What problem do you see?

"Do We See the Same Problem? Addressing Pain and Movement in Rehab"

In this episode of the Talking Rehab Podcast, Dr. Fred Bagares unpacks the challenges of addressing pain and movement patterns in musculoskeletal medicine. He explores the common disconnect between patients and physicians, emphasizing the importance of understanding both the structural and functional components of pain.

Timestamps for Key Topics:

• [00:00:00] What is rehabilitation? Introduction to the episode.
• [00:32:00] Why patients and physicians see different problems in pain management.
• [01:10:00] Pain vs. movement: Why normal movement patterns are often overlooked.
• [02:10:00] Structural changes vs. functional issues: Pain without visible damage.
• [03:32:00] Building therapeutic relationships despite differing perspectives.
• [05:36:00] Does treating pain alone improve movement patterns? The temporary fix.
• [06:01:00] The role of physical therapy in creating better movement patterns.
• [10:03:00] Counseling patients about degenerative changes and non-traumatic pain.
• [11:36:00] Final thoughts: Aligning goals to improve rehab outcomes.

This episode is packed with insights for clinicians and patients alike, emphasizing the value of open communication, shared goals, and a holistic approach to rehabilitation.

Listen now for actionable takeaways that could change the way you think about pain and movement!

Transcript

0:00

What is rehab or rehabilitation? My name is Fred Begaris, a board-certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge dogma, and share my experiences in musculoskeletal medicine. Welcome to the Talking Rehab Podcast. Sometimes one of the biggest problems as a patient and a physician is that we see different problems. Obviously, when a patient comes to see me, they are typically experiencing pain, you know, knee pain, shoulder pain, things like that. But when I see a patient, I actually see two, sometimes three different issues. There's the pain that they experience when they move and how they feel about it. And then there's also the problem with how they move. Now, most people don't look at the way that they move as being abnormal. For the most part, if you move and things don't hurt, everybody assumes that everything is fine. However, that's not usually what I see. Not to say that everybody is moving abnormally, but there are certain patterns that I see that will typically predispose people to experiencing pain. A lot of times the pain is reduced to essentially is a parts problem, meaning like this is an injury that resulted from a slip or a fall. Therefore, something must be broken. Something must be a torn meniscus or a torn rotator cuff, torn labrum, things like that. But I don't know if that's necessarily the way things actually go. People can certainly experience pain without any structural changes. And sometimes people will have underlying structural changes, never feel pain, but then all of a sudden something happens and now they hurt. I know what this must sound like. It sounds like I'm being a little bit nitpicky about people's pain. And oftentimes people will say, I know my body. I know that there's something wrong. And while that very well may be true, feeling the pain is part of the problem. The way that I look at the issue is that there's more than one problem. And I find that this is one of the points of contention that I will often have with patients. But with time, I've started to try and understand their point of view and address their issue while also trying to slowly get them to appreciate that maybe there's more than one problem. And I think this is often sometimes where people will get stuck. It's, you know, we are all human and we can get very stuck in our beliefs and patterns of thinking. And, you know, I've seen several times an interaction where the patient says, I think this is the problem. The physician says, no, I think that this is the problem. And both parties essentially stick to their guns and no one actually gets any treatment. No one gets anything very effective. They both leave with a sour taste and they don't follow up. And or they do follow up and they have feelings or stigmas about each other. And that's, you know, that's not really that's not really good for a therapeutic relationship for therapeutic relationship to occur. People don't necessarily have to agree with one another, but with the exception that they are both trying to head towards the same goals. You know, as long as we may have different beliefs, but as long as we are both trying to accomplish the same goal, if both parties get there, a lot of times the beliefs don't really necessarily make that big of a difference. Obviously, that's a pretty big statement, but I think it is a good principle to approach from both parties, the patient and also the physician. Now, getting back to, you know, the separate problems, again, the superficial problem or the first problem is the pain that the person is experiencing. The secondary problem is their movement pattern is and is their movement pattern contributing to why they continue to hurt or even what led to them hurting in the first place. That being said, you know, treating the movement pattern exclusively, it's hard to get the person to buy in to the treatment plan. So I tend to treat the pain first. Now, does treating the pain and whatever treatment tool I use, does treating the pain first improve the way the person moves? Absolutely. The movement pattern of someone in pain versus when they're not in pain, they're obviously two separate types of movement. Now, the pain is now better controlled with, you know, an injection, a medication, you know, a surgery, a surgery, you