more uncertain and there's more nuance and complexity to our frameworks. Dave Renfrew, I think, is absolutely wonderful at this. Dave's a physio from Newcastle, the clinic owner, but he has explored and read the research around pain science. But what I love is he distills that down into really nice, simple messages and some analogies, and he shares some of those with us today. My name is Michael Risk, and this is Physio Explained. Welcome, Dave. Thank you for joining us. Thanks for having me, mate. We're going to get into some practical pain science frameworks, which you're a genius at. The first thing we had here was treating people with chronic pain differently doesn't help them. What do you think about that? What could you add to that?

SPEAKER_01 1:23

Well, I think chronic pain, even the word now comes with a bit of something attached to it. You know, they're a chronic pain patient or they've got chronic pain. So, you know, Often as clinicians, I think when we see that maybe in a referral or we get a bit of an idea before they come in, it changes how we approach them. So in the sense that we often will think, oh, there's going to be a story here or there's They're going to have all this other stuff in the background. And I just think if you start treating them differently to say the ankle sprain that walks into your clinic, then I think you're sort of putting yourself on the side of healthcare that they've probably been exposed to before that hasn't helped them. So when it comes to the person that comes in, I wouldn't treat them any differently to regardless of what I know about their story. And I think that ultimately will help that person and maybe even give you an advantage in helping them because that's different to most of the stories that people with chronic pain have about accessing healthcare.

SPEAKER_02 2:26

That's super interesting. There's two directions I want to go with that. One is like when we say treat them differently, I imagine a lot of therapists out there might still be doing like acute frameworks and looking at biomechanics and things like that, which might be relevant, but probably less so if someone's been in pain for three years. So there's that part where I'm like, I would want that therapist to treat them differently. But then I think what you're saying is, if you have in your mind that this is a chronic or persistent pain patient, do you think therapists might tend to coddle a little bit or treat them differently and even talk differently?

SPEAKER_01 2:58

Well, this is interesting, right? What do you mean by the word treat? So even in that little two sentences, we could be talking about How do you prescribe an intervention or how do you interact with them as a person? That's what I meant. So I think that's a really important thing because that's the same word, right? Yeah, yeah. I can only speak English and I don't speak it very well, but treat is the right word to use, but it depends what you mean. So I'm talking about how you interact with them as a person. If you interact with them differently from the start, I don't think that's going to be helpful. Would you treat them as in your intervention differently if they were really acute pain and chronic pain? Then I would say yes, definitely. Well, I think they are different when it comes to treatment in terms of acute and chronic pain. I shouldn't say definitely because who knows, right? It depends on the person. But in terms of how you would approach your treatment, I think they're different by how you would approach their clinical treatment. presentation that i don't think you should change anything personally yeah i mean already that's that's murky right that's really tricky it

SPEAKER_02 4:06

is what comes to your mind when you talk about the interaction side of things and not treating them differently not interacting with them differently

SPEAKER_01 4:15

well i think when we make decisions as humans well as even as health professionals i reckon we like to think that we're super rational clinically reasoned very objective people But that's sort of bullshit, really. We're very irrational, emotional beasts, basically just a step up from your average ape. And how we feel about a situation is going to impact the decisions we make. Absolutely. So regardless of whether it's a positive or a negative or whatever framework of thinking you take into that interaction, if you are letting something about their history be already push you in a certain direction, then I think it impairs your decision-making process.

SPEAKER_02 5:00

Let's get onto that because I think you're going to touch on it with these follow-up questions, but acute and chronic pain are different but not in the way we think. What did you mean by that?

SPEAKER_01 5:08

This is just my opinion, but I would think sort of following the same thought process that When you see a chronic pain, and I'm doing the, I'm realising there's no video of this, I'm doing the, you've been quoted quotation marks, when you see a chronic pain diagnosis or referral, I would suggest most clinicians are already thinking not about structures, they're thinking about psychosocial factors, they're thinking about making sure they cover off all their experience and how they feel about it, their beliefs and behaviours, which is great. The trap there is that you're discounting structural pathological issues that might have just been missed. You know, if something's hurt for three years, the hope is that it's not wildly pathological, but that's the trap that you could fall into. And I think with acute stuff, most of us would go, okay, there's probably a pain generator. You know, there's a tissue that's the problem. I probably don't have to worry about this other stuff as much, which might be true, but I think that's the difference we tend to make even subconsciously is we split the BPS up with acute and chronic, right? They are different, but only in the sense that it's always all the things, right? It's everything all the time, all at once. Like that awesome movie that came out recently with Michelle Yeoh, that was a choice, that movie, I loved it. So it's all the things all the time, right? But when someone has acute pain that's been there for 12 hours, They need you to go into their backstory and talk about what happened three years ago. And they may not need you to do that. And it may actually make no sense to them. They're like, you know, bro, I just sprained my ankle. Why are you asking me about how I feel about work and stuff? So, if they're interested in it and if it means something to them, great idea. But it may be that that's not necessary or at least maybe not at the start. They might have more important ideas. questions like, is it broken or how do I manage the swelling? But the trap there is, of course, that we discount some of the other things of their concerns and beliefs and other things like that. So they are different environments, absolutely. But what I would, the way that I would think about it is, is how do I approach it based on this person in front of me and what am I thinking that they need from me? And you may have an acute person that needs a whole heap of information and support and everything around the environment in which it happens. And you may have a person that's had pain for three years and you're like, look, I think you've got this undiagnosed foot that's really messed up and I'm going to get you an x-ray. So they're different, but I think the way that we compartmentalize it is probably not the best way.

