Painful Communications - making them better

'Stop if you feel pain.'

'Rest and give your new knee (post TKR) time to settle.'

'Be very careful when you do that movement.'

'You have the joints of an 80 year old.'

These were some examples of poor communications reported by researcher Emma Karran at the 2019 physio conference in her presentation titled "Screening, scans and choosing words carefully: Optimising care for patients with low back pain". Suggested alternatives were;

'Movements will be initially painful like a sprained ankle - but will get better as you get active.'

'Your knee is strong and robust - let's take it for a test drive.'

'Our tissues heal, they respond best through loading - slowly increasing your walking is the very best thing you can do.'

'These scan changes are about what I would expect – think of it a bit like wrinkles and normal for your age. They do not determine what you are capable of.'

You can access some of Emma's research here, here and here. 

To assist in improving our communications with patients, I have pulled together resources that I believe will help develop capacity to assess and explain the sometime difficult concepts of pain, imaging, activity and medication use.

Like location is key for property, it is impossible to provide an optimal service if you don't have a baseline. It is also impossible to demonstrate progression if you don't have a baseline. For these reason we have created libraries of commonly used risk screening questionnaires and outcome measure questionnaires.

Without the routine use of risk screening tools, only one in 10 clients with psychosocial risks are correctly identified. These risk screening tools are available for download from our website - Psychosocial Risk Screening Tools Library (13+ downloadable questionnaires and associated reference/scoring papers). Here is a very useful document that outlines how GPs and Physios can integrate the use of psychosocial screening tools into their assessment. Risk screening tools become more important in the progression from acute to subacute and chronic.

Also available are outcome measures for a range of anatomical regions and specific conditions - Outcome Measurements Library (20+ downloadable questionnaires and associated reference/scoring papers).

The following information produced by WorkSafeSA relates to discussions about pain, imaging, and activity with downloadable infographics to help you with background information to bring to your discussions with patients. These tool provides a simple framework to accompany and summarise conversations with your patient about common radiological findings (e.g., X-ray, MRI or CT scans) in a way that aims to reassure them about what is normal, promote healing through movement and assist in understanding the concepts or acute and chronic pain.

They have also completed a short webinar (3:11mins) explaining how to use the downloadable resources that can be used to compliment your patient conversations.

Other sites to overview are painHEALTH, Body in Mind resources, and myPainHub.

Chris Maher presented the Journal of Physiotherapy oration at the 2019 physio conference and a portion of his presentation focused on the misuse/overuse of medications. I was aware of the significant issue in North America and Australia with prescription opioids provided to the community through the medical system for management of pain, however there were other medications used in my client groups that had issues I was not aware of...

While clinical guidelines around the world recommend the use of paracetamol as a first line of management for LBP, and OA of hip and knee, I wasn't aware (call me late to the party if you want) that for acute low back pain & disability it has been found to be ineffective. A 2015 systematic review (that was the most downloaded BMJ paper in 2015) reported a similar result for LBP. In regards to OA of the hip and knee, some short term pain relief was provided, but not to a level that was clinically meaningful. The authors noted a 4 fold increase in abnormal liver function tests in paracetamol group participants, which is of unknown clinical significance.

So if paracetamol is as good as placebo, and placebo has some benefit, what is the problem? This was my other eye opener (both eyes open now!). Remember we look at an interventions from benefit and risk perspectives, well paracetamol is the drug most frequently taken in overdose in Australia. Check out the graph from this 2019 paper. The blue line represents all presentations to ED due to paracetamol overdose and the red line represents the proportion of cases attributed to self‐harm (consistently exceeded 75% of the total each year). So a lot of people are overdosing on paracetamol (mean number of deaths per year were 43). That is a short term effect, the other aspect is regular overuse of paracetamol can result in liver toxicity. So none to negligible benefit using paracetamol, but a significant acute and chronic use risk.

What about pregabalin and other anti-epileptic drugs? There were initially promising reports using these medications on neuropathic pain conditions like herpes zoster, what about sciatica? Well, the authors of a 2017 paper have recently looked at that and concluded "Treatment with pregabalin did not significantly reduce the intensity of leg pain associated with sciatica and did not significantly improve other outcomes, as compared with placebo, over the course of 8 weeks. The incidence of adverse events was significantly higher in the pregabalin group than in the placebo group". In a more recent systematic review that included both LBP and sciatic in the review, the results were similar. Nil benefit and significant harm risks including dizziness, loss of balance, altered cognition and suicidal behaviour.

So I circle back to the start. With our skill set, we can;

• record baseline measures to alert us to psychosocial elements and use for future comparisons
• consider the appropriateness of words that we use in our discussions with patients
• educate on the relevance of imaging (e.g., Ottawa rules, red flags) and medications
• support, encourage and progress patient's activity levels to take them from a clinical situation of limitation to a functional situation of optimal health and movement.

Thanks for reading.