When it comes to treating musculoskeletal conditions you will notice there is often a distinct difference between treating acute vs chronic injuries. Chronic injuries present an additional layer of complexity due to the complex nature of pain and the potential sensitisations that can be occurring for the individual.
In an acute injury pain is closely related to the damage to the tissue from the injury itself. What we know for chronic injuries is that the longer pain persists, the less it has to do with tissue damage and is primarily driven by other mechanisms.
Although there are a number of interrelated factors that contribute to chronic pain, peripheral & central sensitisations are commonly identified. These can potentially result in kinesiophobia, pain catastrophising and fear-avoidance behaviours. The main bodies of research on these mechanisms and effects are in relation to lower back pain. However, there are growing bodies of literature that have identified some of these mechanisms in the lower extremity (see articles below).
What are some ways that we as practitioners can improve our approach to treating clients with chronic musculoskeletal conditions?
Understanding the various presentations, risk factors and treatment options for chronic conditions is vital for successful treatment. Not everyone with Achilles tendinopathy will respond to isometric or eccentric loading exercises. If a person’s pain is largely driven by sensitisation and they have a high level of fear-avoidance for certain movements (eg: calf raise or the propulsive-phase of gait) we may need to increase the ‘safe zone of movement’ prior to loading the area with the ‘go to’ exercises. If you are unsure about a certain condition or an aspect of the presentation, read up on it. It becomes very clear to a client very quickly if you are fudging, and all this does is sabotage your treatment outcomes.
Honestly is always the best policy, and using the words ‘I don’t know’ or ‘I’m not sure’ are not a bad thing. Letting your client know this and that you’re going to get in touch with someone who knows about the topic or you’re going to read up on it before you see them again builds trust and confidence.
Relax & Don’t Rush
A person with chronic pain often will have heightened feelings of anxiety relating to the condition. Not to mention feelings of helplessness and uncertainty. Rushing through an assessment creates a disconnect, and you may end up missing some vital pieces of information.
Some studies report that during GP consults when a person is given the chance to explain their symptoms they are interrupted 7 out of every 10 times. Of those who are given the chance to explain, the person speaks on average for 11 seconds before they are interrupted. You may need to guide the conversation, but let them tell their story.
In my experience, allocating longer consultation times for chronic cases has nothing but positives. You’re not rushing, you’re able to spend time covering all bases and if you finish up a little earlier you can have a 5 minute breather before your next consult.
You’re treating a person not a pathology. Each person you treat will have their own unique history, risk factors, thoughts, fears, beliefs, triggers and treatment goals. In order to build a rapport and devise a successful treatment plan you need to explore all of these areas. Oftentimes a client will give you a few pieces of the treatment puzzle through the course of getting to know them.
Clear Communication & Empathy
It is well documented that the biggest cause of health care complaints are secondary to poor communication and a lack of empathy, which can come across as a perceived lack of respect for the client. Adverse events, dissatisfaction and overall poor treatment outcomes are the potential consequences of poor communication and a lack of empathy.
If we take the time and a client understands what is happening to their body & what can be done to help, with a particular focus on self-efficacy. The likelihood of achieving a successful treatment outcome almost instantly improves, and there is literature to back this up!
In order to do this we need to abandon the short get ‘em in, get ‘em out consults, the complex word salads and the idea a client needs to rely on us to ‘fix’ them. Using simple, easy-to-understand language to educate and empower your clients during the treatment process creates a team environment, where you are both on the same page and working towards the same goals.
Chronic musculoskeletal conditions can be complex and there certainly isn’t a one size fits all approach, however, these are some incredibly simple ways you can instantly begin improving your treatment outcomes, as we shift away from the biomedical approach and more towards working under the biopsychosocial treatment paradigm.
Founder Kinetic Therapies
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Plinsinga, M., Brink, M., Vicenzino, B., & van Wilgen, C. (2015). Evidence of Nervous System Sensitization in Commonly Presenting and Persistent Painful Tendinopathies: A Systematic Review. Journal Of Orthopaedic & Sports Physical Therapy, 45(11), 864-875. doi: 10.2519/jospt.2015.5895
Tompra, N., van Dieën, J., & Coppieters, M. (2015). Central pain processing is altered in people with Achilles tendinopathy. British Journal Of Sports Medicine, 50(16), 1004-1007. doi: 10.1136/bjsports-2015-095476
Cotchett, M., Lennecke, A., Medica, V., Whittaker, G., & Bonanno, D. (2017). The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain. The Foot, 32, 8-14. doi: 10.1016/j.foot.2017.03.003