SPEAKER_02 7:51

I

SPEAKER_01 7:51

like what

SPEAKER_02 7:51

you're saying there because I think what you're alluding to is we could, and I think I see this in younger therapists, is once we see that history, which you might get on a form before they come in, you can go into the interaction already making assumptions. And I guess what you're alluding to here is that might be an error. And you could do it in both departments. For a persistent pain patient, you may not check some of those more acute or pathological findings. And for an acute patient, some of that history three years ago might be relevant. It also might not be. It's good reflection.

SPEAKER_01 8:25

Yeah. And I think to make it easy for us, we're always going to develop these models of practice or frameworks or whatever word you want to use, right? Because we have to be able to think categorically sometimes, otherwise it just slows us down. So we're built to create systems and frameworks and models to make it easier for us. We just have to be aware when we're dealing with someone who's not in that model. So we're always having to check ourselves and go, is this the right one for this person or maybe am I missing something?

SPEAKER_00 9:01

www.clinico.com

SPEAKER_02 9:34

What are some of those assessment and treatment frameworks or shortcuts that you found helpful?

SPEAKER_01 9:41

From Newcastle, I tend to think of, is it scary? Is it broken? How pissed off is it? And how changeable is it? Is this something I really need to act on now? Is this something that could be really bad? And they may be in a bit of trouble here. And do I need help? Is this broken? Did they mess it up? Do I need to immobilize it? Did I need to see a surgeon? Should I get the doc involved right now? Do they need some serious pain relief because this is really bad? If we close those off and we're confident, we could still be wrong, but if we're confident to progress, then it's like, if I'm going to start trying to help them, how much are they going to pay for it? How nasty could this get and how quickly? And then how changeable is it? And that might go from zero to a hundred. It might be very changeable or it might not change at all. So that's something that I tend to work through in terms of a decision-making process and go, okay, where am I after all that? And then that informs where I would start with them, including my explanation of what I think is going on and where we're going to start and what they could expect to come next.

SPEAKER_02 10:48

You had some good tips. You've worked with my team a few times around certainty and uncertainty. And you kind of can't promise to a patient that they'll get better. But you have a way of phrasing that or a few analogies or a few frameworks on, if we do this, though, I could say this, this, and this. Do you have a couple of those that you could share? And

SPEAKER_01 11:12

I guess it always depends on what one you're in, right? But I would often think of... plan A and plan B. And I come out and say this to people. I'm like, so based on all this, this is where I think we are. If I'm correct, then I think this will happen. I guess the thing with uncertainty is I'm not trying to get certain. I'm happy that I'm going to be uncertain always, but I have likelihoods in my head, right? So, and I would say to someone, I think this is where we're going. If I'm correct, this is what I would expect. So, if that happens, fantastic. Next one, we'll do this. If that doesn't happen, then perhaps we need to contemplate A and B, which could be slow down, it could be image it, it could be referral, it could be a few different things. And I just outline that to people so they know where they are, but they know what happens either side. Sort of like a confidence interval. So I'm thinking this will happen, but I have an inbuilt uncertainty into that. And I talk about my confidence interval either side, what happens in the event of that. And then I guess when we're talking about pain, Very easily, I would suggest I'm either going to make them feel better, it'll be the same, or I'll make them worse. And again, I'll often talk about that, particularly with very irritable, unpredictable things. I can be certain of it's safe to be moving. You can do this version of what you like, but I don't know how it's going to react. It could get better, in which case, great, we'll do this. It might be the same, in which case, great, we'll do this. It could absolutely get worse. And if that's the case, then give me a call and we'll work out, we'll troubleshoot it as we go. So all of these things that we're perhaps concerned that might happen, like we might be wrong or we might flare them up, that's never going to go away, right? So I'm not saying to people, look, I've got no frigging idea. I'm very likely to be wrong. I'm not saying that, but I am saying building in a healthy level of uncertainty around what I'm doing because that's the truth.

SPEAKER_02 13:10

I think with my team, you were saying with the plan A, plan B, look, there's this movement that we both agree you're pretty worried about. Let's say, you know, we're getting our shoulder above 90 degrees. Here's what I think it'll look like. We need to start planning for this or giving you some graded exposure to that. And this is what I might expect over weeks or months that eventually we get a little bit further, a little bit further, we do some things and then you're lifting your shoulder above your head. You might also present the plan B that that might not happen and we get the scan. What about pain? Does anyone ever say, that sounds good, Dave, like I reckon you can get my shoulder above my head, but what about my pain? Do you ever approach that explicitly and say, I generally see that when that function restores, we're happier, healthier, we have less pain? Or do you go back to that, it could be better, it could be

SPEAKER_01 13:55

worse, it could be the same? Look, I think in the absence of, some people have a ceiling on how much you could expect them to improve, right? If they have a congenital problem, a systemic inflammatory condition, if they have a knee that kicks out 90 degrees, like there are some things that I'm not going to suggest may never be painful. But in the absence of those things, even if pain's been around for a while, I will often say, I don't see a reason why this has to hurt. So I'm not saying I will definitely fix your shoulder because I think that's just unfair. But I am optimistic when I should be optimistic. I'm not reckless, but I'm like, this can change and this can get better. And I can't see why you can't get where you want. I'm not promising. I'm not guaranteeing it, but I'm confident I can help you when I'm in the situation where I am confident. If I'm not confident, then I don't.

SPEAKER_02 14:49

I like when I listen to you, Dave, I can tell like, this is stuff that's taken years and years for you to refine. So it comes out really well. And within that, I think there's confidence and certainty like therapist to therapist. When you talk about these things, the words you're saying are we're uncertain of the outcome, but it sounds confident. And I imagine if younger therapists who are listening to this practice that a lot, which will just take time and practice, that can really reassure their patient without being certain of outcome. So that's what I get every time I talk to you. And thank you for giving us those reflections. And thanks for your time, mate.

SPEAKER_01 15:24

Awesome, mate. As always, thanks for having me.