Why Fragmented Pain Care Leaves Chronic Pain Patients Stuck

Most patients with chronic pain aren't failing to get better because they lack effort. They're failing because they're solving the wrong problem, and nobody in their care has helped them see that yet.

This is the Modern Pain Podcast with Mark Kargela.

So what do we mean by that? And oftentimes, you know, we know that biopsychosocial models, if you've listened to this podcast, of course, you know that's an important thing. So we often are doing a better job screening for yellow flags or things where we know there's some psychosocial challenges that this person in pain is dealing with. Um, you, you might be the most evidence-based guideline following person who's, who's doing that, but I'd argue there's still this perception from a patient, and I see it day by day, and we use behavioral health in our clinic as well, and it's obviously a great resource to have, but to me there's still patients and I, I think it's both, you know, could be better from both behavioral health and the physical therapy side. To make this towards one conversation had by different perspectives within the same conversation, because I still think there's a little bit, actually, I know that because I've taught to patients, and this is the perception they have when I ask them, is that there's the thing that, the problem is it's their back. It's their, their arthritic changes or their widespread pain all over the place that has been. Labeled fascial issues or whatever thing that oftentimes very narrow, uh, minded, you know, clinicians that I was where I would want to encapsulate this big complex thing into one tissue, which obviously we know it's more than that. So the patients, see, I, I, I have this body problem, and yet he's, they're talking about the mind thing. So I guess, yeah, I'm having difficulties, but they default to this biomedical reasoning approach. Um, so again, on paper, this looks great when we have both a psychologist and a physical therapist or a chiropractor on board, but. Again, is this coherent story happening with them? And I, if we talk to patients, there's a lack of coherence. Oftentimes when we hear their stories, where they've come in and they've had different stories from all these different ologists, and if they have a psychologist on board, they, it's kinda the secondary thing that they don't often see as, as something that is, is part of solving the issue in their body. And there's this concept in psychology called the misdirected Problem Solving Model. And it's basically. We sometimes get caught trying to solve the wrong problem. Right? And in pain care, I think the big problem that people. Try to solve is I'm gonna solve this massively complex, difficult, life altering and changing issue through just simple a, uh, addressing an MRI or an x-ray and things. And I'm not saying that that's always completely not helpful to get tissue health, but when we know that there's massive stress and distress and loss and grief and anger and frustration and in emotions that we know ramp up our autonomic system. Behaviors that have people who have been on the sidelines of their life, they're not able to do the things that are important to them. They're not, um, engaged in anything that brings value to them. They feel like they're lost. They've lost a biography or who they are. And so that's hard for an ecosystem to work well in those situations. So. We need to look at really what's true interdisciplinary care with, with folks in this situation. What does it need to look like where there is this coherence where we do have a conversation that happens? And some of you may work in interdisciplinary settings where, hey, I have a team like the Mayo Clinic has a, you know, pain rehab clinic where. They have, uh, psychology, physical therapy, occupational therapy, uh, physicians all on board, having the same conversation, often in the same room with a patient having the conversation. That's obviously rare these days, and it's, it's a, it's a very challenging model to institute unless you have the resources of a Mayo Clinic or somebody who can institute that model. So. With that said, I think we need to have better ways where our psychology colleagues, our physical therapy colleagues and our physician colleagues can all, and again, chiropractors, massage therapists. I'm not saying that can't, they can't play a role. I mean, obviously we all are on the same team, but to where the conversation is one unified conversation and it's not this broken up, incoherent conversation that doesn't make any sense to the patient. It can make all the sense in the world to us where we might be focusing on our, our components of that conversation, but it shouldn't be separate conversations. Again, it shouldn't be this PT conversation where tissue movement, capacity and load is only discussed from the, uh, physical therapy standpoint. You know, a psychologist should be able to mention that, Hey, this stuff will help you be able to move better. You know, engage in loading, do the things that are helpful, you know, and then PT should be able to bring into the room. And we see this with cognitive functional therapy when we bring somebody's fears. In the light where we have them talk about what shows up with them when they try to do some of these movements that they're hyper, you know, protective bracing and movement avoidant on. So I think we're seeing some of that to where these conversations are being had in clinic where physical therapists no longer are just like, you know, isolating and just focusing on strictly the body or, the bio component of somebody. They're able to start bringing in that psychosocial component. And