know, that helps the superficial component of the problem, the pain. But it does not address the other issues, again, the deeper problems of the movement pattern. And that is where I think physical therapy can be very effective is not only is isn't necessarily pain control, but trying to create more effective movement patterns or essentially unlearn compensatory but maladaptive movement patterns. And I think that's essential to a rehabilitation program. But I also think it's it's sometimes not necessarily bought by the patient because, again, they are looking at a superficial problem. And sometimes the treating physician or the treating therapist is looking at the movement pattern. And again, if both parties can't agree on the problem, you know, then it's hard to have a therapeutic relationship. So that being said, does treating the pain help the movement pattern? It does temporarily. Now, I will often ask my patients, is how you move important? I think everybody will often say yes. I think that it's it's kind of a given that if you move one way versus another, you know, they most people have a particular preference. It may not necessarily be pain, but they generally have a preference. So by by that kind of logic, you know, it does make a difference, because if it didn't, then they would obviously move in several different ways. But they have a predilection for one particular pattern for or for one motivation or another. But that is that is that is a factor in how the person moves. Now, the other question I ask is, does how you move create pain? And I think patients will often come to the conclusion that it hurts when I move. And that is the problem. And I don't know. I don't necessarily completely agree with that. I mean, I think, again, it's obvious, like if someone has pain and they move and it's still and it continues to hurt, then you I think you do have to draw that conclusion. But it may not necessarily be the most accurate or not necessarily accurate. And maybe that's not the right term, but it may not be the complete picture. Because, as I said, you know, people, they move a certain way by choice or convenience. But convenience is still a choice. So there was a point in time where however they were moving didn't cause pain or symptoms, you know, so but for whatever reason, let's again, we're using an example of a non traumatic, you know, cause for whatever reason, their typical movement pattern is now painful. Now, did something actually change? I think that's also where people will assume, I have been moving like this for 20 plus years, and now my knee hurts. Therefore, something must have happened. When we get imaging of the knee, we see degenerative changes to the knee. You know, a common one is that there's a degenerative meniscus and people will conclude like, well, see, there's something that's torn. But there does have to be a lot of counseling that is involved with trying to explain that degenerative, there are certain findings of the knee or the shoulder are normal. And they are hard to connect the dots to actual injury or trauma, even though things started on a particular date and time. But again, the movement pattern at one point in time was non painful. And outside of a trauma, if you start hurting, I don't think you can necessarily conclude that something dramatically changed, unless you, you changed your movement pattern one particular day, one particular time, and you develop pain symptoms, then maybe, you know, maybe, maybe that was the cause. But, you know, overall, I think that it is common for people to have movement patterns by choice with degenerative parts that become painful. But again, the purpose of this episode is to discuss, you know, what problems are we seeing? You know, again, from the patient standpoint, I don't necessarily think that they, that they think that there's a problem with how they move. It's, it's, it's kind of too, it's exclusive to no, I hurt, and it's because of something, and that something is often structural. Now, I could spend time trying to, to convince them that there's more than one problem in one visit. That's really, really hard, especially if you're an insurance based model, and you're only spending, you know, less than 10 minutes with a patient, you know, I think in a less than a 10 minute visit, you, both parties can agree. On a structural problem, and then just call it a day and move forward. While that might work for the clinic, I don't think that that's necessarily the best way to manage, need, manage movement brace problems, joint pain, shoulder pain, things like that. I think it does require a, um, a wider lens and thinking outside of the box and being a lot more specific about what can cause pain and what typically does not cause pain. And it can, and it can get pretty, pretty involved. So I'm glad that I do have a 60 minute visit where I can really dive deep into some of these, these issues, because I, I believe that in order to have a therapeutic relationship, you do have to discuss more than the superficial issues. But, again, just some food for thought for you guys. Again, this is really driven by the fact that maybe part of the problem between patients, physicians, and their, and their injuries and pain is that we're looking at one issue, and we see different problems. And maybe if we have more time to talk about all the various issues, we can, we can at least see the same problems, or at the very least, agree on the common goals, the goals of trying to get people more physically active and healthy. But, again, just food for thought for you guys. Thanks again for listening. Thank you for listening to the Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement-filled day. Take care.