then again, I think we need to. Help our psychology colleagues bring the body component in the bio component. They need to be able to tie some of these difficulties people are having, emotionally thoughts, behaviors, and all the things that go with anxiety, depression, all the things that some of our patients unfortunately are dealing with. They need to have the ability to have a conversation that makes sense that I'm gonna help you with things that should translate to you being able to do the things in physical therapy more easily and it's gonna affect your biology.'cause I do think that patients do not have a good grip on how working on thoughts, emotions, uh, behaviors and things will help their biology. They see it as a mental thing and I'm dealing with a body thing and I, I wish we could do better on that. And that's obviously what we're doing in our community at Modern Pain Pro and with our trainings is to help. Clinicians get the resources to have that conversation in their own practice where it's not this separated piecemeal thing where they can integrate thoughts and behaviors and emotions and where they're doing exposure based work. You're doing things that bring in some of their emotions. You're letting people surface some of the difficult things they're going through. Not acting as therapists, but being able to bring those things in their room, help the patient walk through some conversations where they see. Not just that we're saying it does or theorizing. We let them walk through their own experience and notice that, does this experience tend to move me more towards, um, you know, things that are value to me or they move me further away? And when I do notice these difficulties showing up with me, what am I noticing in my body?'cause oftentimes if people can step back and sit with situations where they're. Stress is cranked up or they're really struggling, you know, emotionally or with grief or whatever it may be for that person. They'll often notice that some difficult things are showing up in their body along with that, and hopefully they can start making the, the tie, those two together that, hey, this, these are not separate things. These are, I need to be working on all of it. Not just, you know, trying to stretch it or manipulate it or needle it or do the next PRP or. Whatever thing that just focuses on such a narrow piece of a massively complex issue, we owe it to our patients to be able to look more comprehensively at them. They are whole people. They aren't just what's shown up in the MRI or x-ray where a needle needs to get injected based on a pain physician's aspect. They're more than a person who just needs to have a, a manipulation done to their neck, where their pain's located. They're more than just, uh, you know, the thoughts and beliefs and emotions. They're all of it. And they're also sitting in a context in their world, social determinants of health, what's going on in their context with their relationships. So much. So I would hope. And this episode's gonna be a little bit short this week. I just wanted to come in and we're gonna actually have a webinar and talk to this a little bit about how do you get a framework together that brings these conversations in a room, and then also get some resources where you can help. Bridge that discussion with maybe some psychologist you're working hand in hand on with the patient where you can help, you know, have a a, a mutually beneficial conversation where the psychologist can lean on their skill sets and their expertise and you can lean on yours and you can share a coherent conversation. Same thing with physicians. I think there's ways we can provide resources to patients to help them dial in. What's going on with those physician conversations? That may be why they're not maybe landing as a core part of the store, but we can help translate some of these stories they're getting from other people and help seeing that they're great people. They have well meaning, but they don't maybe. Aren't able to translate their language and their diagnostics into a coherent narrative with them. We can do that as clinicians and we must, patients need this. So if it's something you're interested in, definitely look in the show notes. We have the webinar registration, but on it's free training. We're just looking to improve, uh, pain care. Um, we will talk about our community at the end of it to see if it's something y'all wanna join.'cause that's where we're going deep on this stuff and helping people with their unique cases. Um, but I'd love to hear from you what, what goes on in your practice? Do you feel like there's. The same conversation going on with your patients, where yes, the psychologist and me are, are singing the same tune and the patient most importantly sees how those are two vital pieces of their care. Or are you in a practice where I spend some time too, where patients still are having a hard time connecting the dots of why on earth I would need to see both when it's my back and my whole body that hurts. Where's my mind coming into this piece? Why would I need that? Um, so let me know what you think in the comments. I'd love to hear your, your perspectives on it. And again, would love to see in the webinar. Let's, let's start moving pain care better together.'cause we do better together we can move this thing better together and we'll change pain care across the world. Let's talk to you next week.

This has been another episode of The Modern Pain Podcast with Dr. Mark Karula. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modern pain care.com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs, changing the story around pain. This is the Modern Pain Podcast.